Trauma and Orthopedics Flashcards
How can fractures be classified?
Oblique – fracture lies oblique to the long axis of bone
Commuted fracture – >2 fragments
Segmental fracture – more than one fracture alone a bone
Transverse fracture – perpendicular to long axis of bone
Spiral fracture – severe oblique fracture with rotation along long axis
How are open fractures classified?
Gustilo and Anderson Classification system
Grade 1 – low energy wound < 1cm
Grade 2 – greater than 1cm wound with moderate soft tissue damage
Grade 3 – high energy wound > 1cm with extensive soft tissue damage
Grade 3 subdivided into:
A. Adequate soft tissue coverage
B. Inadequate soft tissue coverage
C. Associated arterial injury – use mangled extremity scoring system (MESS) can be used to help predict need for amputation
How should open fractures be investigated?
Routine bloods
Clotting
Group and Save and Crossmatch
Plain film X-ray
How are open fractures managed?
- ABCDE
- IV broad spectrum antibiotics for open injuries as soon as possible consider tetanus prophylaxis
- Continuous assessment of neurovascular status particularly following reduction and immobilization
- Immobilise the fracture including proximal and distal joints then realignment and splinting of the fracture
- Dress with saline soaked gauze
- Immediate surgery if vascular impairment or compartment syndrome
- Thoroughly debride in theatre within 6 hours of injury with external fixation devices as internal fixation should be avoided or used with extreme caution
- Open reduction and internal fixation if required
What is the first principle in managing closed fractures?
Reduction – restoring the anatomical alignment of a fracture and is important because it:
• Tamponades the bleeding
• Reduces traction on surrounding tissues and so swelling
• Reduces traction on surrounding neurovascular
Closed reduction requires analgesia either via regional block or conscious sedation
What is the second principle in managing closed fractures?
Hold – immobilising a fracture, consider if traction is required on the bony fragments whilst they heal to keep them in the correct anatomical place. Most commonly this is done via splints and plaster casts.
What are three important aspects of plaster casts?
Should not be circumferential for the first 2 weeks to prevent compartment syndrome
Should cover joint above and below if there is a possibility of axial instability e.g. combined tibia/fibula fractures, metaphyseal fractures or combined radio-ulna fractures
Consider the need of the patient for thromboprophylaxis if they are immobilised
What is the final important principle in closed fractures management?
Rehabilitate – intensive period of physiotherapy required following fracture management
What is ORIF and what are the indications for it?
Open reduction and Internal Fixation The majority of fractures involving articulations will be managed with ORIF Other indications include: • Failed conservative management • 2 fractures in one limb • Bilateral identical fractures • Intraarticular fractures • Open fractures and displaced unstable fractures
Methods for internal fixation
- Plates
- Screws
- Intramedullary nails
- Kirschner wires (k-wires)
When is external fixation utilised?
Useful in the case of burns, loss of skin and/or bone or in open fractures as external fixation causes less soft tissue disruption. Can be definitive or temporary. It usually involves pins/wires being places away from the zone of injury giving varying degrees of stability.
What are the 8 physiological steps in fracture healing?
Haematoma Vascular granulation tissue Subperiosteal osteoblast stimulation Bone matrix Endochondral ossification Deformable woven bone (callus) Lamellar bone Fracture union
What complications can occur as a result of fractures?
- Fat embolism – altered mental state, pyrexia, SOB, hypoxia, tachycardia and rash – consider ITU as management is mainly supportive
- Neurovascular injury
- Infection
- Delayed union – not healed within expected time frame usually as a result of poor blood supply, bone finished growing, infection, systemic disease or distraction of bone ends by muscle (ORFI prevents this)
- Non-union – no evidence of progression towards healing clinically of radiologically after 6 months – manage by optimising healing factors and think avascular necrosis
- Malunion – fracture heals in non-anatomical positions causing loss of function and risk of secondary osteoarthritis and contractures
- DVT
What is septic arthritis?
Definition – Infection within the joint capsule of a joint. 50% of the time it is the knee which is affected. Joint will de destroyed within 24 hours and mortality rate is up to 11%. Common in 0-6 years old and children rarer in adults unless immunocompromised
What organisms commonly cause septic arthritis?
