UE Fractures

Question 1

Fractures of the shoulder require what views?

Answer 1

Neer trauma series which includes anterior & posterior views, lateral or Y view in the scapular plane, & an axillary view
85% of all shoulder fx’s are non-displaced or minimally displaced & can be treated with conservative treatment

Question 2

Most Shoulder Fractures require what treatment?

Answer 2

Conservative treatment includes immobilization with a sling for at least 10-14 days
This allows for the weight of the arm to act in a downward distracting fashion to apply traction to the arm & gently reduce the fx
After 10-14 days begin gentle ROM with PT guidance

Question 3

Neer Classification of Shoulder Fractures?

Answer 3

One Part Fracture: no fragments are displaced

Two Part Fracture: one displaced fragment

Three Part Fracture: two displaced fragments but the humeral head remains in contact with the glenoid

Four Part Fracture: three or more displaced fragments & dislocation of the articular surface from the glenoid

Question 4

Treatment for Shoulder Dislocations?

Answer 4

Treatment is determined by the extent of the injury
Some require closed reduction & immobilization, followed by rehabilitation
Some require surgical intervention
If there is glenoid & humeral head destruction may require total shoulder arthroplasty

Question 5

Cause of most humeral Shaft fractures?

Answer 5

Majority of proximal & midshaft fractures are non-displaced & are treated conservatively
Typically result from trauma such as a direct blow or bending force to the humerus & less commonly from a fall on an outstretched hand or elbow
May result from strong muscle contraction with high velocity throwing or arm wrestling

Question 6

How do most humeral shaft fractures present?

Answer 6

Typically present with severe arm pain that may be referred to the shoulder or elbow, localized tenderness to palpation at the fracture site, ecchymosis, & swelling

Question 7

What 3 types of fractures occur with humeral shaft fractures?

Answer 7

spiral, oblique, or transverse
Transverse fractures do not require traction & are usually treated with a coaptation splint & sling or functional bracing
Follow up is usually done every 2 weeks with xray to follow the healing of the bone
Within 1-2 week pendulum exercises while in the splint or brace is begun to prevent shoulder stiffness
Spiral & oblique fractures usually require some sort of traction using a hanging cast or coaptation splint

Question 8

Clavicle Fracture

What is the treatment?

Answer 8

Clavicle is the only rigid bony connection between the shoulder & the chest
Function is to hold the shoulder upward & backward
Clavicle is the most commonly fractured bone in children
There is tenderness to palpation at the fx site
There may be an obvious deformity & tenting of the skin
Treatment is with a sling for comfort
Surgical treatment is only done if there is complete displacement & healing will not occur

Question 9

What happens when there are fragments with a clavicle fracture?

Answer 9

Plates and Screws
The fracture fragments are repositioned (reduced) into normal alignment,
Plates and screws are usually not removed after the bone has healed, unless they are causing discomfort

Question 10

What causes Scapula Injuries/Fractures?

Answer 10

Result from a direct blow or fall
Are always from a high energy injury
CT may be required to determine if there is displacement or comminution of the fx
Fractures that do not involve the glenoid can be treated conservatively with a sling

Question 11

MC location for a shoulder dislocation?

Answer 11

Account for 50% of all major joint dislocations

Anterior dislocation is most common & accounts for 95-97% of cases

Question 12

How does a anterior dislocation occur?

Answer 12

Mechanism of injury (MOI) is usually a blow to the abducted, externally rotated, & extended arm (eg. Blocking a basketball shot)
Less commonly caused by a blow to the posterior humerus or a fall on an outstretched arm

Question 13

How to treat an anterior shoulder dislocation?

Answer 13

Closed reduction with conscious sedation is most often done

Obtain informed consent from the patient for the sedation & procedure

Delays can result in permanent neurovascular damage

Multiple methods with no clear cut advantage of one

Question 14

MOI of Posterior Shoulder Dislocation?

Answer 14

MOI is a blow to the anterior portion of the shoulder, axial loading of an adducted & internally rotated arm or violent muscle contractions following a seizure or electrocution

Question 15

MOI of Inferior Shoulder dislocation

Answer 15

MOI caused by axial loading with the arm fully abducted or forceful hyperabduction of the arm
Occurs when patients fall & suddenly grab on to something above their head

Question 16

Subluxation of the shoulder

Answer 16

Patient dislocates then spontaneously reduces the dislocation
Shoulders that are chronically unstable & sublux will require surgical intervention
Occult instability of the shoulder is often difficult to diagnose & these patients can have years of chronic shoulder pain

Question 17

MOI of AC joint dislocation?

Answer 17

Commonly referred to as a separated shoulder
Result from a fall on to the top of the shoulder
Acromion is driven down & there is injury to the AC & CC ligaments
On exam there is tenderness, swelling, & sometimes a deformity over the AC joint

Question 18

grade 1 of shoulder separation classification?

