Surgery: Upper Limb (Orthopedics) Flashcards
(4) general types of fracture
(re to underlying bone pathology)
- osteoporotic fracture → occurs with minimal trauma to the bone
- pathological fracture → occurs with no trauma
- stress fracture →when prolonged, unaccustomed activity with no specific trauma
- usually, fractures occur with a significant trauma, when the underlying bone quality is normal
What’s that?
Stress fracture
What’s that?
Pathological fracture
(underlying abnormal bone structure)
Bone structure
What muscles insert at the humerus?
- Pectoralis Major
- Deltoid
- Coracobrachialis
(insertion = attachment site that moves when the muscles contract; usually distal to the body)
What muscles the humerus is the origin of? (3)
- Brachialis
- Biceps
- Brachioradialis
(origin = attachment site that doesn’t move when muscles contract; usually proximal to the body)
What nerves run along/close to the humerus?
- Median and Ulnar→ run along the shaft (protected by muscles)
- Radial Nerve → in direct contact along spiral groove;14 cm proximal to lateral epicondyle
Mode of injury and the resulting fracture
- Direct Trauma
- Indirect Trauma
- Direct Trauma → transverse fracture
- Indirect Trauma (arm wrestling) →spiral fracture
Mode of injury and the resulting fracture
- Fall on outstretched hands or RTA
- Minimal or no trauma
- Fall on outstretched hands or RTA → high-velocity comminuted fractures
- Minimal or no trauma → pathological fractures (osteoporosis or metastatic deposits)
Name tyes of fractures (picture)
What clinical examination of a suspected fracture should involve?
- General Exam to assess for other associated injuries (ATLS protocol in polytrauma patients)
- Specific examination of affected limb in isolated injury: examine joint above and below, assess overlying skin for laceration / compromise
- Assess distal neurovascular compromise
What imaging techniques should we use to investigate fractures?
- Plain X-rays usually satisfactory AP and lateral views
- Very rarely CT scan to identify anatomy in complex fractures
- MR scan and bone scan in pathological fractures
(In pathological fractures blood workup to assess serum calcium levels and try to identify primary malignancy)
Initial fracture of upper limb management
- Pain relief
- Splintage in cuff and collar or broad arm sling
- X-ray examination
- Temporary splintage till definitive management can be planned by senior intervention
Definitive management of humeral fractures
- Conservative
- Splintage in Sugar Tong Humeral Brace
- Regular monitoring with serial check x-rays
- Adjustment of splint which can get loose as swelling reduces with time
- Intervene surgically if satisfactory alignment is difficult to maintain
What’s a functional brace used for?
Functional brace → conservative treatment for humeral shaft fractures
- Indications
- indicated in vast majority of humeral shaft fractures
once swelling has reduced. Suitable for most mid-shaft humeral fractures
Criteria for functional humeral brace use
criteria for acceptable alignment include:
- < 20° anterior angulation
- < 30° varus / valgus angulation
- < 3 cm shortening
What are definitive indications for surgery in a humeral fracture? (6)
Definite indications for surgical treatment:
- Open fractures
- Presence of neurovascular injury
- Segmental fractures
- Polytrauma
- Floating elbow (when there is fracture of humerus as well as forearm) or floating shoulder (fracture humerus and fracture clavicle or scapula)
- Adequate alignment is difficult to maintain (e.g. transverse fractures)
Intramedullary Nailing
- types (2)
- indications (3)
- disadvantages (as compared to plating)
Intramedullary Nailing
- Can be done anterograde or retrograde
- Indicated in cases with pathological fractures, segmental fractures and very osteoporotic fractures
Is inferior to plating in terms of union rate and complication rates
Compression plating
- advantages compared to nailing
Compression plating
- Method of choice for fixing humeral shaft fractures
- Better union rate and lower complication rate compared with nailing
Complications of surgical treatment of the fractures (4)
- Infection
- Delayed union
- Non- union
- Nerve damage (radial nerve palsy)
How long does it take for the humeral fracture to heal?
8 - 10 weeks
What’s needed to be done in case of non-union?
Further surgery with internal fixation and bone grafting needed in cases with non-union
How most humeral shaft fractures are treated?
Conservatively → collar and cuff for three weeks
Which nerve involvement should be checked before and during treatment for humeral shaft fracture?
Radial nerve involvement
Management of the fracture of the clavicle
Conservative treatment
- broad arm sling for 3 weeks
- analgesia
*surgical treatment with ORIF is only needed when there is an open fracture or neurovascular compromise
What does the abbreviation ORIF mean?
Open Reduction Internal Fixation
What is a possible neurovascular compromise with fractures of the clavicle?
neurovascular compromise of a distal limb → rare but may damage: brachial plexus and subclavian artery
Presentation of a patient with a fracture of the humerus
- pain
- tenderness
- swelling
- deformity
- inability to move the shoulder
Is neurovascular compromise common in the fractures of surgical neck of the humerus?