Staph Aureus
Streptococci
Neisseria gonococcus
Gram-negative bacilli
What are the main risk factors for septic arthritis?
Pre-existing joint disease such as Rheumatoid arthritis
Diabetes or Immunosuppression
Chronic Renal failure
Recent joint surgery
Prosthetic joints (also particularly difficult to treat)
IV drug use
80 years and over
What are the clinical features of septic arthritis?
Hot swollen joint with effusion
Systemic fever
Non-weight bearing
Very painful on both active and passive movement
Usually preceding history of trauma or infection
Joint held in position of maximal comfort
How should septic arthritis be investigated?
Urgent joint aspiration with USS to assess effusion and guide aspiration
Do not aspirate if prosthesis is present
X-ray may show joint space widening or subluxation
Crystallography on aspirate
Blood cultures and culturing of aspirate
Routine bloods
CT or MRI rarely required unless need specific detail e.g. mediastinal or pelvic extension from sternoclavicular or sacroiliac respectively
What are the Kocher criteria?
Non-weight bearing CRP > 4 Fever > 38.5 WCC > 12000 1 = 3%, 2 = 40% 3 = 93% and 4 = 99%
How is septic arthritis managed?
IV antibiotics for at least 4-6 weeks (IV for only 2 weeks)
Fluid resuscitation
Open or arthroscopic drainage of the joint with irrigation
What complications can follow septic arthritis?
Sepsis
Loss of joint
Osteoarthritis
Osteomyelitis
What are the features of a normal, non-inflammatory arthritis, inflammatory arthritis and septic joint aspirate?
Normal – clear <200 WC and <25% neutrophils
Non-inflammatory arthritis – clear/straw coloured, <2000 WC and < 25% neutrophils
Inflammatory arthritis – clear or cloudy yellow, >2000 WC and < 50% neutrophils
Septic arthritis – turbid, > 50’000 WC and >75% neutrophils
What is haematogenous osteomyelitis?
Haematogenous osteomyelitis
This occurs from bacteraemia and is usually monomicrobial. It is the most common form in children and usually affects the vertebrae in adults.
What are the risk factors for haematogenous osteomyelitis?
Risk factors
• Sickle cell anaemia
• Intravenous drug user and alcohol excess
• Immunosuppression due to either medication or HIV
• Infective endocarditis
What is non-haematogenous osteomyelitis?
Non-haematogenous osteomyelitis
This occurs from the contiguous spread of infection from adjacent soft tissues to the bone or from direct injury/trauma to bone. It is often polymicrobial and is the most common form in adults.
What are the risk factors for non-haematogenous osteomyelitis?
Risk factors
• Diabetic foot ulcers/pressure sores
• Diabetes mellitus
• Peripheral arterial disease
What are the clinical features of osteomyelitis?
Raised inflammatory markers Constant pain with gradual onset and worse at night Low grade pyrexia Tender to touch Warm and erythematous Slight effusion Systemic infection Inability to weight bear
What organisms causes osteomyelitis?
Staph Aureus is the most common
Pseudomonas, E. coli and streptococci
Salmonella species predominate sickle cell patient
How should osteomyelitis be investigated?
Routine bloods
Blood cultures
X-rays – show nothing in first 10-14 days but later show haziness and loss of density
MRI is the most sensitive modality
Bone biopsy and culture is gold standard but rarely required
How is osteomyelitis managed?
Drain any abscess
When organism and sensitivities not known – 6 weeks of IV vancomycin and cefotaxime
Flucloxacillin for 6 weeks and clindamycin if penicillin allergic may also be appropriate
Ciprofloxacin in pseudomonas infections
What is chronic osteomyelitis and why does it occur?
Chronic Osteomyelitis
If osteomyelitis is poorly treated this will result in progression to chronic characterised by pain, fever, infected dead bone (sequestrum), sinus suppuration (pathognomonic) and long remissions. Suspect in vascular insufficiency with non-healing tissue ulceration overlying bony prominences.