Answer 18

• AC ligament is strained but there may be a partial tear
  
  • presents with tenderness at the AC joint, mild
    swelling, but no deformity
    -active overhead ROM & cross body ROM are limited

Question 19

grade 2 of shoulder separation classification?

Answer 19

• complete tear of the AC ligament & partial tear of the
  CC ligament
  
  • typically is prominent & tender AC joint often with
    significant swelling

Question 20

grade 3 of shoulder separation classification?

Answer 20

• involve complete disruption of both the AC & CC ligaments
  
  • deformity of the AC joint is clearly visible
  • there is marked tenderness of the AC joint & CC ligaments

Question 21

grade 4 of shoulder separation classification?

Answer 21

• occur with forceful shoulder trauma that causes
  disruption of the AC & CC ligaments & displaces the
  clavicle into or through the trapezius muscle
  
  • usually a palpable posterior fullness or deformity to
    the shoulder despite significant swelling
  • Sternoclavicular (SC) dislocations are common
  • axillary view confirms posteriorly displaced distal
    clavicle

Question 22

grade 5 of shoulder separation classification?

Answer 22

• significant disruption of AC & CC ligaments along with the
  disruption of the muscular attachments of the distal clavicle
  
  • shoulder appears to droop due to the inferior position of the
    scapular & GH joint
  • severe superior displacement of the clavicle, with tenting of the skin
  • clavicle does not reduce with pressure

Question 23

grade 6 of shoulder separation classification?

Answer 23

• rare
  
  • involves severe dislocation of the AC joint with the clavicle forced into the subacromial or
    subcoracoid position
  • urgent intervention is needed to relieve pressure on the neurological bundle

Question 24

Treatment for grades 1-3

Answer 24

Treatment is usually conservative with Grade I – III including ice, sling immobilization from 3 -21 days, & pain medication for 2-5 days, along with orthopedic referral
ROM exercises are begun as tolerated & strengthening exercises may require referral to PT
May return to normal activity in 6 – 12 weeks
Surgery in Grades I – III is usually for cosmetic reasons at the request of the patient
Grades IV – VI require surgical intervention

Question 25

Intercondylar fractures of the elbow?

Answer 25

Occur when the condylar fragments of the humerus are separated
More common in adults
MOI is direct force against the posterior elbow such as a fall on to a flexed elbow that drives the olecranon against the humeral articular surface separating the condyles
Treatment is often complicated & requires anatomic reduction either open surgically or closed

Question 26

Supracondylar fractures of the elbow?

Answer 26

Most common pediatric elbow fracture
Rarely seen after 15 y/o
Most commonly caused by extension type injuries
Complications include injuries to the median, radial, & anterior interosseus nerves
Most deficits are neuropraxias that resolve with conservative management
Motor function usually recovers within 7-12 weeks, while sensory function recovers in 6 months
Vascular injuries should always be suspected
Most common complication is usually cubitus varus deformity with a loss of the carrying angle

Question 27

Types 1-3 of supracondylar fractures of the elbow for extension injuries?

Answer 27

Type I - nondisplaced & treatment consists of immobilization with splint or cast with the elbow flexed for 4-6 weeks
Type II – displaced with the posterior cortex intact & treatment consists of closed reduction & pinning followed by immobilization with a splint or cast
Type III – displaced with both the anterior & posterior cortex disrupted & treatment consists of closed or open reduction & pinning followed by immobilization with a splint or cast for 4-6 weeks

Question 28

Types 1-3 of supracondylar fractures of the elbow for flexion injuries?

Answer 28

Type I – nondisplaced & treatment require immobilization in a flexed position
Type II – displaced with anterior cortex still intact & treatment requires reduction & surgical management
Type III – displaced with both anterior & posterior cortexes disrupted & distal fragments migrant anteriorly & proximally & treatment requires reduction & surgical management

Question 29

Medial Epicondylar fracture

MOI?

Answer 29

Usually in children as an avulsion type injury
MOI includes direct blow or elbow dislocation
Nondisplaced or minimally displaced are treated non-operatively
Fragment displacement > 1 cm or valgus instability is often treated with ORIF
Conservative management includes immobilization of the elbow in flexion, pronation of the forearm, & wrist in flexion

Question 30

Radial Head Fracture

MOI?

