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
Very Displaced II,III,IV or NV Compromise - Closed Reduction and K Wire
Describe three complications of Supracondylar Fractures
Nerve Palsies (Anterior Interosseous Nerves) Malunion (Cubitus Varus Deformity) Volkmann's Contracture - Ischaemia and necrosis of flexor muscles cause fibrosis and contraction
What is the Olecranon?
Proximal Ulna to Coronoid Process, articulating with the Trochlea of the distal Humerus
Site of insertion for Triceps Tendon
How does an Olecranon Fracture present?
FOOSH followed by elbow pain/swelling/lack of movement
Inability to extend at elbow against gravity
Generally easy to recognise clinically as the triceps displace the joint
Describe the Non-Operative Management of Olecranon Fractures
Suitable when the displacement < 2mm
Immobilised at 60-90 degrees with introduction of movement after two weeks
Describe the Operative Management of Olecranon Fractures
Proximal To Coronoid - Tension Band Wiring
Distal to Coronoid - Olecranon Plating
Describe the pathophysiology of a Radial Head Fracture
Normally a FOOSH causing Radial Head to impac against Capitulum
What is an Essex Lopresti Fracture?
Fracture of Radial Head and disruption of distal radio-ulnar joint
What planes would you XRay for a suspected Radial Head Fracture, what signs would you see?
AP and Lateral
‘Sail’ Sign due to elevation of anterior fat pad (from effusions)
Describe the Mason Classification of Radial Head Fractures
I - Non Displacement or Minimally Displaced
II - Displacement > 2mm or Angulation
III - Complete Fracture/Displaced/Comminuted
Describe the management of Radial Head Fractures
Mason I - Immobilisation with sling for a week
Mason II - No mechanical block then treated as I, if mechanical block then ORIF
Mason III - ORIF/Radial Head Excision
Give two static and two dynamic stabilisers of the Elbow Joint
Static - Humeroulnar Joint, Medial/Lateral Collateral Ligaments
Dynamic - Anconeus, Triceps Brachialis
What planes would you XRay for a suspected Elbow Dislocation, what signs would you see?
AP and Lateral
Loss of congruence of radiocapitellar and ulnotrochlear
90% Posterior
How are Elbow Dislocations (without soft tissue damage) managed?
In line traction
Immobilisation (around 2 weeks) with an above elbow backslab at 90 degrees fixed flexion
How are Elbow Dislocations (with soft tissue damage) managed?
LCL Damage - Elbow more stable in pronation
MCL Damage - Elbow more stable in supination
Give two complications of Elbow Dislocations
Early Stiffness
Stretching of Ulnar Nerve
What is the ‘Terrible Triad’?
Elbow dislocation with LCL injury
Radial Head Fracture
Coronoid Fracture
As a result of fall on an extended arm with rotation (resulting in posterlateral dislocation)
Olecranon Bursitis can have an infective or non infective aetiology. Give two non infective causes
Repetitive Flexion
Gout
How does Olecranon Bursitis present?
Pain and Swelling
Generally doesn’t affect ROM
Give 3 investigations for Olecranon Bursitis
Bloods
XRays (rule out bony injuries)
Aspiration (microscopy and culture, needle SHOULDN’T enter joint capsule as to avoid seeding)
How would you manage a Non - Infective Bursitis?
Analgesia and Rest
If swelling is large and causes enough discomfort - washout in theatre
How would you manage Infective Bursitis
IV antibiotics and surgical drainage
Potentially even Bursectomy
What is Lateral Epicondylitis (AKA Tennis Elbow)?
Chronic symptomatic inflammation of Common Extensor origin as it inserts at Lateral Epicondyle
Caused by microtears from repetitive use (microtears - granulation tissue - fibrosis - tendinosis)
Give four clinical features of Lateral Epicondylitis
Elbow Pain (radiating down forearm)
Weakened Grip
Localised Tenderness
No impact on ROM
Name a clinical test for Tennis Elbow
Cozen’s Test (Elbow flexed at 90 degrees, lateral epicondyle palpated while wrist extended against resistance)
Generally the management of Tennis Elbow is conservative, describe the surgical management.
Can be open or arthroscopic
If more than 50% damaged - tendon transfer
What is Medial Epicondylitis (AKA Golfer’s Elbow)?
Chronic symptomatic inflammation of Common Flexor origin as it inserts at Medial Epicondyle
Caused by microtears from repetitive use (microtears - granulation tissue - fibrosis - tendinosis)
What is a Distal Radius Fracture? State the three subtypes.
Fracture occurring through the distal metaphysis of the radius (with or without articular involvement)
Colles, Smiths, Bartons
Describe the features of a Colles Fracture
- Following a fall on a dorsiflexed hand
- Dorsal angulation of distal segment
- DINNER FORK
Name a complication of a Colles Fracture
Avulsion fracture of Ulnar Styloid
What is an Avulsion Fracture?
A fracture at part of the bone where a tendon/ligament inserts due to pull of it
Describe the features of a Smiths Fracture
- Following a fall on a palmar flexed hand
- Volar/Palmar angulation of distal segment
- GARDEN SPADE
What is a Barton’s Fracture?
INTRA-ARTICULAR fracture of distal Radius and associated dislocation of Radio-Carpal joint
How would you assess for Median Nerve damage?
Thumb Abduction
How would you assess for Anterior Interosseous Nerve Damage?
‘Okay’ Sign
How would you assess for Ulnar Nerve Damage?
Thumb Adduction
5th Digit Sensation
How would you assess for Radial Nerve Damage?