Sequestrum acts as a reservoir for infection as it is avascular and so is not penetrated by antibiotics.
How does chronic osteomyelitis appear on X-ray?
X-rays will show thick irregular bone and if bone can be felt on probing an ulcer this is sufficient to diagnose chronic osteomyelitis.
How is chronic osteomyelitis managed?
Management – excision of dead bone, skeletal stabilisation, dead space management and antibiotics as for acute or modified for sensitivities.
What is compartment syndrome?
Definition – build up of pressure in a muscle compartment that results in compression of blood vessels and muscles causing ischaemia and death of the muscle. Fractures at highest risk of this are supracondylar fracture and tibial shaft fractures.
What causes compartment syndrome?
Reperfusion of ischaemic limb
Plaster cast
Physical trauma especially fractures
Crush injuries
What are the clinical features of compartment syndrome?
Severe pain especially on movement
Excessive requirement of breakthrough analgesia should raise suspicion
Pulseless (although the presence of a pulse does not rule out compartment syndrome)
Paralysis
Paraesthesia
Pallor
Death of muscle will occur within 4-6 hours
How should compartment syndrome be investigated?
Clinical diagnosis
Can measure intercompartmental pressure – anything in excess of 20mmHg are abnormal and > 40mmHg is diagnostic
Routine bloods including creatinine kinase
Note no pathology will be seen on X-ray
How is compartment syndrome managed?
Removal of cause if present and placement of limb at heart level
Emergency fasciotomy with wound closure around 7 days afterwards
Management of rhabdomyolysis with aggressive IV fluids
If muscle groups are frankly necrotic at fasciotomy they should be debrided and amputation may be required
What is osteoarthritis?
Definition – progressive loss of articular cartilage and remodelling of underlying bone, originally thought to be simple wear and tear now its thought it may be due to slight deformities within joints causing inflammation over time.
What are the general risk factors for osteoarthritis?
Obesity
Advancing age
Female
Manual labour jobs
What are the clinical features of osteoarthritis?
Painful and stiff joints – most commonly, fingers, hips and knees
Reduced movements
Typically insidious onset, chronic and gradually worsening
Relieved by rest and worsened through activity
Pain gets worse through day but stiffness improves
Localised swelling
Crepitus
How does osteoarthritis appear on X-ray?
Loss of joint space
Subchondral Sclerosis (bright white)
Osteophytes
Subchondral cysts
How should osteoarthritis be investigated?
X-ray
Routine blood tests to rule out other disorders
How is osteoarthritis managed?
Education on protection and physiotherapy strengthening exercises
Loss of weight
First line analgesics such as Paracetamol and NSAIDs (topical NSAIDs or knee and hand only)
Second line analgesics such as opioids, capsaicin cream and intraarticular steroid injections
Replacement of joint in surgery
What is osteoarthritis of the hand sometimes referred to as?
Osteoarthritis (OA) of the hands is sometimes referred to as nodal arthritis. The presence of hand OA increases the risk of future hip and knee OA (higher for hip OA than for knee OA)
What are the risk factors for osteoarthritis of the hand?
Family history Female (M:F 1:3) Increasing age (rare to present before 55 years of age) Previous trauma of a joint Obesity Hypermobility Occupation e.g. cotton workers and farmers are more susceptible to hand OA Osteoporosis reduces the risk of OA
What are the clinical features of osteoarthritis of the hand?
- Radiologic signs are more common than symptoms
- Usually bilateral with one joint affected at a time over several years.
- The carpometacarpal joints (CMCs), distal interphalangeal joints (DIPJs) are affected more than the proximal interphalangeal joints (PIPJs)
- Episodic joint ache provoked by movement and relieved by resting the joint
- Stiffness worse after long periods of inactivity such as in the morning, stiffness lasts only a few minutes compared to the morning joint stiffness seen in rheumatoid arthritis
- Painless nodes – Heberden’s nodes at the DIPJs, Bouchard’s Nodes at the PIPJs, these nodes are the result of osteophyte formation
- Squaring of the thumbs, deformity of the carpometacarpal joint of the thumb resulting in fixed adduction of the thumb
- Functionally patients do not usually have any problems unless there is severe involvement of the DIPJs, there may be reduced grip strength which can result in disuse atrophy
How is osteoarthritis of the hands investigated?
