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Huang's Orthopaedic Surgery > Trauma - Upper Extremity > Flashcards

Trauma - Upper Extremity Flashcards

0
Q

What happens if the radial bow of the radius is not repaired appropriately?

A

Results in loss of supination/pronation The radius rotated around the stationary ulna, requiring proper radial bow

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1
Q

Why is it important the central band of the IoM of the forearm not be cut (either via injury or iatrogenically)?

A

Sectioning the central band alone reduces forearm stability by 71%

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2
Q

What must you monitor for in forearm fractures (especially both bones forearm fractures)?

A

Compartment syndrome Bc these usually come from high energy traumas

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3
Q

On what principle is plate fixation the treatment of choice of radius and ulna fractures based on

A

That the radius and ulna is considered a ‘joint’

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4
Q

What are the principles of plate fixation of the radius and ulna?

A

Restoring radial and ulnar length (prevents subluxation of the PRUJ/DRUJ) - use bone graft acutely if requird Restore rotational alignment Restore radial bow (essential for rotational function of the forearm)

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5
Q

How can you reduce the risk of radioulnar synostosis?

A

Use separate incisions for bony fixation of the radius and ulna

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6
Q

What are the risk factors for post traumatic radioulnar synostosis?

A

Anything that increases inflammation between the bones: - Fracture of both bones at the same level - Closed head injury - Surgical delay > 2 weeks - Single incision for fixation of both bone forearm fractures - Penetration of the interosseous membrane by bone graft or screws, bone fragments or surgical instruments - Crush injury - Infection

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7
Q

What are the major complications of both bones forearm fracture

A

Non/malunion Infection Neurovascular injury Volkmann’s ischaemic contracture Post traumatic radioulnar synostosis

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8
Q

What is a Monteggia fracture?

A

Fracture of the proximal ulnar with dislocation of the radial head

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9
Q

What is a nightstick injury? Why is it a unique type if ulnar fracture?

A

Isolated ulnar shaft fracture from a direct blow to the subcutaneous border. It’s unique bc it is an isolated injury, whereas most ulnar fractures are associated with either a radial injury or a PRUJ/DRUJ injury bc of the ring principle of the forearm

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10
Q

What is the classification for Monteggia fractures?

A

Bado classification: depends on direction of radial head dislocation - Type 1: anterior dislocation of the radial head with fracture of the ulnar diaphysis at any level with anterior angulation. Mechanism is forced pronation of the forearm - Type 2: posterior/ posterolateral dislocation of the radial head with fracture of the ulnar diaphysis with posterior angulation. Mechanism is axial loading of the forearm with a flexed elbow - Type 3: lateral/anterolateral dislocation of the radial head with fracture of the ulnar metaphysis. Mechanism is forced abduction of the elbow - Type 4: anterior dislocation of the radial head with fractures of the radius and ulna within the proximal 1/3 at the same level. Same mechanism as type 1 but the radius fails also

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11
Q

What is the indication for operative management of a nightstick fracture?

A

Non-op management unless displaced: >10 degrees angulated in any plane >50% displaced ORIF with 3.5mm DCP

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12
Q

What is the management of Monteggia fractures?

A

ORIF is the rule for adults (paediatrics may be treated closed) Closed reduction of radial head and restoration of ulnar length is a must. ORIF of ulnar shaft with 3.5mm DCP. Radial head generally reduces once you fix the ulna

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13
Q

When is non-union most commonly seen with Monteggia fractures?

A

Bado type 2

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14
Q

When is nerve injury most commonly seen with Monteggia fractures?

A

Bado type 2 & 3 Involved radial/median nerves +- PIN/AIN

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15
Q

What is the management of radial head redislocation following Monteggia fracture ORIF?

A

If < 6 weeks post-op, repeat ORIF ulna +- open reduction of radial head If > 6 weeks post-op, radial head excision

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16
Q

What percentage of distal 1/3 radius fractures involve the DRUJ?

A

All until proven otherwise Fractures of the proximal 2/3 may be considered truly isolated if no other injuries

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17
Q

What is a Galeazzi fracture?

A

Fracture of the radial diaphysis at the distal 2/3 junction with associated disruption of the DRUJ

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18
Q

What injury is the “Fracture of necessity” and why is it called that?

