T&O - Humerus, Scaphoid Fractures, Shoulder ds, Radius, Ulna Flashcards
Scaphoid fracture: what are the borders and content of the anatomical snuff box?
Borders
- Medial: Extensor pollicis Longus
- Lateral: Extensor pollicis brevis and Abductor pollicis Longus
Contents
- Superficial branch of Radial nerve and Radial artery
Scaphoid fractures: clinical features
FOOSH
- Pain in anatomical snuffbox
- Pain on telescoping thumb
- Swollen thumb
Scaphoid fractures: Mx
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
Scaphoid fracture: identify all of the carpal bones in picture and the fracture
Carpal bones
Scaphoid fractures: complications
-
Avascular Necrosis
- Blood supply enters bone distally - proximally
- Proximal fragments more at risk of AVN (esp if displaced fracture)
- pt has pain and wrist stiffness as a result
Supracondylar fractures of humerus: presentation
- Most common in children, esp after FOOSH
- Elbow swollen and semi flexed in position
- Distal fragment: usually displaces backwards + proximal humeral edge may compress the brachial artery or median nerve
Supracondylar fracture of humerus: Key Mx
- Check for neurovascular damage (check radial pulse and median nerve territory). Ulnar nerve and radial can also be damaged if the fragments displace weirdly
-
Fracture management
- 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
Supracondylar fracture: main risks
-
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
What is the aetiology of posterior dislocation?
- Caused by direct trauma, epilepsy and electrocution
- Will show light bulb sign b/c greater tuberosity isn’t seen - must be reduced by specialist
Shoulder dislocation: Rx
- Reduce and rest in sling for 3-4 weeks, then rehabilitate with physio
- Avoid abduction and external rotation (eg throwing baseball)
Shoulder dislocation - specific Mx
- Check for neurovascular deficit:
- Axillary nerve - Regimental badge area
- Do AP and Trans-scapular view to see direction of humeral head
Shoulder dislocation: general presentation
- Shoulder contour lost - appears square
- Bulge in infraclavicular fossa: humeral head
- Arm supported in opposite hand
- Severe pain
Shoulder dislocation:
Why does it dislocate?
What are the muscles of the rotator cuff?
Which dislocations are most common?
- 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.
What three radiological features to you look for when interpreting wrist fractures?
Features of adequate reduction:
- 11mm radial height (<5mm variance)
- 22 degrees radial inclination (<5 degrees variance)
- 11 degrees of volar tilt (<5 degrees variance)
Which distal radius fracture require operative intervention?
- Intra-articular
- Volar fragments (smith’s)
- Dorsal fragments with inadequate reduction of comminution
What is a Barton fracture?
- Fracture dislocation where distal radial fracture is oblique and extends into wrist joint (intra articular fracture)
- Can get either volar or dorsal Barton
What is a Colles fracture?
- 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)
Colles fracture: Mx and Rx
- 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
Colles fracture: complications
- Malunion
- Median nerve problems
- Stiff/frozen shoulder
- Tendon rupture
- Sudek’s atrophy
- Carpal tunnel syndrome
What is a Smith’s Fracture?
- Increased volar tilt (>11 degrees) of distal fragments
- Fracture of distal radius with volar displacement and angulation of distal fragment
What is a Monteggia or Galleazzi fracture?
- Monteggia fracture: fracture of ulna shaft with dislocation of radial head
- Galleazzi: fracture of radial shaft with dislocation of distal radioulnar joint
How should you position a cast in midshaft fractures? What Rx is used for unstable fractures in children and adults?
- Fracture in proximal radius and ulna: more stable in supination
- Midshaft: neutral
- Distal: pronation *extend cast above elbow to prevent movement
Unstable fractures:
- Adults: ORIF
- Children: MUA + above elbow plaster
Important principle to remember when thinking about radius and ulna midshaft fractures
Isolated fractures of the shafts is uncommon: should always suspect associated dislocation/fracture at either prox/distal end