X-ray signs as for standard OA – osteophyte and joint space narrowing
What are the risk factors for osteoarthritis of the hip?
Increasing age Female gender (twice as common) Obesity Developmental dysplasia of the hip AVN of the hip
What are the clinical features of osteoarthritis of the hip?
What scoring system can be used to assess severity?
Chronic history of groin ache following exercise and relieved by rest
Red flag features suggesting an alternative cause include rest pain, night pain and morning stiffness > 2 hours
Oxford Hip Score is used to assess severity
What investigations should be done in someone with suspected osteoarthritis of the hip?
NICE recommends that if the features are typical then a clinical diagnosis can be made
otherwise, plain x-rays are the first-line investigation
How is osteoarthritis of the hip managed?
Oral analgesia
Intra-articular injections: provide short-term benefit
Total hip replacement remains the definitive treatment
What are the complications of total hip replacement?
Venous thromboembolism
Intraoperative fracture
Nerve injury
What reasons are there for a revision of a total hip replacement?
Aseptic loosening (most common reason)
Pain
Dislocation
Infection
What are the 3 main techniques for hip arthroplasty?
- Cemented hip replacement – metal femoral component is cemented into the femoral shaft accompanied by a cemented acetabular polyethylene cup
- Uncemented replacement, more popular in younger patients but expensive
- Hip resurfacing – metal cap placed over the femoral head and is often used in younger patients as it preserved the femoral neck in case its needed for conventional surgery later on in life
What advice should be given to patients following hip arthroplasty to prevent dislocation?
- Avoid flexing hip > 90 degrees
- Avoid low chairs
- Do not cross your legs
- Sleep on your back for first 6 weeks
What causes osteoarthritis of the knee?
Primary osteoarthritis appears idiopathic although research is suggesting small underling defects may be the cause.
Secondary Causes Post traumatic Postoperative Post-infection Malposition Mechanical instability Osteochondritis dissecans
What are the risk factors for osteoarthritis of the knee?
Obesity Female Genetics Age Occupation
What are the clinical features of osteoarthritis of the knee?
Pain on initiating movement
Stiffness following inactivity but resolves in 30minutes
Posterior patellar and medical compartment most affected leading to varus deformity
Limited range of movement
Crepitus during active and passive movement
How is osteoarthritis of the knee managed?
NSAIDs topical or oral
Physiotherapy focusing on quadriceps strengthening exercises
Weight loss
Steroid injections
Total knee replacement – lasts about 15 years
If young then osteotomies are preferred and can delay TKR for 10 years
What are the two most common types of rotator cuff injuries?
A syndrome comprising two aetiologies
• Subacromial impingement – impingement syndrome or painful arc syndrome
• Rotator cuff tears – tear in supraspinatus tendon, subscapularis, or infraspinatus
What actually causes subacromial impingement
Definition – supraspinatus becomes inflamed due to impingement below acromion and coraco-acromial ligament.
What cause subacromial impingement?
Osteoarthritis of the acromio-clavicular joint and resulting osteophytes
Thickening or calcification of the coracoacromial ligament
Rotator cuff injuries destabilising the joint
Bursitis of the subacromial bursa
What are the clinical features of subacromial impingement?
Painful mid arc (60-120 degrees)
Positive Neer’s impingement test or Hawkins-kennedy test
What are the clinical features of a rotator cuff tear?
Positive test for rotator cuff tears (Jobe’s test, Bell-press test, infraspinatus, and teres minor tests and drop arm sign)
If there is a rotator cuff tear, then there may be pain in the first 60 degree of abduction and an inability to abduct above 90 degrees
Particularly pain at night disturbing sleep
How are rotator cuff tears investigated?
If suspecting tear, then X-ray to exclude fracture
USS scan of the arm – can determine tear or no tear
MRI – size characteristic and location of tear
Subacromial impingement is a clinical diagnosis but how can it be confirmed?
MRI used to confirm impingement
How is subacromial impingement managed?