A

Galeazzi fracture. Bc it necessitates an ORIF to achieve a good result”

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19
Q

What is the management of galeazzi fractures?

A

ORIF

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20
Q

Describe the galeazzi variants:

A

Fractures may occur anywhere along the radius and be associated with fractures of both the radius and ulna with DRUJ instability

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21
Q

A fracture in what area is at increased risk of galeazzi fracture?

A

Distal 7.5cm of the radius

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22
Q

A radius fracture in the distal 7.5cm is associated with what injury?

A

DRUJ injury - aka a Galeazzi fracture

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23
Q

What are the deforming forces that contribute to a loss of reduction in nonoperative management of a radialmsuaft/galeazzi fracture?

A
  • Weight of the hand: dorsal angulation of the fracture and subluxation of the DRUJ - Pronator quadratus insertion: pronates the distal fragment with proximal and volar displacement - Brachioradialis: causes proximal displacement and shortening - Thumb extensors and abductors: shortening and relaxation of the radial collateral Iigament, allowing displacement of the fracture despite immobilization of the wrist in ulnar deviation
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24
Q

What is a reverse Galeazzi fracture?

A

Fracture of the distal ulna with associated disruption of the distal radioulnar joint

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25
Q

What is the classification of Galeazzi fractures?

A

Walsh classification: depends on position of the radius (the fracture displacement, NOT the ulnar DRUJ dislocation) Type 1: dorsal displacement of radius. Most common. Caused by supination force. Reduces with pronation force and dorsal to volar force on distal radius Type 2: volar displacement of the radius. Caused by pronation. Reduces with supination and volar to dorsal force on distal radius

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26
Q

What are the normal radiographic relationship of the distal radius?

A

11/22/11 Radial length: 11mm (avg 8-18mm) Radial inclination: 22 degrees (avg 13-30) Volar tilt: 11 degrees (avg 0-28 degrees)

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27
Q

What is a radiologically acceptable reduction of a distal radius fracture?

A

Radial length: within 2-3mm of contralateral wrist Palmar tilt: neutral, but up to 10 degrees of dorsal angulation Intra-articular step-off: <5 degree loss

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28
Q

Describe the eponym of distal radius fractures: Colles fracture Smith’s fracture Barton’s fracture Chauffeur’s fracture

A

Colles: classically, an extra-articular fracture of the distal radius with dorsal angulation, radial deviation, impaction. Now used to denote any fracture of the distal radius Smith’s: reverse Colles. Volar angulation, volar displacement of hand Barton’s: fracture-dislocation or subluxation of the wrist with in which the dorsal or volar rim of the distal radius is displaced with the hand or carpus Chauffeur’s: radial styloid avulsion fracture with the extrinsic ligaments still attached

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29
Q

What are the operative indications of distal radius fractures?

A

High-energy injury Secondary loss of reduction Articular comminution or step-off or gap Metaphyseal comminution or bone loss Loss of volar buttress with displacement DRUJ incongruity Open fractures

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30
Q

What are the types of medial 1/3 clavicle fractures? When do you operate on them?

A

Anteriorly displaced (more common) & posteriorly displaced Operate if they are posteriorly displaced - There is risk to the great vessels and lungs. Have a thoracic surgeon on standby

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31
Q

What kind of medial clavicle fracture is more common?

A

Anteriorly displaced (vs. posteriorly displaced)

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32
Q

What is the operative indications for midshaft clavicle fractures?

A

Open fracture Skin tenting >100% displaced (ie no cortical contact) - controversial Shortened >2cm Neurovascular injury Multiple trauma Floating shoulder

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33
Q

What is the classification of lateral 1/3 clavicle fractures?

A

Dddddd

34
Q

What percentage of scapulae fractures have associated injuries?

A

80-90% So high index of suspicion

47
Q

Is radial nerve palsy an indication for acute operative management of humeral shaft fracture?

A

No

48
Q

Name 8 principles of ORIF of distal humerus fractures:

A

Concerning screws in the distal fragment: - Each screw should pass through a plate - Each screw should engage a fragment on the opposide side that is also fixed by a plate - An adequate number of screws should be placed in the distal fragment - Each screw should be as long as possible - Each screw should engage as many articular fragments as possible - The screws should lock together by interdigitation, thereby creating a fixed-angle structure and linking the columns together Concerning the plates used for fixation: - Plates should be applied such that compression is achieved at the supracondylar level for both columns - Plates used must be strong and stiff enough to resist breaking or bending before union occurs at the supracondylar level

50
Q

What are the indications for radial head excision?

