T&O (Upper) Flashcards
Describe the pathophysiology of a Clavicle Fracture
Normally caused by a FOOSH
Medial segment displaced superiorly, inferior segment dislaced inferiorly
Describe the Allman classification of Clavicle Fractures
I - Fractured middle 1/3
II - Lateral 1/3
III - Medial 1/3 (associated with polytrauma, pneumothorax/haemothorax)
How do clavicular fractures present?
Sudden onset localised severe pain (worsened by movement)
How are claviular fractures managed?
- Conservatively as too superficial for metal work
- Sling until patient regains movement of shoulder (try to
early to avoid frozen shoulder - Generally heals in 4 to 6 weeks
Surgery indicated if not healed, comminuted or open
Name the four Rotator Cuff muscles and their innervation
Supraspinatus (Suprascapular Nerve)
Infraspinatus (Suprascapular Nerve)
Teres Minor (Axillary Nerve)
Subscapularis (Subscapular Nerve)
Describe the movements of the Rotator Cuff muscles
Supraspinatus - Abduction
Infraspinatus and Teres Minor - Lateral Rotation
Subscapularis - Medial Rotation
Name two ways Rotator Cuff Tears can be classified
- Acute or Chronic (>3 months)
- Can be full or partial thickness
Describe three features of a Rotator Cuff Tear
- Pain over lateral aspect of shoulder
- Inability to abduct arm over 90 degrees
- Tenderness over Greater Tuberosity
How can you test the integrity of each Rotator Cuff Muscle?
Supraspinatus - Empty Can Test
Subscapularis - Gerber’s Lift Off (dorsum on back and pushing against resistance)
Infraspinatus and Teres Minor - Posterior Cuff (abducting fists against resistance)
How do you manage Rotator Cuff Tears?
Conservative - Analgesia, Physiotherapy, Corticosteroid Injections
Surgery - If conservative has failed or if presenting after 2 weeks (can be done arthroscopically or open)
What is the main complication of Rotator Cuff Tears?
Adhesive Capsulitis
Describe the cause of an Anteroinferior and Posterior Shoulder Dislocation respectively
Anteroinferior - Force applied to extended/abducted/externally rotated arm
Posterior - Seizures/Electrocution
Describe three clinical features of Shoulder Dislocation
Pain and Reduced Mobility
Instability
Asymmetry/Flattened Deltoid
Give 3 associated injuries of Shoulder Dislocations
Bankart - Fracture of anteroinferior Glenoid
Hill Sachs - Impaction fracture to Humeral Head
Rotator Cuff Tears
Name the three XRay views used in a Shoulder Dislocation
AP
Axial
Y Scapular (useful for differeniating between anterior and posterior)
How would an Anterior and Posterior Dislocation present on an Xray?
Anterior - Humeral head is out of glenoid fossa
Posterior - Lighbulb sign
How would you manage a Shoulder Dislocation?
A to E
Analgesia
Reduction/Immobilisation (broad arm sling for two weeks)/Rehabilitation
How would a Humeral Shaft Fracture present?
Pain and Deformity (commonly after a FOOSH)
Radial Nerve Involvement (Reduced sensation in dorsal web space, weakness in wrist extension
What is a Holstein Lewis Fracture?
Fracture of distal 1/3 of Humerus
How are Humeral Shaft Fractures investigated?
AP and Lateral X-Ray films
Describe the conservative and surgical management of Humeral Shaft fractures
Conservative - Realignment and Humeral/Over elbow cast
Surgical - ORIF Plating, IM Nails
What is Biceps Tendinopathy?
Encompasses a variety of pathological changes resulting in a weaker tendon and greater risk of rupture
Presenting with pain/associated stiffness/weakness
Describe the two tests for Biceps Tendinopathy?
Speed Test - Proximal Biceps Tendon
Yergason’s Test - Distal Biceps Tendon (Queens Wave against resistance)
Describe the conservative and surgical management of Biceps Tendinopathy
Conservative - Analgesia/Ice/Physio
Surgical - Arthroscopic Tenodesis (cut and reattached) and Tenotomy (Division of Tendon)
One of the main complications of Biceps Tendinopathy is Biceps Rupture. How does this occur?
After forced extension of a flexed elbow
Describe the clinical features of Biceps Rupture
Sudden pop followed by pain and swelling
Reverse Pop-Eye feature as muscle belly retracts
Describe the surgical management of Biceps Rupture
Anterior single incision, forming a bone tunnel in radius and reinserting ruptured end
Define Adhesive Capsulitis
Glenohumeral Joint becomes contracted and adherent to Humeral Head
What are the three stages of Adhesive Capsulitis?
Initial Painful
Freezing
Thawing
Adhesive Capsulitis can be Primary (Idiopathic) or Secondary. Give 3 Secondary causes.
Rotator Cuff Tendinopathy
Subacromial Impingment
DM
Give two clinical features of Adhesive Capsulitis
Pain (deep and constant pain that may disturb sleep)
Reduced ROM
Give two differentials for Adhesive Capsulitis
Subacromial Impingment - preserved passive movement
Muscular Tear - Weakness persists when pain resolve
How would you manage Adhesive Capsulitis?
Self limiting (Physio and Shoulder Exercises)
Pain management (Paracetamol/NSAIDs/Intra-articular Steroids
Describe the surgical management of Adhesive Capsulitis
If no improvement after 3 months of Conservative Treatment/Symptoms affect QoL
Joint manipulation under General Anaesthetic and removal of capsular adhesions
What is Sub-Acromial Impingement Syndrome?
Inflammation and irritation of the tendons as they pass through subacromial space
Encompasses Rotator Cuff Tendinosis/Subacromial Bursitis/Calcific Tendinitis
The Coracoacromial Arch is formed of the Coracoid Process, Acromian and Coracoacromial Ligament. Name three structures running through the space
Rotator Cuff Tendons
Long Head of Biceps Tendon
Coraco-acormial Ligaments
State two Intrinsic and two Extrinsic causes of Sub-Acromial Impingement Syndrome
Intrinsic - Muscle Weakness, Overuse Microtrauma
Extrinsic - Anatomical abnormalities, Weak Scapular Musculature
How does Sub-Acromial Impingement Syndrome present?
Progressive pain in anterior and superior shoulder (exacerbated by abduction, relieved by rest)
Name a test for Sub-Acromial Impingement Syndrome
Hawkin’s Test - passive internal rotation of flexed arm
Describe the surgical management of Sub-Acromial Impingement Syndrome
If ongoing for 6 months without improvement
Usually arthroscopic
Supracondylar Fractures are normally a paediatric injury, how would they present?
Recent Trauma/FOOSH resulting in sudden onset severe pain
Gross Deformity
Bruising in cubital fossa
Name four nerves at risk in Supracondylar Fracture
Median Nerve
Anterior Interosseous Nerve
Ulnar Nerve
Radial Nerve
What X-Ray planes would you use to image a Supracondylar Fracture? What would they show?
AP and Lateral
Posterior Fat Pad Sign
Describe the Gartland Classification of Supracondylar Fractures
I - Undisplaced
II - Displaced with intact posterior cortex
III - DIsplaced in two or three planes
IV - Displaced with complete periosteal disruption
How would you manage Supracondylar Fractures?
I and II - Above Elbow Cast for 3-4 weeks with interim XRay at 1 week
Very Displaced II,III,IV or NV Compromise - Closed Reduction and percutaneous pinning
Any NV compromise - the above is an emergency