Conservative management of impingement with analgesia, physio, and steroid injection
If after 6 months of conservative management there is no response then surgical management can be considered such as arthroscopic acromioplasty, bursectomy or repair of muscle tears
How are rotator cuff tears managed?
For tears conservative management preferred if presenting within 2 weeks of injury and especially in patients not limited by pain and those with co-morbidities and unsuitable for surgery. Surgery indicated if presenting >2 weeks since the injury or remaining symptomatic despite conservative management.
Incomplete tendon tear – surgery only if symptoms persist
Complete tendon tear – open or arthroscopic repair
What is frozen shoulder syndrome?
Frozen Shoulder Syndrome (adhesive capsulitis)
Idiopathic severe pain and then persisting stiffness. Fairly common especially in middle aged females, associated with diabetes mellitus thyroid disease, and cervical spondylosis.
What is primary vs secondary adhesive capsulitis?
Primary – idiopathic
Secondary – rotator cuff tendinopathy, impingements, biceps tendinopathy, previous surgery, trauma or joint arthropathy
What are the clinical features of adhesive capsulitis?
External rotation affected more than internal rotation or abduction, loss of arm swing
Both active and passive movements are affected
Split into 3 phases that last over 6-24 months
1. Deep and constant painful freezing phase (up to 12 months)
2. Adhesive phase (6-12 months)
3. Recovery or thawing phase (12-36 months)
Stiffness and pain is worse at night and often disturbs sleep
Bilateral in 20% of cases
How is adhesive capsulitis investigated?
Typically, a clinical diagnosis
Imaging may be required in atypical or persistent symptoms and MRI scan is the modality of choice in this case
How is adhesive capsulitis managed?
No single intervention has been shown to improve outcomes
NSAIDs, physiotherapy, oral corticosteroids, and intra-articular corticosteroids
Surgical release with manipulation under anaesthetic or arthroscopic arthrolysis
How common is shoulder dislocation and when does it occur?
This is the most common joint in the body to dislocate accounting for 50% of all major dislocations. Typically young males in contact sport where arm was forced into abduction, extension, and external rotation. In the elderly may simply be a FOOSH.
What can dislocate in a shoulder dislocation?
Types of Shoulder dislocation
• Glenohumeral dislocation – 95% are anterior
• Acromioclavicular dislocation – next most common and clavicle loses all attachment to the scapula
• Sternoclavicular – uncommon
What are the two main types of Glenohumeral shoulder dislocation?
Anterior – occurs due to external rotation and abduction, 40% of cases will become recurrent. Associated with greater tuberosity fracture, Bankert lesion (avulsion of glenoid labrum from the glenoid) and Hill-sachs lesion (impaction fracture of humeral head).
Posterior – often misdiagnosed, Rim’s, Light bulb sign and Trough sign. Present with limited external rotation, usually occurs following epileptic seizures or electric shock
What are the clinical features of shoulder dislocation?
Pain Reduced mobility Asymmetry on examination Loss of contours – flattened deltoid Anterior bulge from head of humerus
How should shoulder dislocation be investigated?
Trauma X-ray of shoulders – AP, Y scapular and axial views (Lightbulb sign seen in posterior dislocation)
Must check neurovascular status before and after reduction as well as an x-ray to confirm no fracture has occurred
If soft tissue damage suspected such as rotator cuff tears then MRI shoulder may be indicated
How are anterior shoulder dislocations managed?
If dislocation recent then reducing may be done without analgesia
Some patients may require sedation/analgesia to make sure rotator cuffs are relaxed - usually Entonox, parenteral opioid or intra-articular local anaesthetic)
Support the arm in a broad arm sling and refer to fracture clinic and physiotherapy
In recurrent dislocation surgical repair will be required
Simple reduction – apply longitudinal traction to the arm in abduction and replace head of the humerus with gentle pressure
Kocher’s method – flex elbow to 90 degrees, abduct the shoulder, externally rotate the shoulder and then abduct the upper arm back across the body before internally rotating the shoulder
What is a proximal humerus fracture and when do they occur?