No, because these fractures are extracapsular → blood supply is not disturbed (avascular necrosis is rare)
Is neurovascular compromise common in the fractures of anatomical neck of the humerus?
High risk of avascular necrosis
What to assess with the fracture of the proximal humerus?
Deltoid sensation → to assess for axillary nerve injury
What are (3) most common wrist&hand fractures?
- Colles Fracture
- Scaphoid Fracture
- Boxer’s Fracture
Wrist anatomy (bones)
Anatomy of the hand (bones)
Colle’s fracture
- anatomical location and deformity
the distal end of the radius + dorsal angulation
Colle’s fracture
- mechanism of injury
- common in what group of patients
Mechanism: following a FOOSH
Common group: women over 50 y old (osteoporosis)
What’s that?
Colle’s fracture
Management of Colle’s fractures
- Reduction of the fracture under regional anaesthesia (Bier’s block) or LA (haematoma block) → to reverse deformities
*radiographs to confirm satisfactory reduction
- Plaster backslap (from the elbow to metacarpophalangeal) for 6 weeks
Possible complications of Colle’s fracture
- carpal tunnel syndrome
- mal-union → persistent dinner fork deformity
- stiffness
- rupture of extensor pollicis longus
Indications for surgical management of Colle’s fracture
- intra-articular involvement
- failed reduction
- mal-union
Smith’s fracture
- How does it look like?
- Management
- reverse Colle’s → anterior angulation and tilt
*it is uncommon
Management:
manipulation under anaesthesia and a plaster cast above the elbow for 6 weeks
What is fractured in a Chauffeur’s fracture?
Fracture of radial styloid
What’s most frequently fractured carpal bone?
Scaphoid
Possible clinical findings in a scaphoid fracture (3)
Tender anatomical snuffbox may be the only sign
What’s the danger with a scaphoid fracture?
Scaphoid has a retrograde blood supply ( enters via distal end) → a complete fracture may disturb a blood supply to proximal end → avascular necrosis
What investigations to do for a suspected scaphoid fracture?
- Four x-ray views (‘scaphoid series’)
- it may not be visible at early stage
*variation in the choice of when and how to re-image for suspected scaphoid fracture. Repeat plain x-ray, isotope bone scans, CT and MRI are all used
(MRI as imaging as second line)
When to suspect and how to manage a scaphoid fracture?
- even with series of x-ray imaging, a scaphoid fracture may not be seen
- therefore, suspect if there is tenderness over the anatomical snuffbox
Management:
- apply scaphoid plaster (from the elbow to knuckles)
- repeat x-ray at 2 weeks (bone may be needed) → if this show fracture → plaster cast remain for further 8 weeks
- if the fracture has not united after 12 weeks → internal fixation is needed
Complications of scaphoid fracture
- Non-union
- Malunion
- Osteoarthritis
- Scapho-lunate disassociation
- Avascular necrosis due to interruption of blood supply by fracture
What’s the most common metacarpal fracture?
Boxer’s fracture
What’s Boxer’s fracture?
- Fracture of the 5th metacarpal neck with palmar displacement of the metacarpal head
- Transverse fracture after striking a hard object with a clenched fist, i.e. a punch
Clinical features of Boxer’s fracture
Management of a boxer’s fracture
- if sustained in a fight consider other injuries
- antibiotics for open wounds
- x-ray should be examined for foreign bodies such as glass or teeth
- most fractures will heal well with minimal immobilisation or splintage
- Angulation of > 45 degrees or rotation of > 20 degrees may require operative fixation with percutaneous wires
- T&O / Hand Clinic follow-up
Case 1
What is the initial management?
The initial management should be based on ATLS principles:
- Acute control of airway (A), breathing (B), and circulation (C)
- Prevention of hypoxia
- Prevention of hypotension
- A brief initial neurologic evaluation, including the Glasgow Coma Scale (GCS) (D), assessment of the pupils, and an evaluation for any focal deficit
- Assessment of the cranium and face for external injuries
- Evaluation of the spine for deformities and / or open abnormalities
- Concomitant head-to-toe evaluation for other life- or limb-threatening injuries (E)
How should you initially assess that arm clinically?
- initial inspection → look for any open wounds, penetrating injuries or marked deformities
- a quick but thorough neurovascular examination should be done and recorded
- Any open wounds should be addressed (e.g. dressed, antibiotics, anti-tetanus cover etc.)
- Analgesia or sedation should be given
- The fracture should be reduced and stabilised with a back-slab immobilising the joint below (elbow) and above (shoulder)
- A repeat neurovascular and radiological assessment should be made and recorded in the notes
Case 1
How would the fracture be assessed (after initial/clinical examination)?
