Trauma - Upper Extremity Flashcards
What happens if the radial bow of the radius is not repaired appropriately?
Results in loss of supination/pronation The radius rotated around the stationary ulna, requiring proper radial bow
Why is it important the central band of the IoM of the forearm not be cut (either via injury or iatrogenically)?
Sectioning the central band alone reduces forearm stability by 71%
What must you monitor for in forearm fractures (especially both bones forearm fractures)?
Compartment syndrome Bc these usually come from high energy traumas
On what principle is plate fixation the treatment of choice of radius and ulna fractures based on
That the radius and ulna is considered a ‘joint’
What are the principles of plate fixation of the radius and ulna?
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)
How can you reduce the risk of radioulnar synostosis?
Use separate incisions for bony fixation of the radius and ulna
What are the risk factors for post traumatic radioulnar synostosis?
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
What are the major complications of both bones forearm fracture
Non/malunion Infection Neurovascular injury Volkmann’s ischaemic contracture Post traumatic radioulnar synostosis
What is a Monteggia fracture?
Fracture of the proximal ulnar with dislocation of the radial head
What is a nightstick injury? Why is it a unique type if ulnar fracture?
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
What is the classification for Monteggia fractures?
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
What is the indication for operative management of a nightstick fracture?
Non-op management unless displaced: >10 degrees angulated in any plane >50% displaced ORIF with 3.5mm DCP
What is the management of Monteggia fractures?
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
When is non-union most commonly seen with Monteggia fractures?
Bado type 2
When is nerve injury most commonly seen with Monteggia fractures?
Bado type 2 & 3 Involved radial/median nerves +- PIN/AIN
What is the management of radial head redislocation following Monteggia fracture ORIF?
If < 6 weeks post-op, repeat ORIF ulna +- open reduction of radial head If > 6 weeks post-op, radial head excision
What percentage of distal 1/3 radius fractures involve the DRUJ?
All until proven otherwise Fractures of the proximal 2/3 may be considered truly isolated if no other injuries
What is a Galeazzi fracture?
Fracture of the radial diaphysis at the distal 2/3 junction with associated disruption of the DRUJ
What injury is the “Fracture of necessity” and why is it called that?
Galeazzi fracture. Bc it necessitates an ORIF to achieve a good result”
What is the management of galeazzi fractures?
ORIF
Describe the galeazzi variants:
Fractures may occur anywhere along the radius and be associated with fractures of both the radius and ulna with DRUJ instability
A fracture in what area is at increased risk of galeazzi fracture?
Distal 7.5cm of the radius
A radius fracture in the distal 7.5cm is associated with what injury?
DRUJ injury - aka a Galeazzi fracture
What are the deforming forces that contribute to a loss of reduction in nonoperative management of a radialmsuaft/galeazzi fracture?
- 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
What is a reverse Galeazzi fracture?
Fracture of the distal ulna with associated disruption of the distal radioulnar joint
What is the classification of Galeazzi fractures?
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
What are the normal radiographic relationship of the distal radius?
11/22/11 Radial length: 11mm (avg 8-18mm) Radial inclination: 22 degrees (avg 13-30) Volar tilt: 11 degrees (avg 0-28 degrees)
What is a radiologically acceptable reduction of a distal radius fracture?
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
Describe the eponym of distal radius fractures: Colles fracture Smith’s fracture Barton’s fracture Chauffeur’s fracture
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
What are the operative indications of distal radius fractures?
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
What are the types of medial 1/3 clavicle fractures? When do you operate on them?
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
What kind of medial clavicle fracture is more common?
Anteriorly displaced (vs. posteriorly displaced)
What is the operative indications for midshaft clavicle fractures?
Open fracture Skin tenting >100% displaced (ie no cortical contact) - controversial Shortened >2cm Neurovascular injury Multiple trauma Floating shoulder
What is the classification of lateral 1/3 clavicle fractures?
Dddddd
What percentage of scapulae fractures have associated injuries?
80-90% So high index of suspicion
Is radial nerve palsy an indication for acute operative management of humeral shaft fracture?
No
Name 8 principles of ORIF of distal humerus fractures:
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
What are the indications for radial head excision?
Indications: - Low demand, sedentary patients - In a delayed setting for continued pain of an isolated radial head fracture`
What is the management of intrathoracic scapular dislocation?
Closed reduction & immobilization, followed by early ROM in 2 weeks
What is the blood supply to the humeral head?
Arcuate artery via the ANTERIOR humeral circumflex artery
Which of the coracoclavicular ligaments is responsible for resisting superior migration? For resisting axial load?
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
What are the radiographic features that indicate an acceptable reduction of a distal radius fracture?
