ortho - 1 Flashcards
what is the classification of clavicular fractures?
Allman classification system
type 1 - fracture of middle of the clavicle (most common) - generally stable
type 2 - fractures involving the lateral third of the clavicle - if displaced often are unstable
type 3 - medial third (least common) - can be associated with neurovascular compromise, pneumothorax and haemothorax
clinical features of clavicular fracture?
sudden onset localised severe pain made worse on active movement of arm
nearly always following trauma
focal tenderness and deformity
look for open injuries and threatened skin
ensure to check neurovascular status of upper limb
investigations for clavicular fracture?
plain film AP and modified axial radiographs
CT is rarely indicated
how are clavicle fractures managed?
most can be treated conservatively
initial treatment is with a sling
early movement of shoulder is recommended to prevent frozen shoulder - healing time is usually 4-6 weeks
open fractures need surgical intervention
if fractures fail to unite and ORIF will be needed - usually 2-3 months post injury
what muscles make up the rotator cuff?
supraspinatus (abduction) infraspinatus (external rotation) teres minor (external rotation) subscapularis (internal rotation)
what joint does the rotator cuff muscles support and rotate?
glenohumeral joint
how are rotator cuff tears classified?
either acute (lasting <3 months) or chronic (lasting >3 months) tears.
either partial thickness or full thickness tears.
> Full thickness tears can be further classified into small (<1cm), medium (1-3cm), large (3-5cm), or massive (>5cm or involves multiple tendons) tears.
risk factors for rotator cuff tears?
age trauma overuse repetitive overhead shoulder motions BMI>25 smoking DM
what are the clinical features of rotator cuff tears ?
pain over the lateral aspect of the shoulder
inability to abduct arm above 90 degrees
tenderness over the greater tuberosity and subacromial bursa regions
what are the specific tests to look for rotator cuff tears and elucidate which tendons are affected?
Jobe’s test (the ‘empty can test’; tests supraspinatus)
Gerber’s lift-off test (tests subscapularis) – internally rotate the arm so the dorsal surface of hand rests on lower back.
Posterior cuff test (tests infraspinatus and teres minor) – the arm positioned at patient’s side, with the elbow flexed to 90°. The patient is instructed to externally rotate their arm against resistance.A positive test is present if there is weakness on resistance.
differentials for rotator cuff tears?
fracture
persistent glenohumeral subluxation
brachial plexus injury
radiculopathy
investigations for rotator cuff tears ?
plain XR to exlude fracture
USS to establish presence of tear and size of tear
MRI can also be used
management of rotator cuff tears?
conservative management is preferred in patients who are not limited by pain or loss of function or if they are unsuitable for surgery - analgesia and physiotherapy, corticosteroid injections into the subacromial space can be trialled
Surgical - large and massive tears or if they remain symptomatic despite conservative
prognosis with surgical repair is very good
what is the main complication of rotator cuff tears?
adhesive capsulitis -leading to stiffness of the glenohumeral joint
what is the most common site of shoulder fracture?
the proximal humerus
(occurs usually in elderly when they fall onto and outstretched hand - usually in the context of osteoporosis)
if in younger patients and high energy traumatic injury there may be associated soft tissue or neurovascular injuries
RF for shoulder fracture?
osteoporosis female gender early menopause prolonged steroid use recurrent falls frailty
clinical features of shoulder fracture?
pain around upper arm and shoulder
restriction of movement - inability to abduct arm
swelling and bruising of shoulder
due to close proximity of axillary nerve and circumflex vessels it is important to check the neurovascular status of the arm
what would damage to the axillary nerve result in?
loss of sensation of the lateral shoulder (regimental badge area)
loss of power in deltoid muscle
investigations for shoulder fracture?
any trauma - urgent bloods including a coagulation and group and save
plain XR
work up bloods to look for cause. - serum calcium and myeloma screen
CT may be done for pre-operative planning
what classification is used for shoulder fractures?
the Neer classification system (used to characterise proximal humeral fractures) - based on the relationship between 4 main segments of the proximal humerus:
Greater tuberosity
Lesser tuberosity
Articular segment (anatomical neck)
Humeral shaft (surgical neck)
what is the management for shoulder fractures?