Thumb Extension
Dorsal 1st Webspace
In order to reduce a distal radius fracture, local anaesthetic is likely required. Describe two methods
Haematoma Block (Insert straight into fracture site, and check by withdrawing blood)
Biers Block (Use a cuff to temporarily reduce blood supply to the arm and add the LA to the venous system)
How would you ‘Stabilise’ a distal radius fracture?
Stable - Below elbow backslab
Unstable - ORIF/K Wire/External Fixation
Describe the anatomy of the Scaphoid Bone
- Can be split into three parts, Proximal Pole/Waist/Distal Pole
- Blood supply is retrograde from branches of radial artery entering at the distal pole and travelling back to proximal pole
Why is Avascular Necrosis a risk for Scaphoid Fractures?
Due to the retrograde blood supply
The more proximal the fracture, the higher the risk
State the borders of the Anatomical Snuffbox
Lateral Border - Abductor Pollicis Longus, Extensor Pollicis Brevis
Medial Border - Extensor Pollicis Longus
Base - Scaphoid, Trapezium, Styloid
State the contents of the Anatomical Snuffbox
Radial Artery
Radial Nerve
Cephalic Vein
How would you image a suspected Scaphoid Fracture?
- AP, Lateral and Oblique XRays
- Likely to be initially negative, so splint and repeat XRay in two weeks
- If repeat is negative and still symptomatic
How would you manage a Scaphoid Fracture?
Undisplaced - a splint is normally sufficient, but a fracture at the proximal pole may warrant surgery due to AVN risk
Displaced - Percutaneous variable pitched screw
What is Carpal Tunnel Syndrome?
Compression of the median nerve within the carpal tunnel due to raised pressure within this compartment
Give four risk factors for Carpal Tunnel Syndrome
Pregnancy
Obesity
DM
RA
Give four clinical features of Carpal Tunnel Syndrome
- Pain, numbness and paraesthesia in median nerve distribution
- Palm sparing (Palmar cutaneous branch given off pre tunnel)
- Symptoms worse at night
- Late stage may get weakness/wasting of thenar eminence
Describe two clinical tests for Carpal Tunnel Syndrome
Tinnels (tapping on the Carpal Tunnel for 30 seconds produces sensory symptoms)
Phalens (forced flexion of wrists for one minute produces sensory symptoms)
Describe the conservative management of Carpal Tunnel Syndrome
Wrist Splint (commonly worn at night)
Physiotherapy
Corticosteroid Injections
Describe the surgical management of Carpal Tunnel Syndrome
Cut through flexor retinaculum under LA
What is Dupuytren’s Contracture?
Contraction of the longitudinal palmar fascia
Fibroplastic hyperplasia and altered collagen matrix of palmar fascia leading to thickening and contraction
Give four risk factos for Dupuytren’s Contracture
Smoking
Alcoholic Liver Disease
DM
Use of vibration tools
How does Dupuytren’s Contracture present?
Thickening/Contracture commonly on ring or little finger
45% Bilateral
May have reduced ROM/complete loss of movement
The diagnosis of Dupuytren’s Contracture is mainly clinical, name a diagnostic test
Hueston’s Test - Patient is unable to lie the dorsum of their hand flat on the table
Dupuytren’s Contracture can be conservatively managed using physio exercises, or surgically managed. Describe 4 different surgical techniques
Regional - entire cord is removed
Segmental - Points of cord are removed
Dermofasciotomy - Cord and overlying skin are removed and replaced with graft
Finger amputation
What is DeQuervain’s Tenosynovitis?
Inflammation of the tendons in the first extensor comparment of the wrist
What does the first extensor compartment of the wrist contain?
Extensor Pollicis Brevis
Abductor Pollicis Longus
Give four risk factors for DeQuervain’s Tenosynovitis
Age (between 30 and 50)
Female
Pregnancy
Occupations/Hobbies with repetitive wrist movements
Give 3 clinical features of DeQuervain’s Tenosynovitis
Pain near the base of the thumb with associated swelling
Painful to grasp/pinch
Palpable Thickening
Describe a clinical test for DeQuervain’s Tenosynovitis
Finkelstein’s Test (Pain at radial styloid process when radial traction and ulnar deviation applied)
How would you manage DeQuervain’s Tenosynovitis
Wrist Splint Steroid Injections Surgical Decompression (via transverse/longitudinal incision)
What is a Ganglionic Cyst?
Non cancerous soft tissue lump occurring along any joint/tendon
Occurs when joint capsule/tendon sheat degenerates causing them to become filled with synovial fluid
How do Ganglionic Cysts present?
Smooth spherical painless lump adjacent to affected joint
Soft and will transilluminate
How would you manage Ganglionic Cysts?
Usually just monitor as they disappear spontaneously
Aspirate (+/- steroid injections)
Cyst Excision
What is a Trigger Finger?
Finger/Thumb click or lock into place when in flexion, preventing return to extension
What is the Flexor Sheath and Pulley System?
Ensures tendons remain in the joints axis of motion and prevents bow stringing
Describe the pathophysiology of Trigger Finger
Usually preceded by flexor tenosynovitis
Superficial and deep tendons develop nodules that can pass under the pulley system on flexion, but get stuck on extension
Risk Factors include: DM, RA, Age
Trigger Finger is generally painless, but can become painful. Describe the conservative and surgical management.
Conservative - Splint holding finger in extension at night, steroid injections
Surgical - Percutaneous trigger finger release (using needle), Slit in roof of tunnel
What is a Bennett Fracture?
Fracture of the thumb metacarpal base