Radial height: 11mm (AP) Radial inclination: 22deg (AP) Volar tilt: 11deg volar (Lat) Articular step-off <2mm
Describe how you measure radial height
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
How do you measure radial inclination?
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
How do you measure volar tilt?
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)
Describe the relationship of the scaphoid and lunate fossae?
Both are on the distal radius articular surface. The scaphoid fossa is radial
What is a die-punch fracture of the distal radius?
A distal radius depression fracture of the lunate fossa
In tension band fixation of a fractured olecranon, what happens if your K-wire goes to far volarly or too far radially?
It impairs forearm rotation
Penetration of the anterior (volar) cortex of the ulna with the K-wire in tension band fixation of the olecranon reduces what?
Migration and loosening of the K-wire
What are the adverse effects of not fixing an associated ulnar styloid fracture in ORIF of a distal radius fracture?
None proven
Name 5 indications for acute operative management of humeral shaft fracture:
Failure of closed reduction Associated articular injury Vascular injury Brachial plexus injuries Associated ipsilateral forearm fractures Segmental fractures Pathologic fractures
What are the contraindications of radial head excision?
Contraindications: - Presence of destabilizing injuries - Forearm ligament injury (identify with radius pull test) - Coronoid fracture - MCL deficiency
What is a Comolli sign?
Triangular swelling over posterior thorax (over scapula) indicating hematoma after scapula fracture and increased pressure - Suspicious for compartment syndrome
What is the classification of acromion fractures?
Type 1: nondisplaced Type 2: displaced but not decreased subacromial space Type 3: displaced & decreasing subacromial space
What is the classification of coracoid fractures?
Type 1: proximal to the CC ligament Type 2: distal to the CC ligament
What constitutes a floating shoulder
Disruptions of 2 or more parts of the superior shoulder suspensory complex (SSSC)
What comprises the SSSC?
Superior shoulder suspensory complex: 6 things: Acromion Distal clavicle CA ligaments AC joint Coracoid Glenoid
What is scapulothoracic dislocation?
Dislocation of the scapula from the posterior thorax
What is the prognosis?
Poor: 10% death 80% neurolgic injury (complete brachial plexopathy) 88% subclavian or axillary artery injury
What is intrathoracic scapular dislocation?
When the inferior scapular apex gets entrapped in the intercostal space
What are Hertel’s criteria and what do they identify?
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
Name two relevant classification systems for capitellar fractures. What is the better one? Why?
Dubberley and Bryan-Morrey classification with McKee Modification. Dubberley is better because it offers prognostic and treatment factors
Describe the Dubberley classification of capitellar fractures:
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
For capitellar fractures, what is the more biomechanically superior construct of fixation?
Posterior to anterior screws
What is the main issue theorized for posterior to anterior screws to fix capitellar fractures?
Strip the remaining soft tissue from the bone (posteriorly), leading to poor biological healing
What is the reduction mechanism for capitellar fractures?
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
In a humeral shaft fracture, what are the acceptable limits of deformity?
20 deg if anterior angulation 30 deg of varus angulation 3cm of bayonet apposition
What percentage of humeral shaft fractures will heal with non-operative management?
90%
What are the operative indications for humeral shaft fractures?
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
What do you do with a primary radial nerve palsy after humeral shaft fracture? Secondary (aka after fracture manipulation)?
Primary: leave it Secondary: explore (controversial)
What is the fracture eponym of the humeral shaft that is at high risk of radial nerve palsy?
Holstein-Lewis fracture of distal 1/3 of humeral shaft
At what point do you explore a radial nerve pals after humeral shaft fracture?
after 3-4 months with no evidence of recovery - Most are neurapraxia or axonotmesis which should recover by then
What are the indications for external fixation in humeral shaft fractures?
Infected nonuions Open fractures with extensive soft tissue loss Burn patients with fractures
What is the incidence of radial nerve injuries with humeral shaft fractures?
18%
What is the outcome of humeral shaft malunion?
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
How much can you shorten the humerus?
?
What are your approach options for humeral shaft fractures?
Anterior, anterolateral, posterior
What is the supracondylar region made out of?
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
What is an Essex-Lopresti injury of the wrist?
Radial head fracture with disruption of the IoM extending distally to the DRUJ
What is the management of Essex Lopresti injuries of the forearm?
Treat radial head fracture with pinning of DRUJ
What may prevent reduction of a DRUJ injury following Galeazzi injury?
Entrapped ECU
Acceptable reduction criteria in humeral shaft fracture
Anterior angulation <20o
Varus/valgus angulations <30o
Shortening <3cm
Indications for surgial exploration of radial nerve palsy in humeral shaft fracture
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
Risk factors for non-union of humeral shaft fracture
Vitamin D deficiency (most common endo cause)
Open fracture
Segmental injury
Obesity
Smoking