most managed conservatively
immobilization initially with early mobilisation including pendular exercises at 2-4 weeks post injury
a sling that allows their arm to hang - the gravity on arm will aid the reduction of the fragments of most humeral fractures
surgery - needed when displaced, open or neurovascularly compromised fractures
multiple segment injuries - they may have open reduction internal fixation (ORIF) or intramedullary nailing
hemiarthroplasty or reverse shoulder arthroplasty are options
complicaitons of shoulder fractures?
reduced range of motion
avascular necrosis of the humeral head - in such cases a hemiarthroplasty or reverse shoulder arthroplasty may be required
scapular fractures?
very rare
almost always due to high energy trauma - 2-5% mortality due to their concurrent sevre injuries
treated non-operatively
ORIF is indicated in patients with glenohumeral instability, displaced scapular neck or complex fracture patterns
what are the different types of shoulder dislocation ?
An anterior dislocation is classically caused by force being applied to an extended, abducted, and externally rotated humerus - most common
A posterior dislocation is typically caused by seizures or electrocution, but can occur through trauma (a direct blow to the anterior shoulder or force through a flexed adducted arm) - often missed
what are the clinical features of shoulder dislocation?
painful shoulder acutely reduced mobility feeling of instability asymmetry of the contralateral side loss of shoulder contours anterior bulge from head of humerus
what are the bony injuries associate with shoulder dislocation ?
Bony Bankart lesions are fractures of the anterior inferior glenoid bone, most commonly present in those with recurrent dislocations
Hill-Sachs defects are impaction injuries to the chondral surface of the posterior and superior portions of the humeral head, present in approximately 80% of traumatic dislocations
Fractures of the greater tuberosity and the surgical neck of humerus can also occur
what are the ligamentous injuries associate with shoulder dislocation ?
(Soft) Bankart lesions are avulsions of the anterior labrum and inferior glenohumeral ligament
Glenohumeral ligament avulsion
Rotator cuff injuries occur frequently in anterior dislocations; in younger patients, around a third have at least one tear
what investigations should you perform for suspected shoulder dislocation ?
XR
how are shoulder dislocations managed?
analgesia
closed reduction using the hippocratic method
*ensure to assess the neurovascular status pre and post reduction
immobilisation - with a braod-arm and rehabilitation with physio
what are the clinical features of humeral shaft fractures?
pain
deformity
due to the location of the radial nerve within the spiral groove there is a high risk of injury to it - if it is involved the patient may also complain of reduced sensation over the dorsal 1st webspace and weakness in wrist extension
**ensure to assess and document neurovasular status and assess for open wounds
what is a holstein lewis fracture?
A Holstein-Lewis fracture is a fracture of the distal third of the humerus resulting in the entrapment of the radial nerve.
The resultant neuropraxia to the radial nerve will result in loss of sensation in the radial distribution and a wrist drop deformity. Surgical management is indicated in such cases.
what investigations for humeral shaft fracture ?
XR
in severe cases - CT may be needed for pre-operatively planning
how is humeral shaft fracture managed?
re-alignmenet of the limb - usually done conservatively in a functional humeral brace
Fractures that are <20o anterior angulation, <30o varus or valgus angulation, and with <3cm of shortening are typically deemed suitable for conservative management, requiring regular follow-up with repeated plain film imaging. Around 90% of patients will go on to full union within 8-12 weeks.
surgical management: surgical fixation - open reduction and internal fixation
Intramedullary nailing may be indicated in the presence of pathological fractures, polytrauma, or severely osteoporotic bones.
what is tendinopathy?
Tendinopathy is a broad term used to encompass a variety of pathological changes that occur in tendons, typically due to overuse. This results in a painful, swollen, and structurally weaker tendon that is at risk of rupture
where can bicep tendinopathy occur?
proximal and distal bicep tendons
what are the clinical features of bicep tendinopathy?
pain - made worse with stressing the tendon and alleviated through rest and ice therapy
weakness (flexion and supination)
stiffness
loss of muscle bulk due to disuse atrophy
what specific tests can be performed for bicep tendinopathy?
