Injuries of shoulder and upper arm

Question 1

Classification of clavicle fracture

Answer 1

Group 1: Middle third fracture
Group 2: Lateral third fracture
Group 3: Medial third fracture

Group 2
- Neer type 1: Coracoclavicular ligament intact (prevent further displacement)
- Neer type 2: Coracoclavicular ligament torn but trapezoid ligament intact to distal regent
- Neer type 3: Intraarticular fracture

Question 2

ACJ injury classification

Answer 2

Type 1: Acute sprain of AC ligament, joint undisplayed
Type 2: AC ligaments are torn, joint sublimated
Type 3: AC and CC ligaments are torn and joint is dislocated, clavicle elevated
Type 4: Clavicle displaced posteriorly
Type 5: Clavicle very markedly upwards
Type 6: Clavicle inferiorly beneath coracoid process

Question 3

ACJ injury management

Answer 3

Indication of surgery
- Extreme prominence of clavcicle
- Posterior or inferior dislocation of clavicle
- To resume strenuous overhead activities

Modified Weaver-Dunn procedure
- Lateral end of clavcicle is excised and coracoacromial ligament is transfer to outer end of clavicle and attached by transosseous suture

Question 4

Factors of dislocation of shoulder

Answer 4

Shallowness of glenoid socket
Extraordinary range of movement
Underlying condition eg: Ligamentous laxity/ glenoid dysplasia
Sheer vulnerability of joint during stressful activities of upper limb

Question 5

X-rays of dislocation of shoulder

Answer 5

Anterior dislocation
AP view : Overlapping shadows of humeral head and glenoid fossa, head is lying below and medial to socket
Lateral view: humeral head out of line with socket

Posterior dislocation
- Head of humerus internally rotated, showing classic ‘electric light-bulb’ appearance
- empty glenoid sign

Question 6

Methods of CMR of shoulder dislocation

Answer 6

Stimson’s technique
- Patient prone with arm hanging over side of bed

Hippocratic method
- Gently increasing traction applied to arm with shoulder in slight abduction,while assistant applies firm counetrtraction to the body, towel around patient’s chest/ axilla

Kocher’s method
- Elbow bent to 90 degree, arm rotated 75 degree laterally, elbow lifted forwards and arm rotated medially

Question 7

Management of shoulder dislocation

Answer 7

Under 30 yo: Arm sling for 3/52 (Prone to recurrent)
OVer 30 yo: Arm sling for 1/52

Question 8

Causes of recurrent instability of shoulder dislocation

Answer 8

Size of Hill- Sachs lesion (posterolateral part of humerus head is crushed)
Presence of glenoid rim fracture
Soft tissues state

Question 9

Criteria for displacement for proximal humerus

Answer 9

Distance >1cm, angulation >45 degree

Question 10

Blood supply of humeral head

Answer 10

Anterior circumflex artery and ascending branch (arcuate artery)

Question 11

Risk of AVN in proximal humerus

Answer 11

Fracture at anatomical neck with medial metaphysical (calcareous spike shorter than 8mm)
Disruption of medial periostea hinge

Question 12

Management of humeral shaft fracture

Answer 12

Indication of surgery
- Severe multiple injury
- Open fracture
- Segmental fracture
- Pathologiacal fracture
- Displaced intra articular extension
- Floating elbow
- Radial nerve palsy after manipulation
- Non union
- Problemswith nursing care in dependent person

If non union due to nail distraction
- For exchange nailing and bone grafting

For segmental fracture
- external fixation

Question 13

Complication of humeral shaft fracture

Answer 13

Early
- Vascular injury- brachial artery
- Nerve injury- radial nerve (Holstein-Lewis fracture)

Late
- Delayed union and non union
- Joint stiffness