Injuries and Management Tutorial Flashcards
Case 1 - 20F
Fell off her bike, developed immediate severe pain in the left shoulder and deformity
What does the x-ray show?
Dislocated left shoulder - humerus should normally articulate with the glenoid fossa, but the head of the humerus is not there
What normally causes a shoulder dislocation?
How does shoulder dislocation usually present?
Often caused by direct trauma
Presents as:
Pain
Restricted movement
Skinny = obvious dislocation / deformity - loss of normal shoulder contous
What clinical examinations and investigations do you do for a suspected shoulder dislocation?
Examinations =
Assess neurovascular status – axillary nerve
Investigations =
X-ray prior to any manipulation – identify fracture e.g. humeral neck, greater tuberosity avulsion or glenoid
Scapular-Y view/modified axillary in addition to AP
What are the 3 types of shoulder dislocation?
Anterior - commonest type (90%), bimodal distribution (most common in 20-30 year olds), humeral head not overlying glenoid
Posterior - rare (6%), associated with seizures/ shocks, ‘lightbulb sign’ on XR
Inferior - rare (<2-4%), arm held abducted above head, humeral head not articulation correctly
How are shoulder dislocations managed?
Numerous techniques to reduce a dislocated shoulder:
Vigorous manipulation or twisting manipulation should be avoided to avoid fractures
Safest method is to use traction-counter traction +/- gentle internal rotation to disimpact humeral head
Ensure adequate patient relaxation – Entonox; benzodiazepines
If alone could use Stimson method
Undertake in safe environment, especially in elderly e.g. resus, ask for senior/anaesthetic support early on if necessary
Traction OR Stimson method (weights and gravity)
Set-up most important
How was the Case 1 patient’s reduced?
Patient placed into A&E resus (need urgent attention)
Pre-manipulation neurovascular status normal
Sedation provided by anaesthetist colleagues
Shoulder reduced using traction-counter traction method
Reduction felt to be complete clinically with relocation of shoulder and normal appearance of shoulder contour
Patient sent for post reduction films
Plan to check neurovascular status once sedation worn off
What do the x-rays now show?
Hill-Sachs defect and Bankart lesion - a complication of a shoulder dislocation that has been tried to be fixed with traction
What are some shoulder dislocation complications?
When reducing, humerus head gets caught on the glenoid and so -
Hill-Sachs defect = chipped humerus head
Bankart lesion = fragment of humerus head caught in the glenoid fossa
Can cause instability or impingement at joint
The patient returns 6 months later to A&E and they have fallen over again
What does the x-ray show?
Lightbulb sign = posterior dislocation
Case 2 - 82F
Fell onto right hand
Pain
Tenderness over right shoulder
What do the radiographs show?
Proximal humerus fracture
How do proximal humerus fractures normally occur?
How does it present?
Fall onto outstretched hand - although this may also cause wrist fractures
Typically in elderly or those with osteoporosis
Pain
Tenderness
What investigations are usually carried out for suspected shoulder fractures?
How are they usually classified?
Investigation:
Plain x-rays
CT if concern over articular involvement or high degrees of comminution (splintering of bone into more than 2 fragments)
Classification (described by Neer) =
Surgical neck fractures (2 parts)
Avulsion fractures of greater tuberosity (2 parts)
Comminuted fractures (>=3 parts)
What are the management options for proximal humerus fracture?
Collar and cuff = used for 2-part fracture minimally displaced, on patients with high surgical risk / comorbidities, and not compliant with post-operative care
ORIF – plate and screws = used for any fracture with displacement i.e. 2-part+ but not highly comminuted
Arthroplasty = used for large displacement of humeral head and high risk of non-union ness
Reverse arthroplasty = used for unrepairable rotator cuff, previous unsuccessful shoulder replacement, a complex fracture/chronic shoulder dislocation
Case 3 - 50M Right hand dominant - falls onto right arm Immediate pain and gross swelling Limited movement of wrist Neurovascularly intact
What do the radiographs show?
Lateral view shows extra articular distal radius fracture
Dorsally displaced distal radius fracture
How are distal radius fractures classified?
Displacement gives its name
e.g.
Extra-articular with dorsal angulation = Colles fracture
Extra-articular with volar (palmar) angulation = Smith fracture
Intra-articular with dorsal angulation = Dorsal Barton
Intra-articular with volar (palmar) angulation = Volar / Reverse Barton
How do distal radius fractures present clinically?
What investigations are carried out for suspected distal radius fractures?
Presentation =
Very common, bimodal distribution
Often present with clear mechanism of falling onto affected area, swelling and visible deformity
Commonest presentation is dorsal displacement due to fall on outstretched hand
Investigation =
Plain radiographs – PA/lateral views to assess fracture type
Thorough clinical examination to avoid associated injuries
How can distal radius fractures be managed?
What is the goal of operative management?
Cast/splint =
Temporary treatment for any distal radius fracture – reduction of fracture and placement into cast until definitive fixation
Definitive if minimally displaced, extra articular fracture
MUA (manipulation under anaesthetics) and K-wire =
For fractures that are extra-articular but have instability, particularly in children that are prone to displacing it later on, MUA in theatre with K-wire fixation can be used. Wires can then be removed in clinic post-op
ORIF (open reduction internal fixation)
Surgery to fix severely broken bones
Any displaced, unstable fractures not suitable for K-wires or with intra-articular involvement may benefit from open reduction internal fixation with plate and screws
Goals = restore articular surface congruency, radial inclination, radial height and volar tilt
Case 4 - 20M
Drunk student fell on his wrist
What does the x-ray show?
Scaphoid fracture
What are the 8 carpal bones?
First row (lateral to medial) = Scaphoid Lunate Triquetrum Pisiform
Second row (lateral to medial) = Trapezium Trapezoid Capitate Hamate
Some Lovers Try Position That They Can’t Handle
If struggling remember ‘trapeziUM under thUMb’
How are scaphoid fractures caused?
How do they present clinically?
Commonest carpal bone injury, usually young patients
Typically a fall backwards onto their hand, but think in any distal radius
Presents clinically as =
Pain
Swelling
What clinical examinations and investigations are carried out for a suspected scaphoid fracture?
What is difficult about scaphoid fractures?
Clinical Examinations =
Anyone with FOOSH or with distal radius fracture should have scaphoid exam
Palpation of anatomical snuffbox, scaphoid tubercle or telescoping of thumb
Investigation =
Plain radiographs difficult to assess – request scaphoid views
Delayed radiographs if normal but clinical suspicion
Consider CT/MRI if still concerned
Often missed as they do not show up on xrays but often have interrupted blood supply of proximal pole leading to avascular necrosis = palpation in the clinical exam v. important
What is the management for a scaphoid fracture?
Displaced fractures =
Retrograde blood supply means high risk of non-union/AVN of proximal pole
Most displaced fractures disrupt this and therefore ORIF usually undertaken
Undisplaced fracture =
Can be treated conservatively in a scaphoid cast
Length of time to heal can be long, some surgeons opt for fixation as a result