Speed test (proximal biceps tendon) – The patient stands with their elbows extended and their forearms supinated. They then forward flex their shoulders against the examiners resistance Yergason’s test (distal biceps tendon) – The patients stands with their elbows flexed to 90 degrees and their forearm pronated. They actively supinate against the examiners resistance
differentials for bicep tendinopathy?
inflammatory arthropathy
radiculopathy
osteoarthritis
rotator cuff disease
how is bicep tendinopathy managed?
conservative management
analgesia and ice therapy
physio
USS steroid injections can help in unresponsive cases
Rarely, surgical options are required in refractory cases. Arthroscopic tenodesis (tendon is severed and reattached) or tenotomy (division of the tendon) for decompression are options that may be discussed with the patient if indicated.
what causes bicep tendon rupture?
These injuries typically occur following sudden forced extension of a flexed elbow.
risk for bicep tendon rupture?
previous episodes of beicep tendinopathy steroid use smoking CKD fluoroquinolone antibiotics
how does bicep tendon rupture present?
sudden onset of pain and weakness
often they will feel a pop
swelling and bruising in the antecubital fossa
a bulge may become evident in the arm - reverse popeye sign
what test can be used to identify a potential distal bicep tendon rupture?
the hook test
The elbow is actively flexed to 90º and fully supinated, the examiner attempts to ‘hook’ their index finger underneath the lateral edge of the biceps tendon (which cannot be done in a ruptured biceps tendon)
what investigations for tendon rupture?
usually a clinical diagnosis
but and USS can aid the diagnosis
how is bicep tendon rupture managed?
in lower demand patients - conservative management is the mainstay of treatment - analgesia and physio
surgical management: anterior single incision or a duel incision technique will used The operation involves forming a bone tunnel in the radius and re-inserting the ruptured tendon end
what is adhesive capsulitis?
aka frozen shoulder
a condition where the glenohumeral joint capsule becomes contracted and adherent to the humerus head
results in pain and reduced rage of movement
what are the two types of adhesive capsulitis?
Primary adhesive capsulitis (idiopathic)
Secondary adhesive capsulitis – associated with rotator cuff tendinopathy, subacromial impingement syndrome, biceps tendinopathy, previous surgery or trauma, or known joint arthropathy
what are the three stages of adhesive capsulitis?
Classically, adhesive capsulitis progresses in three stages (an initial painful stage, a freezing stage, and finally a thawing stage). However, there is little evidence to support the segregation of these phases, and that the pain associated with limitation in shoulder movement is thought to be present throughout.
what are the clinical features of adhesive capsulitis
generalised deep and constant pain of the shoulder that often disturbs sleep
joint stiffness and a reduction in function
loss of arm swing and atrophy of the deltoid
generalised tenderness
the limited range of motion will principally affecting external rotation and flexion of the shoulder
differential for adhesive capsulitis?
Acromioclavicular pathology (e.g. acriomioclavicular joint injury, acromioclavicular arthritis, glenohumeral arthritis) – a more generalised pain may be present with weakness and stiffness related to pain
Subacromial impingement syndrome (rotator cuff tendinopathy, subacromial bursitis) – may present with preserved passive movement and history of repetitive overuse/external compression of subacromial space risk factors
Muscular tear (rotator cuff tear, long head of biceps tear) – the weakness often persists when the shoulder pain is relieved
Autoimmune disease (polymyalgia rheumatica, rheumatoid arthritis, systemic lupus erythematous) – may present with a polyarthropathy and systemic symptoms
investigations for adhesive capsulitis
usually clinical
XR are generally unremarkable
MRI may show thickening of the glenohumeral joint capsule
how is adhesive capsulitis managed?
it is a self limiting condition however recurrence is common
recovery usually occurs over months to years - some will never recover full ROM
physio and appropriate shoulder exercises
management of pain with simple analgesia. glenohumeral joint corticosteroid injections may be considered
surgical options - in resistant cases - joint manipulation under general anaesthetic to remove capsular adhesions to the humerus
what is subacromial impingement syndrome?