Common fracture that usually occurs through the surgical neck (very rare for it to happen through the anatomical neck) usually after FOOSH in the elderly causing a stable osteoporotic fracture. Can sometimes occur in the young in high energy trauma and often associated with tissue or neurovascular injuries.
What types of proximal humeral fracture carries the greatest risk of AVN?
Avascular necrosis risk if there is an anatomical neck fracture with displacement of >1cm
What proximal humeral fracture is most common in children?
In children the most common pathology is a greenstick fracture through the surgical neck.
What are the clinical features of proximal humeral fractures?
Pain
Restricted arm movement
Significant swelling
Check neurovascular status, especially axillary distribution
How are proximal humeral fracture investigated and classified?
Trauma shoulder X-ray – AP, Y scapular and axial views
Neer Classification – classification based on relationship between greater tuberosity, less tuberosity, articular segments (anatomical neck) and humeral shaft (surgical neck)
How are proximal humeral fractures managed?
Majority managed conservatively with immobilisation and early mobilisation. Use polysling that allows the arm to hand aiding the reduction of fragments
If significantly displaced, open or neurovascular compromise then will require ORIF with use or intramedullary nailing. ORIF usually preference is head splitting fracture and intramedullary nail if fracture involved surgical neck or combined humeral fracture
Hemiarthroplasty in complex injuries where ORIF and intramedullary nails are inappropriate.
What causes fractures of the shaft of the humerus
Typically direct blow to the arm rather than a FOOSH, be aware of radial nerve injury (seen in 10%) so document neurovascular status before and after intervention. Typically occur from FOOSH or falling laterally onto an adducted arm.
What is a Holstein-Lewis fracture?
Holstein-Lewis fracture – distal third of humerus resulting in entrapment of the radial nerve – loss of sensation in radial distribution and wrist drop deformity. Surgical management required.
How are humeral shaft fractures managed?
Typically does not need surgery, simple splinting with a humeral brace and gravity traction by means of collar and cuff gives satisfactory reduction. Must immobilise for 8-12 weeks. Full union expected with 8-12 weeks.
In minority of cases ORIF with a plate is required and may involve faster healing times
Intramedullary nailing indicated in pathological fracture, polytrauma or severe osteoporosis
When do clavicular fracture occur?
Most commonly occurs following direct blow to the clavicle and is common in cycling accidents. The most common location in the middle third where the medial fragment is pulled superiorly by sternocleidomastoid and the lateral fragment is displaced inferiorly from weight of the arm.
What is the Allman classification of clavicular fractures?
- Type 1 – middle third of the clavicle (75% of all clavicular fractures), generally stable but significant deformity may be present
- Type 2 – lateral third and make up 20% of clavicular fractures. When displaced these are often unstable
- Type 3 – remaining 5% in the medial third of the clavicle usually involving multi system polytrauma. Must check neurovascular compromise due to proximity of mediastinum. Think pneumothorax and haemothorax
How are clavicular fractures managed?
Broad arm sling with follow up X-ray at 6 weeks to ensure union, encourage early mobilisation of shoulder to prevent adhesive capsulitis. Sling maintained until there is pain free movement. If fragments failed to unite then ORIF
ORIF if severely displaced, open fracture or bilateral
What is epicondylitis?
Inflammation of the epicondyles of the elbow termed tennis elbow if the lateral epicondyle and golfer’s elbow if the medial epicondyle.
Describe the features of lateral epicondylitis?
Lateral Epicondylitis (Tennis elbow)
Pain and tenderness localised to the lateral epicondyle
Pain worse on resisted wrist extension with the elbow extended or supination of the forearm with the elbow extended
Patients in acute pain for 6-12 weeks
Episodes typically last between 6-24 months
Cozen’s and Mill’s tests
Describe the features of medial epicondylitis?
Medial Epicondylitis (Golfer’s elbow)
Pain and tenderness localised to the medial epicondyle
1/5 less common than tennis elbow
Pain aggravated by wrist flexion and pronation
Symptoms may be accompanied by numbness/tingling in the 4th and 5th finger due to ulnar nerve involvement
How is epicondylitis managed?