A

Indications: - Low demand, sedentary patients - In a delayed setting for continued pain of an isolated radial head fracture`

59
Q

What is the management of intrathoracic scapular dislocation?

A

Closed reduction & immobilization, followed by early ROM in 2 weeks

61
Q

What is the blood supply to the humeral head?

A

Arcuate artery via the ANTERIOR humeral circumflex artery

70
Q

Which of the coracoclavicular ligaments is responsible for resisting superior migration? For resisting axial load?

A

Conoid - more medial, is responsible for superior migration. Is fibres go more straight up and down Trapezoid ligament - more lateral, is responsible for resisting axial load. It’s fibres go more medial/lateral

71
Q

What are the radiographic features that indicate an acceptable reduction of a distal radius fracture?

A

Radial height: 11mm (AP) Radial inclination: 22deg (AP) Volar tilt: 11deg volar (Lat) Articular step-off <2mm

72
Q

Describe how you measure radial height

A

Distance between a line drawn at the articular surface of the ulna to the tip of the radial styloid on AP x-ray of the wrist. Normal is 11mm -5mm

73
Q

How do you measure radial inclination?

A

Angle between a line perpendicular to the long axis of the radius at the tip of the ulnar styloid and a line from the ulnar part of the radius to the tip of the radial styloid (aka along the joint line) on AP x-ray Normal: 22 deg +/- 5deg

74
Q

How do you measure volar tilt?

A

Angle between a line perpendicular to the long axis of the radius and another parallel to the joint line of the radius on lateral x-ray. Normal: 11 degrees volar angulated +/- 11deg (so can be neutral)

75
Q

Describe the relationship of the scaphoid and lunate fossae?

A

Both are on the distal radius articular surface. The scaphoid fossa is radial

76
Q

What is a die-punch fracture of the distal radius?

A

A distal radius depression fracture of the lunate fossa

77
Q

In tension band fixation of a fractured olecranon, what happens if your K-wire goes to far volarly or too far radially?

A

It impairs forearm rotation

78
Q

Penetration of the anterior (volar) cortex of the ulna with the K-wire in tension band fixation of the olecranon reduces what?

A

Migration and loosening of the K-wire

79
Q

What are the adverse effects of not fixing an associated ulnar styloid fracture in ORIF of a distal radius fracture?

A

None proven

80
Q

Name 5 indications for acute operative management of humeral shaft fracture:

A

Failure of closed reduction Associated articular injury Vascular injury Brachial plexus injuries Associated ipsilateral forearm fractures Segmental fractures Pathologic fractures

81
Q

What are the contraindications of radial head excision?

A

Contraindications: - Presence of destabilizing injuries - Forearm ligament injury (identify with radius pull test) - Coronoid fracture - MCL deficiency

82
Q

What is a Comolli sign?

A

Triangular swelling over posterior thorax (over scapula) indicating hematoma after scapula fracture and increased pressure - Suspicious for compartment syndrome

83
Q

What is the classification of acromion fractures?

A

Type 1: nondisplaced Type 2: displaced but not decreased subacromial space Type 3: displaced & decreasing subacromial space

84
Q

What is the classification of coracoid fractures?

A

Type 1: proximal to the CC ligament Type 2: distal to the CC ligament

85
Q

What constitutes a floating shoulder

A

Disruptions of 2 or more parts of the superior shoulder suspensory complex (SSSC)

86
Q

What comprises the SSSC?

A

Superior shoulder suspensory complex: 6 things: Acromion Distal clavicle CA ligaments AC joint Coracoid Glenoid

87
Q

What is scapulothoracic dislocation?

A

Dislocation of the scapula from the posterior thorax

88
Q

What is the prognosis?

A

Poor: 10% death 80% neurolgic injury (complete brachial plexopathy) 88% subclavian or axillary artery injury

89
Q

What is intrathoracic scapular dislocation?

A

When the inferior scapular apex gets entrapped in the intercostal space

90
Q

What are Hertel’s criteria and what do they identify?