Subacromial impingement syndrome (SAIS) refers to the inflammation and irritation of the rotator cuff tendons as they pass through the subacromial space, resulting in pain, weakness, and reduced range of motion within the shoulder.
it encompasses a range of pathology including:
- rotator cuff tendinosis
- subacromial bursitis
- calcific tendinitis
what are the different causes of subacromial impingement syndrome?
intrinsic and extrinsic mechanisms
Intrinsic mechanisms involve pathologies of the rotator cuff tendons due to tension, including:
- muscular weakness: Weakness in the rotator cuff muscles can lead to muscular imbalances resulting in the humerus shifting proximally towards the body
- overuse of the shoulder: Repetitive microtrauma can result in soft tissue inflammation of the rotator cuff tendons and the subacromial bursa, leading to friction between the tendons and the coracoacromial arch
- degenerative tendinopathy:Degenerative changes of the acromion can lead to tearing of the rotator cuff, which allows for proximal migration of the humeral head
Extrinsic mechanisms - nvolve pathologies of the rotator cuff tendons due to external compression, such as:
- anatomical factors - congenital or acquired anatomical variations in the shape and gradient of the acromion
- scapular musculature - A reduction in function of the scapular muscles, particularly the serratus anterior and trapezius, that normally allow the humerus to move past the acromion on overhead extension, may result in a reduction in the size of the subacromial space
- Glenohumeral instability: Any abnormality of the glenohumeral joint or weakness in the rotator cuff muscles can lead to superior subluxation of the humerus, causing an increased contact between the acromion and subacromial tissues
what are the clinical features of subacromial impingement syndrome?
progressive pain in the anterior superior shoulder
pain is exacerbated by abduciton
what are the examination signs that can be elicited in cases of subacromial impingement syndrome?
Neers Impingement test – The arm is placed by the patient’s side, fully internally rotated and then passively flexed, and is positive if there is pain in the anterolateral aspect of the shoulder.
Hawkins test – The shoulder and elbow are flexed to 90 degrees, with the examiner then stablising the humerus and passively internally rotates the arm, and the test is positive if pain is in the anterolateral aspect of the shoulder.
what are the differentials for subacromial impingement syndrome?
- muscle tear - e.g. rotator cuff or long head bicep tear)
- neurological pain - e.g. thoracic outlet syndrome, cervical radiculopathy, brachial plexus injury)
- frozen shoulder syndrome - adhesive capsulitis or calcific tendinitis
- acromioclavicular pathology - e.g. acromioclavicular arthritis or glenohumeral arthritis
what are the investigations for subacromial impingement syndrome?
usually clinical diagnosis MRI would show: - formation of subacromial osteophytes - sclerosis - subacromial bursitis - humeral cystic changes - narrowing of the subacromial space
what is the management for subacromial impingement syndrome?
conservative management usually - NSAIDs, regular physio
they may need corticosteroid injections in the subacromial space
Surgery - if it persists beyond 6 months without response to conservative management
who are supracondylar humeral fractures most common in?
usually in children 5-7 years
usually because of falling on an outstretched hand with elbow in extension
Due to the close proximity of surrounding neurovascular structures, injury is common and a careful thorough assessment is essential.
how does a supracondylar humeral fracture present?
recent fall or direct trauma - results in sudden-onset severe pain and reluctance to move affected arm
gross deformity and swelling
limited range of movement at elbow
It is essential to carefully examine the median nerve, the anterior interosseous nerve (the deep motor branch of the median nerve), the radial nerve, and the ulnar nerve.
Check hand for features of vascular compromise
differentials to exclude with supracondylar humeral fracture?
distal humerus fractures and olecranon fractures are important to exclude as management differs significantly
other differentials include soft tissue injury and subluxation of the radial head
what investigations would you perform for supracondylar humeral fractures?
X-ray
subtle signs on the xray include:
- posterior fat pad sign (lucency visible on the lateral view)
- displacement of the anterior humeral line
CT imaging may be useful for comminuted fractures or where intra-articular extension is suspected, which aides with surgical planning.
what classification system is used for supracondylar humeral fractures?
The Gartland classification system of supracondylar fractures is a system commonly used in clinical practice, also aiding in management planning:
Type I – Undisplaced
Type II – Displaced with an intact posterior cortex
Type III – Displaced in two or three planes
Type IV – Displaced with complete periosteal disruption
how are supraconylar fractures managed?
if there is neurovascular compromise - immediate closed reduction is required
reduction is secured with K-wire fixation
conservative management can be trialed with undisplaced fractures or minimmaly displaced which can be done with an elbow cast in 90 degrees flexion
surgical management:
- close reduction with percutaneous K-wire fixation
- open fractures warrant open reduction with percutaneous pinning
what are the complications of supracondylar fractures?
nerve palsies are common (the anterior interosseous nerve is the most commonly affected in initial injury, however ulnar nerva palsy is the most common post operative complication
malunion, some may develop cubitus varus deformity
volkmann’s contracture can occur following vascular compromise - Ischaemia and subsequent necrosis of the flexor muscles of the forearm, eventually begins to fibrose and form a contracture; this results in the wrist and hand to be held in permanent flexion, as a claw-like deformity.
where is the olecranon?