Most cases will spontaneously resolve via restriction of activity within 1 year and analgesia
Physiotherapy in motivated patients may speed this up as well as corticosteroid injections
What is bicep tendinopathy and who does it occur in?
Painful swollen and weak tendon that can pose a risk of rupture. This can occur proximally or distally (most common) and is most common in young active individuals or in older people with a degenerative tendinopathy.
How does bicep tendinopathy present?
Presentation – pain, worse on stressing the tendon, weakness and stiffness. Tender to examine and muscular atrophy due to disuse atrophy. Specific tests – speed test (proximal tendon) and Yorgason’s test (distal tendon)
How should bicep tendinopathy be investigated?
Investigations – blood tests and play x-ray to exclude other causes. US and MRI may be used but are rarely warranted.
How is bicep tendinopathy managed?
Management – conservative with analgesia, ICE and physiotherapy. US guided steroid injections if persistent and very rarely surgical intervention with arthroscopic tenodesis or tenotomy.
What is a bicep rupture?
Two tendons, long from glenoid and the short from the coracoid process that insert distally together onto the radial tuberosity. Tendon rupture occurs when one of these separate form their attachment site or is torn across its full width. Typically, this involves the long tendon (90%) but can rarely occur at the distal tendon.
What are the risk factors for bicep rupture?
Male (3:1 ratio) Elderly – over age of 60 Distal rupture usually in 40s and almost always men Heavy overhead activities Shoulder overuse or underlying shoulder injuries Smoking Corticosteroid Bicep tendinopathy
What are the mechanisms of bicep ruptures?
Long tendon – typically occurs when biceps are lengthened and contracted, and a load is applying e.g. descent phase of a pull-up
Distal tendon – flexed elbow is suddenly and forcefully extended whilst bicep is contracted
What are the clinical features of bicep ruptures?
Sudden pop or tear in the shoulder or elbow followed by pain, bruising and swelling
If long tendon rupture then Popeye deformity, also less reliable reverse Popeye in distal tendon rupture
Weakness in shoulder and elbow especially with supination
Hood test – flex elbow to 90 degrees fully supinated and attempt to hook index finger underneath lateral edge of bicep tendon (can’t be done if ruptured)
How are bicep ruptures investigated?
General examination of elbow and shoulder and assess neurovascular function
Bicep squeeze test – if intact then squeeze should cause forearm supination
USS by skilled clinician usually done to confirm diagnosis
Urgent MRI if suspected distal tendon rupture
How are bicep rupture managed?
Long tendon rupture – conservative management with analgesia and physiotherapy
Distal tendon rupture – surgical intervention
What are distal humeral fractures and who do they most often occur in?
Supracondylar Fracture
Most common fracture in childhood (but very rare in adults) and usually due to FOOSH with hyperextension.
What is the presentation of a supracondylar fracture?
Clinical features – pain, swelling and inability to move elbow
Neurovascular problems are common due to the proximity of surrounding structures
How should suspected supracondylar fracture be investigated for?
Investigations – X-ray in AP and lateral views. Look for posterior fat pad sign and displacement of the anterior humeral line which should intersect the middle of the capitellum in children > 5 years
How are supracondylar fractures classified?
Gartland Classification (lateral x-ray)
- Anterior humeral line passes through the middle of the capitellum (undisplaced)
- Anterior humeral line passes anterior to the capitellum (displaced with intact posterior cortex)
- Unstable with posterior displacement, if medial then threatens the radial nerve, if lateral displacement then threatens the median nerve
How are supracondylar fractures managed?
Keep elbow in extension to minimise brachia artery damage
Type 1 – above elbow back slab and sling – conservative management
Type 2 – closed reduction under GA (and fixation with k wires)
Type 3 – closed reduction under GA and fixation with k wires
What causes fracture of the head of the radius?
Most common elbow fracture in adults usually through indirect trauma with axial load being placed on the forearm causing radial head to be pushed against the capitulum of the humerus, usually this is during extension and pronation.
What are the clinical features of a fracture of the head of a radius?
History of FOOSH with swollen and tender elbow over the radial head
Flexion/extension may be possible, but supination and pronation hurt
Effusion on x-ray or sail sign
How are radial head fractures classified?