A

Identify signs of poor perfusion to the humeral head after fracture: - Length of metaphyseal head extension <8mm - Disruption in integrity of the medial hunge - Basic fracture patterns: 2, 9, 10, 11, 12 (basically when the anatomic neck is fractured) Worst: anatomic neck fracture with a short calcar (medial metaphyseal segment) and disrupted hinge

91
Q

Name two relevant classification systems for capitellar fractures. What is the better one? Why?

A

Dubberley and Bryan-Morrey classification with McKee Modification. Dubberley is better because it offers prognostic and treatment factors

92
Q

Describe the Dubberley classification of capitellar fractures:

A

Type 1: Fracture of the capitellum Type 2: Fracture of the capitellum & trochlea as 1 piece Type 3: Fracture of the capitellum & trochlea as separate fragments Each type divided into: A: no posterior condylar comminution B: posterior condylar comminution

93
Q

For capitellar fractures, what is the more biomechanically superior construct of fixation?

A

Posterior to anterior screws

94
Q

What is the main issue theorized for posterior to anterior screws to fix capitellar fractures?

A

Strip the remaining soft tissue from the bone (posteriorly), leading to poor biological healing

95
Q

What is the reduction mechanism for capitellar fractures?

A

First: elbow extension with supination Then: varus pressure with manual force over the capitellum (if required) Then flexion of elbow and pronation to lock it in

96
Q

In a humeral shaft fracture, what are the acceptable limits of deformity?

A

20 deg if anterior angulation 30 deg of varus angulation 3cm of bayonet apposition

97
Q

What percentage of humeral shaft fractures will heal with non-operative management?

A

90%

98
Q

What are the operative indications for humeral shaft fractures?

A

Open fracture Inadequate closed reduction Associated vascular injury Polytrauma/bilateral humeral fractures Neurologic loss after penetrating injury Radial nerve palsy after fracture manipulation Unacceptable malunion Nonunion Pathologic fracture Floating elbow Segmental fracture Intra-articular extension

99
Q

What do you do with a primary radial nerve palsy after humeral shaft fracture? Secondary (aka after fracture manipulation)?

A

Primary: leave it Secondary: explore (controversial)

100
Q

What is the fracture eponym of the humeral shaft that is at high risk of radial nerve palsy?

A

Holstein-Lewis fracture of distal 1/3 of humeral shaft

101
Q

At what point do you explore a radial nerve pals after humeral shaft fracture?

A

after 3-4 months with no evidence of recovery - Most are neurapraxia or axonotmesis which should recover by then

102
Q

What are the indications for external fixation in humeral shaft fractures?

A

Infected nonuions Open fractures with extensive soft tissue loss Burn patients with fractures

103
Q

What is the incidence of radial nerve injuries with humeral shaft fractures?

A

18%

104
Q

What is the outcome of humeral shaft malunion?

A

Unless severe (as per angular acceptabilities), likely functionally inconsequential. Arm musculature and shoulder, elbow and trunk range of motion can compensate for angular, rotational and shortening deformities

105
Q

How much can you shorten the humerus?

A

?

106
Q

What are your approach options for humeral shaft fractures?

A

Anterior, anterolateral, posterior

107
Q

What is the supracondylar region made out of?

A

Epicondyle: nonarticulating terminal of the supracondylar ridge Condyle: articulating unit of the distal humerus So supracondylar part of the distal humerus is made of the epicondyle and condyle

108
Q

What is an Essex-Lopresti injury of the wrist?

A

Radial head fracture with disruption of the IoM extending distally to the DRUJ

109
Q

What is the management of Essex Lopresti injuries of the forearm?

A

Treat radial head fracture with pinning of DRUJ

110
Q

What may prevent reduction of a DRUJ injury following Galeazzi injury?

A

Entrapped ECU

111
Q

Acceptable reduction criteria in humeral shaft fracture

A

Anterior angulation <20o

Varus/valgus angulations <30o

Shortening <3cm

112
Q

Indications for surgial exploration of radial nerve palsy in humeral shaft fracture

A

Open fracture with radial nerve palsy (as it’s likely a neurontmesis)

Failure to improve after 3-6 months after closed injury

Fibrillations (denervation) seen at 3-4 months

113
Q

Risk factors for non-union of humeral shaft fracture

A

Vitamin D deficiency (most common endo cause)

Open fracture

Segmental injury

Obesity

Smoking

Huang's Orthopaedic Surgery (15 decks)

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