The olecranon is the region of the proximal ulna from its tip to the coronoid process. It articulates with the trochlea of the distal humerus
the olecranon is the site of insertion for the tricep muscles
what are the clinical features of olecranon fractures?
they typically present with a history of falling on an outstretched hand followed by elbow pain, swelling and lack of mobility
o/e - tenderness when palpating the posterior aspect of the elbow with a potential deformity present
inability to extend against gravity due to disruption of the tricep mechanism
what investigations would you perform for olecranon fracture?
plain XR
Generally, olecranon fractures are easily identifiable on a lateral projection and with the pull of the triceps have a degree of displacement.
CT can be useful in comlex injuries
how are olecranon fractures managed?
adequate analgesia
treatment is usually guided by the degree of displacement on imaging
Non-operative management - if displacement <2mm, - immobilisation in 60-90 degrees elbow flexion and early introduction of movement at 1-2 weeks
operative management - usually indicated for displacement >2mm - techniques such as tension band wiring or olecranon plating
what usually causes radial head fractures?
Radial head fractures typically occur via indirect trauma; with axial loading of the forearm causing the radial head to be pushed against the capitulum of the humerus. This most commonly occurs with the arm in extension and pronation.
There are complex ligament structures that can also be damaged in these injuries, which may need further clinical/imaging assessment.
what are the clinical features of radial head fracture?
A history of falling on an outstretched hand followed by elbow pain. The patient may report variable degrees of swelling and bruising at the elbow.
o/e tenderness on palpation of the lateral aspect of the elbow and radial head with pain and crepitation on supination and pronation
what are the investigations doe radial head fractures?
Xray - on the xray there is sometime an elbow effusion - elbow effusions on the lateral projection is terme a sail sign
CT can be used
what classification is used for radial head fractures?
mason classification
Mason Type 1 – Non-displaced or minimally displaced fracture (<2mm).
Mason Type 2 – Partial articular fracture with displacement >2mm or angulation.
Mason Type 3 – Comminuted fracture and displacement (a complete articular fracture).
how are radial head fractures managed?
analgesia and stabilse
Treatment is usually guided by the severity of the fracture on imaging, however ensure to check for presence of neurovascular compromise and any mechanical block of elbow motion
Definitive management can vary depending on local guidelines. However, management can be guided by Mason classification:
> Mason type 1 injuries – treated non-operatively, with a short period of immobilization with sling (less than 1 week) followed by early mobilisation
Mason Type 2 injuries – if no mechanical block then can be treated as per a type 1 injury, whilst if a mechanical block is present then these may need surgery (typically an open reduction internal fixation (ORIF))
Mason Type 3 injuries – will nearly always warrant surgical intervention, either via ORIF or radial head excision or replacement (especially in highly comminuted fractures)
what are the clinical features of an elbow fracture?
patients usually present with a high energy fall
the joint will be painful and deformed with swelling and decreased function
**a complete neurovascular examination of the upper limp is essential:
A deficit is often found in the territory of the ulnar nerve as neuropraxia of this nerve is common
A good capillary refill can be found even in those with an arterial injury, due to the elbow having a rich collateral circulation
what investigations would you perform for elbow fracture?
XR - both AP and lateral
elbow dislocations can be identified from the loss of the radiocapitellar and ulnotrochlea congruence
how are elbow dislocations managed?
closed reduction
analgesia and sedation of needed
apply an above elbow backslab once reduced to keep at 90 degrees.
if the dislocation is comlicated by a fracture, open type injury or has neurovascular compromise, and operative fixation can be considered - this involves open reduction and internal fixation of ther coronoid, radial head or olecranon with appropriate soft tissue repair
what is the terrible triad?
The Terrible Triad injury refers to an elbow dislocation with (1) lateral collateral ligament injury (2) radial head fracture (3) coronoid fracture
This combination of injuries causes a very unstable elbow and is associated with a poor outcome. The forces applied to the joint result from a fall onto an extended arm with rotation, resulting in a posterolateral dislocation. Patients are likely to have recurrent problems with instability, stiffness, and arthrosis.