Mason Type 1 – non-displaced or minimally displaced
Mason Type 2 – partial articular fracture with displacement > 2mm or angulation
Mason Type 3 – Comminuted fracture and displacement (complete articular fracture)
How are radial head fractures managed?
Check for position and neurovascular compromise before and after intervention
Undisplaced – collar and cuff e.g. Mason Type 1 and some Type 2
Displaced or fragments prevent supination/pronation then ORIF or excision of radial head such as in Mason Type 3 and some Type 2.
How do elbow dislocations occur?
Almost always posterior due to fall on not quite fully outstretched hand with partially flexed elbows causing posterior ulna displacement on the humerus. Often have ulnar nerve deficit.
How are elbow dislocations managed?
Manage with closed reduction +/- GA which is confirmed by hearing a clunk. Must have post reduction image and check neurovascular status before and after. Keep immobilised in a backslab for 10 days. Check neurovascular status and X-ray before and after.
Dislocations complicated by fractures, open injury or neurovascular compromise requires ORIF of the coronoid, radial head or olecranon with appropriate soft tissue repair.
What is the terrible triad?
Terrible triad – elbow dislocation with lateral collateral ligament injury, radial head fracture and coronoid fracture. This will cause a very unstable elbow. This usually occurs with falls onto extended arm with rotation resulting in posterolateral dislocation.
How do olecranon fractures occur?
All olecranon fracture are intraarticular and occur after direct blow or avulsion when triceps contacts during a fall on semiflexed, supinated arm.
How do olecranon fractures present?
Presentation is with tenderness and inability to extend the elbow against gravity
How are olecranon fractures managed?
Conservative management if displacement < 2mm – immobilisation in 60–90-degree elbow flexion and early introduction of movement from week 1-2. Increasingly conservative management is used in elderly patients despite a larger displacement.
Surgical management if displacement is > 2mm with ORIF and tension band or a plate. Often requires a high rate of removal of metal work due to how superficial everything is over the olecranon.
What is olecranon bursitis?
Inflammation of the olecranon bursa – sometimes referred to as student’s elbow due to it occurring from resting elbows on a desk for long periods of time. Can also have an infective cause.
How does olecranon bursitis present and how is it managed?
Presents with pain and swelling over the olecranon but with range of movement preserved and can be definitively diagnosed with aspiration of the fluid.
If infective manage with IV antibiotics and washout, noninfective treated with rest and analgesia.
What causes fracture of the distal radius and/or Ulna?
Usually caused by a fall on the outstretched hand or FOOSH and is very common in elderly osteoporotic women. Be aware of compartment syndrome and injuries to ulnar, radial, and medial nerve as well as the radial and ulnar arteries.
Describe a colles’ fracture
Colles’ Fracture
Distal transverse radial fracture (usually 1 inch proximal to the radio-carpal joint) with posterior displacement of the fragments and ulnar deviation. Described as a dinner fork type deformity.
Describe a Smith’s or reverse colles’ fracture
Smith’s or reverse Colles’ fracture
Falling onto flexed wrists (falling backwards and arms flexed behind you) or direct blow to the forearm resulting in volar angulation (anterior displacement) of the distal radial fragment described as a Garden spade deformity.
Describe a Barton’s fracture
Barton’s Fracture
Intra-articular fracture of the distal radius (Colles’/Smith’s) with associated radiocarpal dislocation, usually due to fall onto extended and pronated wrist.
Describe a Bennett’s fracture?
Bennett’s Fracture
Intraarticular fracture of the first carpometacarpal joint due to impact on flexed metacarpal such as in fist fight. On X-ray triangular fragment at ulnar base of metacarpal is seen.
Describe Monteggia’s and a Galeazzi’s fracture
Monteggia’s Fracture
Dislocation of the proximal radioulnar joint in association with an ulnar fracture. Fall on outstretched hand with forced pronation. Need prompt diagnosis to avoid disability.
Galeazzi Fracture
Radial shaft fracture with associated dislocation of the distal radioulnar joint due to direct blow to the forearm.