After clinical examination → the fracture should be assessed radiologically
- Clear AP and lateral radiographs of the humerus pre and post-reduction would be taken
- The Joint above and elbow would also be assessed both clinically and radiologically
Case 1
Describe that fracture
This fracture is:
- comminuted (more than one fragment)
- transverse (fracture pattern)
- 100% displaced (no end to end contact)
- in the mid diaphyseal region of the left humerus
Case 1
What would be definitive management?
Open reduction internal fixation (ORIF) with plate fixation (absolute stability-primary bone healing)
Case 1
Is that the x - ray of ORIF with a plate fixation?
No
X-ray 2 shows an intramedullary nail fixation and this is NOT the optimal fixation method for the fracture from case 1
Possible complications of nail fixation management
- restriction of shoulder movements
- risk of delayed union
- rotator cuff violation /naruszenie/
- adhesive capsulitis
Impairment of shoulder function with the antegrade interlocking nails could be because of impingement due to proximal migration of nail
Case 2
- What is the most likely metabolic or endocrine abnormality contributing to this patient’s presentation?
- What other conditions should you consider?
- osteoporosis
- cancer → either metastatic or primary bone cancer
How to investigate for osteoporosis and what value defines it?
- To assess the actual bone mineral density → dual-energy X-ray absorptiometry (DEXA) scan is used
- The DEXA scan looks at the hip and lumbar spine
- If either have a T score of < -2.5 then treatment is recommended
T score
> -1.0 = normal
-1.0 to -2.5 = osteopaenia
< -2.5 = osteoporosis
What is T score and what is Z score in DEXA scan?
- T score: based on bone mass of young reference population
- T score of -1.0 means bone mass of one standard deviation below that of young reference population
- Z score is adjusted for age, gender and ethnic factors
T score
- > -1.0 = normal
- -1.0 to -2.5 = osteopaenia
- < -2.5 = osteoporosis
What other investigations would you perform?
- Bloods: FBC, U+E, Calcium and 25 hydroxyvitamin D level
*Low 25 hydroxy vit D in patients sustaining low energy fractures needs further investigation
- Dexa Scan (Dual Energy X-ray Absorptiometry)
- CT scan to assess boney union
Case 2
Can we consider conservative management only for this patient?
Conservative managemen
- the patient is 80 years old and patient-specific risk factors need to be taken into consideration → possibly a number of co-morbidities that would make surgery extremely high risk
- The activity level of the patient should also be considered → If the patient is a low demand patient, i.e. nursing home resident, then conservative management with regular analgesia and physiotherapy is an option
Case 2
May this patient be considered for surgery?
- patient has to fulfil certain criteria in order to be considered for surgical intervention
- CT scan / radiographs and clinical examination must show signs of a painful non-union which is affecting the patient’s daily life
- patient and patient’s family would need to be counselled on the risks of surgery and whether it is suitable
- If the patient has minimal co-morbidities and is independent of all activities of daily living, surgical management by open reduction internal fixation using a locking plate construct may be offered
Case 2
What impact such an injury could have on this patient. What assessments would you do and which agencies might you wish to consider involving?
- This injury has a large impact on the patient’s life: there will be a long period (6-12 months) of rehabilitation. This may impact her independence and subsequent living situation
- She will firstly need to be assessed by physiotherapy and occupational therapy (OT) to quantify her social needs
(Living adaptations and care packages will need to be introduced or re-evaluated)
- Social workers liaise with physiotherapy, O.T and the family to create the best social and care package for the patient and her needs
Case 3
Describe what you can see
- fracture at the waist of the right scaphoid
- showing signs of proximal pole sclerosis indicating avascular necrosis
Why does avascular necrosis may occur with scaphoid fractures?
- The blood supply to the scaphoid is retrograde → it comes from distal to proximal
- Dorsal carpal branch of the radial artery provides 70% and superficial palmar branch of the radial artery provides 30%
- If this blood supply is disrupted, the more proximal fracture has the highest non-union / AVN rate
What can happen if a scaphoid fracture goes undiagnosed?
- Undiagnosed and untreated scaphoid fractures can go into non- / malunion → increased risk of complications such as arthritis in the wrist and Scaphoid Non-Union Advanced Collapse (SNAC wrist) as the biomechanics of the wrist do not function properly
- This will need more complex orthopaedic surgery and sometimes salvage procedures which carry a poor functional outcome
- if it is patient’s dominant hand, it will cause issues with his grip strength and overall function
Difference beteween Galeazzi and Monteggia fractures
- Monteggia fracture → ulnar fracture with dislocation of radial head
- Galeazzi → radial fracture with dislocation of distal radioulnar joint
Management of:
- Monteggia and Galeazzi fractures
Both → ORIF with plates or intramedullary nail