Treatment revolves around operative fixation of each of the components. Radial head ORIF or arthroplasty with LCL reconstruction and coronoid ORIF. MCL reconstruction is also sometimes undertaken following intraoperative assessment.
what is olecranon bursitis?
a common inflammatory pathology of the elbow
the olecranon bursa is prone to inflammation due to its superficial position and vulnerability to pressure and trauma
most patients develop the condition die to repetitive flexion-extension movements at the elbow causing irritation of the bursa
Less common non-infective causes include gout and rheumatoid arthritis.
Less commonly, the fluid within the bursa can become infected, through a skin abrasion or puncture (most commonly from S. aureus), leading to a bursitis too.
clinical features of olecranon bursitis?
pain, redness and swelling over the olecranon
as joint capsule is not involved, range of motion is usually preserved with minimal discomfort unless at the extremes of movement (this contrasts with septic arthritis of the elbow in which any movement causes large amounts of pain)
what are the differentials for olecranon bursitis?
inflammatory arthropathies
gout
cellulitis
septic arthritis
what investigations would you perform for olecranon bursitis?
Bloods, any suggestion of rheumatological causes may warrant further specialist tests
serum urate levels should be check if anything suggests gout
plain XR will not confirm diagnosis but will aid to rule out boney injury
definitive diagnosis is from aspiration of the fluid, microscopy and culture to assess for evidence of infection and for presence of crystals
how is olecranon managed?
it depends if there is an infection or not
swelling without infection can be treated with analgesia (ideally NSAIDs) and rest.
sometimes splinting of elbow for short period is required
Occasionally if the swelling is large and causing high levels of discomfort, patients can undergo a washout in theatre
If infection present - IV Abx as per local guidlines as well as surgical drainage
what is lateral epicondylitis?
Epicondylitis is a chronic symptomatic inflammation of the forearm tendons at the elbow.
- an overuse syndrome in the elbow caused by micro-tears in the tendons attaching to the epicondyles of the elbows following repetitive injury.
what are the two common types of epicodylitis?
lateral epicondylitis (or “Tennis elbow”) and medial epicondylitis (or “Golfer’s elbow”)
lateral is most common
what are the epicondyles and what causes epicondylitis?
The medial and lateral epicondyles are small bony tuberosities on the distal end of the humerus
The common extensor tendon attaches to the lateral epicondyle, acting as the common attachment for the superficial extensor muscles of the forearm
repetitive overuse of tendons causes microtears at the origin, the tendon adapts to the multiple tears, leading to the formation of granulation tissue, fibrosis an eventually tendinosis
risk factors for epicondylitis?
occupations and hobbies that are associated with excessive use of forearm muscles - including tennis
what are the clinical features of epicondylitis?
pain in the elbow radiating down to the forearm
pain typically worsens over weeks to months
o/e - local tenderness on palpation
what are the special tests for lateral epicondylitis?
Cozen’s Test – The patient’s elbow is held flexed to 90 degrees, with one examiner’s hand held over the lateral epicondyle, whilst the other hand holds the patient’s hand in a radially deviated position with the forearm pronated. The patient is then asked to extend their wrist against resistance from the doctor
Mill’s Test – The patient’s lateral epicondyle is palpated by the examiner, whilst also pronating the patient’s forearm, flexing the wrist, and extending the elbow
what are the differentials for epicondylitis?
Cervical radiculopathy – often associated with neck pain and stiffness, as well as a sensorimotor deficit in the affected dermatome/myotome
Elbow osteoarthritis – joint stiffness, worse towards the end of the day, associated with reduced range of movement and end-range pain
Radial carpal tunnel syndrome – maximal tenderness is localised to area distal to radial head (rathe
how is epicondylitis usually investigated ?
usually clinical diagnosis
USS or MRI can be used to confirm diagnosis
how is lateral epicodylitits usually managed?
patients should modify their activities
simple analgesics and topical NSAIDs
if symptoms persist - corticosteroid injection
physio can provide longer term relief
if symptoms are not controlled through conservative management 0 open or arthroscopic debridement of tendinosis and/or release or repair of any damaged tendon insertions may be required
