T&O - Fractures Of The Distal Radius and Shoulder Dislocations

Question 1

What is a Colles fracture?

Answer 1

• Colles: extra-articular fracture of distal radius (within an inch and half of joint) with dorsal displacement and radial shift of distal fragment + in rotational injuries, ulna styloid may also get pulled off by its attachment to the triangular fibrocartilagenous disc (MOI = FOOSH)

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Question 2

Colles fracture: Mx and Rx

Answer 2

◦ Assess neurovascular function: median nerve and radial artery lie very close to radius
◦ If displaced: correct deformity (manipulation) under either local (haematoma block), regional (Bier’s block) or GA
◦ Colles plaster: elbow to metarcaropophalangeal joints + thumb metacarpal

Question 3

Colles fracture: complications

Answer 3

malunion, median nerve problems, stiff/frozen shoulder, tendon rupture, Sudek’s atrophy, carpal tunnel syndrome

Question 4

What is a Smith’s Fracture?

Answer 4

• Increased volar tilt (>11 degrees) of distal fragments
• Fracture of distal radius with volar displacement and angulation of distal fragment

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Question 5

What is a Barton fracture?

Answer 5

• Fracture dislocation where distal radial fracture is oblique and extends into wrist joint (intra articular fracture)
• Can get either volar or dorsal Barton

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Question 6

Which distal radius fracture require operative intervention?

Answer 6

• Intra-articular
• Volar fragments (smith’s)
• Dorsal fragments with inadequate reduction of comminution

Question 7

What three radiological features to you look for when interpreting wrist fractures?

Answer 7

Features of adequate reduction: 11mm radial height, 22 degrees radial inclination and 11 degrees of volar tilt

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Question 8

Scaphoid fractures: clinical features

Answer 8

FOOSH, Pain in anatomical snuffbox, pain on telescoping thumb.

Question 9

Scaphoid fractures: specific Mx

Answer 9

• If clinical Hx and exam suggest scaphoid fracture, treat as such even if X-ray is normal
• Place wrist is scaphoid plaster (beer glass position)
• If initial X-ray is -ve, return pt in 10 days for re X-ray
• Must be in plaster for 6 weeks, if mal-united, can do further 6 weeks or ORIF (single screw) + bone graft

Question 10

What are the borders (in anatomical position) and contents of the anatomical snuffbox

Answer 10

• Medial border: extensor pollicis Longus
• Lateral border: extensor pollicis brevis and abductor pollicis Longus
• Contents: superficial branch of radial nerve and radial artery

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Question 11

Scaphoid fractures: specific complications

Answer 11

-AVN: blood supply enters bone distally - proximal fragments at risk of AVN (esp if displaced fracture) - pt has pain and wrist stiffness

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Question 12

Supracondylar fractures of the humerus: presentation

Answer 12

◦ Most common in children, esp after FOOSH - elbow swollen and semi flexed in position
◦ Distal fragment: usually displaces backwards + proximal numeral edge may compress the brachial artery or median nerve.

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Question 13

Supracondylar fracture: what is key in Mx?

Answer 13

Check for neurovascular damage (check radial pulse and median nerve territory)
-Ulnar nerve and radial can also be damaged if the fragments displace weirdly

Question 14

Supracondylar fracture: Rx for displaced and undisplaced

Answer 14

◦ Undisplaced: collar and cuff (with very flexed arm) or back slab - 3 week immobilisation
◦ Displaced: needs manipulation under GA (MUA- manipulation under anaesthesia) +position held in place by K wires + Collar and cuff or back slab applied with arm fully flexed

Question 15

Supracondylar fracture: risks associated with the injury

Answer 15

◦ compartment syndrome (check for pain on passive extension), angular deformities
◦ Neurovascular injury: brachial artery, radial nerve, median nerve (esp anterior interosseus branch- which supplies FPL, lat half of FDP and pronator quadratus)
◦ Gun stock deformity: valgus, varus and rotational deformities in the coronal place that do not remodel and lead to cubital varus

Question 16

Shoulder dislocation: why does it dislocate? What are the muscles of the rotator cuff? Which dislocations are most common?

Answer 16

• Most mobile of all joints
• Rotator cuff muscles: supraspinatus, infraspinatus, teres minor and subscapularis
• 95% are anterior dislocations: direct trauma, falling on hand where humerus is driven forward teaching capsule of joint.

Question 17

Shoulder dislocation: general presentation

Answer 17

◦ Shoulder contour lost - appears square
◦ Bulge in infraclavicular fossa: humeral head
◦ Arm supported in opposite hand
◦ Severe pain

Question 18

Shoulder dislocation - specific Mx

Answer 18

◦ Check for neurovascular deficit: axillary nerve - regimental badge area
◦ Do AP and trans-scapular view to see direction of humeral head

Question 19

Shoulder dislocation: Rx

Answer 19

• Reduce and rest in sling for 3-4 weeks, then rehabilitate with physio
• Avoid abduction and external rotation (eg throwing baseball)

Question 20

Which is which?

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Answer 20

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Question 21

What is the aetiology of posterior dislocation?

Answer 21

Caused by direct trauma, epilepsy and electrocution: will show light bulb sign b/c greater tuberosity isn’t seen - must be reduced by specialist