Shoulder and Humeral Fractures Flashcards
How are clavicle fractures managed?
Middle third fractures:
- Most heal with sling (3-4 weeks) as mostly undisplaced/mildly displaced.
- Consider surgery if severely displaced and shortened >2 cm (ORIF).
Distal/lateral third fractures:
- Greater risk of non-union/needing surgery.
- ORIF.
How are acromioclavicular sprains managed?
• AC joint sprains usually treated non-operatively
• Usually only require surgery if >50% displacement
(implying damage to coracoclavicular ligaments
as well), and significant ongoing pain (beyond 2-3
months) as most settle with time.
• Surgery involves a risk of major N/V injury, so
usually only required in professions with “over-
head” work e.g. electricians.
What is the typical mechanism/aetiology of shoulder dislocation?
- FOOSH
- High energy
- Usually dislocated anteriorly
Are shoulder dislocations typically anteriorly or posteriorly dislocated?
Anteriorly
What are the important components of examining a dislocated shoulder?
• Neurovasculature: axillary nerve injury (regimental badge area sensation) or brachial plexus
– (always document neuro exam)
• Open/closed
• Other sites of injury (e.g same limb)
What imaging is appropriate in shoulder dislocation? Important considerations?
- ALWAYS get 2 views
- AP & AXIAL OR VELPEAU VIEW
- (AP & Y-scapular views can both miss dislocation)
+/- other scans
– High risk of rotator cuff tear during dislocation (especially if aged over 60) so assess clinically +/- USS early in follow-up
– If the greater tuberosity (AKA greater tubercle) is detached, the rotator cuff muscles have usually gone with it!!
– In younger patients, recurrent dislocation which was first caused by trauma should be considered for MR arthrogram for possible glenoid labrum detachment
What X-ray views must you get in shoulder dislocation?
- AP
- Axial or Velpeau view
(AP and Y-view can miss shoulder dislocations)
What other imaging modalities may be used in shoulder dislocation cases?
– High risk of rotator cuff tear during dislocation (especially if aged over 60) so assess clinically +/- USS early in follow-up
– If the greater tuberosity (AKA greater tubercle) is detached, the rotator cuff muscles have usually gone with it!
– In younger patients, recurrent dislocation which was first caused by trauma should be considered for MR arthrogram for possible glenoid labrum detachment
How is shoulder dislocation managed?
- Closed reduction with sedation (MUS) maintainted in a sling for 4-5 weeks (to minimise risk of recurrence)
- Closed reduction with GA (MUA) maintained in a sling for 4-5 weeks (to minimise risk of recurrence)
- Open reduction +/- internal fixation if fracture contributing to instability
What are the risks of shoulder dislocation management?
• Risk of injury to axillary nerve (regimental badge
area sensation) or brachial plexus
• Risk of rotator cuff tear, or labral injury
In shoulder injuries with pain and no fracture; what MUST be considered as a differential?
Rotator cuff injuries
NB/if functioning rotator cuff cannot be proven by clinical examination - have a low threshold for URGENT USS or MRI. Delay of diagnosis can make acute cuff repair more difficult and less successful.
What is the typical mechanism/aetiology of proximal humeral fractures (humeral neck fractures)?
- Usually FOOSH
- Low energy
- Osteoporotic bone
What are important components of examining a proximal humeral fracture?
- Neurovasculature: axillary nerve
- Open/closed
- Other sites of injury in same limb
What imaging is appropriate in proximal humeral fractures?
AP & axial/velpeau X-rays
+/- other scans (CT rarely if comminuted & displaced)
How are proximal humeral fractures managed?
- Undisplaced: SLING 5-6 weeks, weaning out gradually from 3 weeks
- Displaced or comminuted (multiple fragments risk for AVN - from blood supply damage): ORIF (usually with locking plates/philos)
- Unreducible: hemiarthroplasty
What is the typical mechanism/aetiology of humeral shaft fractures?
- FOOSH
- Low energy
- Elderly
- Osteoporotic
- High energy injuries in younger patients
What important components are there to consider in examining a humeral shaft fracture?
• N/V: radial nerve
– Most radial nerve injuries resolve after several months
– Always reassess nerves after new backslab/brace/surgery
• Open/closed, +/- Other sites of injury (e.g same limb)
What imaging is appropriate for humeral shaft fractures?
X-rays : AP & lateral humerus
What angulation of the shaft of the humerus is acceptable?
Up to 15 degrees
How are humeral shaft fractures managed?
- Undisplaced/mildy displaced: Bohler-U backslab for 1-2 weeks then humeral brace until 8-12 weeks post-injury
- GA closed reduction (MUA): intramedullary nail rare (rotator cuff/radial nerve injury risk) - mainly for pathological fractures
- GA open reduction internal fixation (ORIF) - with identificaiton and protection of radial nerve
Why are Bohler-U backslabs used in managing undisplaced/mildly displaced humeral shaft fractures in first 1-2 weeks?
Allows for early swelling
What is the typical mechanism of distal humeral fractures?
- FOOSH
- Elderly
- Osteoporotic
- High energy in younger patients
What are important considerations in the examination of a distal humeral fractures?
- N/V: all nerves for forearm especially radial & anterior interosseous nerve (branch of median)
- Open/closed; other sites of injury (e.g same limb)
What imaging is appropriate in distal humeral fractures?
X-rays: AP & lateral elbow; +/- CT if comminuted
How are distal humeral fractures managed?
- Undisplaced: no reduction; long-arm cast.
- Displaced/intra-articular: GA closed reduction in CHILDREN only with per-cutaneous K-wires to maintain
GA ORIF usually required in adults.
Unreducible: rare and requires total elbow replacement.
How are undisplaced supracondylar fractures managed in children?
3 weeks in long arm backslab with weekly X-rays
How are displaced supracondylar fractures managed in children?
Urgent MUA & K-wiring
What IMPORTANT considerations are there in supracondylar fractures in children?
• Risk of injury to brachial artery & nerves (especially anterior
interosseous nerve): document pulses, not just perfusion!
• Discuss all with orthopaedics, & do not attempt reduction
without their agreement due to risk of N/V damage
What is the usual mechanism of elbow dislocation?
FOOSH
What important components are there when examining a dislocated elbow?
• N/V: all nerves for forearm especially radial & anterior interosseous nerve (branch
of medial)
• Open/closed, Other sites of injury (e.g same limb)
What imaging is appropriate in elbow dislocation?
X-rays: AP & lateral elbow , +/- CT if also fractures or joint not congruent e.g. fragment in joint
How is elbow dislocation managed?
Early reduction essential
• Stability less likely if also fractures e.g. radial head, coronoid, or collateral ligament
tear
• Any joint incongruity is unacceptable, fractures usually require internal fixation to
achieve stability