Answer 30

Most common of all elbow fractures
MOI is FOOSH injury
Characterized by point tenderness to palpation at the radial head & pain with supination & pronation
Fractures may be subtle on xray
Treatment for non-displaced fx’s includes a sling with the elbow in flexion
Displaced fx’s need immobilization with a long arm posterior splint with the elbow flexed to 90 degrees & the forearm in supination & placed in a sling for comfort

Question 31

Olecranon Fracture

MOI

Answer 31

MOI is a direct blow or FOOSH type injury
Fx is usually transverse passing into the trochlear notch
Patients demonstrate an inability to actively extend the elbow
There is point tenderness to palpation over the olecranon
Ulnar nerve injury is common
Treatment includes a well padded long arm posterior splint with the elbow flexed to 70 degrees & the forearm in neutral position

Question 32

Type 1 Monteggia Fractures

Answer 32

Type I (60%) – extension type ulna shaft angulates anteriorly & radial head angulates anteriorly

Question 33

Type 2 Monteggia Fractures

Answer 33

15%) – flexion type ulnar shaft angulates posteriorly & radial head dislocates posteriorly

Question 34

Type 3 Monteggia Fractures

Answer 34

20%) – lateral type ulna shaft angulates laterally & radial head dislocates to the side

Question 35

Type 4 Monteggia Fractures

Answer 35

5%) – Combined ulna & radial shaft both fx & radial head dislocates typically anteriorly

Question 36

Forearm Fractures

MOI?

Answer 36

MOI is usually direct blow or FOOSH injury
Deformity is often obvious with a roller coaster type appearance
Can be a fracture of both the radius & ulna or just one or the other
Symptoms include pain & loss of supination, pronation, flexion, & extension
Pain to palpation at the sight of the fx
Need good neurovascular check to assess for compartment syndrome especially in crush injuries

Question 37

Wrist Fractures

MOI?

Answer 37

Most common MOI is FOOSH type injury
Symptoms include pain at the fx site, swelling, & sometimes paresthesias
There is pain to palpation at the site of the fx & many times a palpable step off or deformity

Question 38

Colles Fracture
MOI?
Treatment?

Answer 38

Classic MOI FOOSH type injury
Classic definition is fx of the distal radius with dorsal angulation & fx of the ulna styloid
Many times is now used as a catch phrase for all distal radius fx’s
Treatment includes closed reduction using longitudinal traction with flexion & then ulna deviation to reduce the fx & then placing the patient in a sugar tong long arm splint to control supination & pronation
ORIF with plate & screw is more common

Question 39

Smith Fracture
MOI?
Treatment?

Answer 39

MOI is fall on to a flexed wrist
Also called reverse Colle’s fx
The distal fx fragment displaces volarly
Treatment is closed reduction with longitudinal traction & extension
ORIF is usually done with percutaneous pinning

Question 40

Scaphoid Fracture

MOI?

Answer 40

MOI is usually a FOOSH type injury
Most missed fx in all of emergency medicine
May not always be present on the first x-ray
Pain & swelling at the base of the thumb is the most common presenting symptom
Pain is worse with movement of the thumb

Question 41

Treatment for Scaphoid Fracture?

Answer 41

Initial treatment is with a thumb spica splint for 6 weeks
For waist or proximal fx’s a thumb spica with an extending sugar tong splint may be used for as long as 3-6 months
Surgical fixation with a screw may be needed for non-union fx’s
Bone grafting can be indicated with a comminuted fx

Question 42

Scapho-Lunate Dissociation
MOI?
Xray finding?
Treatment?

Answer 42

Most common carpal instability
MOI is FOOSH type injury with forearm in pronation & wrist hyperextended
Clicking & clunking of wrist most common presentation in chronic presentation
Tenderness to palpation at scapho-lunate interval just distal to Lister’s tubercle
X-ray shows widening of scapho-lunate interval
Normal interval = 3 mm
Acute treatment is with open reduction of the dissociation & pinning of lunate to the scaphoid
Chronic treatment is controversial & includes multiple procedures

Question 43

Gameskeepers Thumb

MOI?

Answer 43

Also known as skier’s thumb
Injury to the ulnar collateral ligament (UCL) of the thumb
UCL is torn at its insertion site on the proximal phalanx
MOI is fall onto thumb with forced abduction or hyperextension of the proximal phalanx of the thumb

Question 44

Treatment for Gameskeeper Thumb?

Answer 44

Stener’s lesion present in 80% of all UCL rupture without fx & flouroscopic evaluation of the joint laxity is indicated
Partial tears can be treated with immobilization with a thumb spica splint for 6-8 weeks
UCL complete rupture requires surgical repair of the ligament
Avulsion fxs require pinning to stabilize the joint

Question 45

Bennet’s Fracture
MOI?
What does it affect?

Answer 45

Intra-articular fx at the base of the 1st MC that extends into the CMC joint
Unstable fx usually
Most common fx of the thumb
Almost always accompanied by subluxation or dislocation of the CMC joint
MOI is fall on to the thumb or striking the thumb on a solid object (fall off of bike)
Can affect the ability to grasp, pinch, & oppose the thumb

Question 46

Treatment for Bennet’s Fracture?

Answer 46

In small avulsion fx’s with little instability a thumb spica splint for 6 weeks is indicated
For displacement of the trapeziometacarpal joint of
1-3 mm closed reduction with percutaneous pinning & a thumb spica splint for 6 weeks is indicated
For > 3 mm displacement ORIF is indicated

Question 47

Boxer Fracture
MOI
Treatment

Answer 47

MOI is punching a solid object with a closed fist
Fx is at the 5th MC head usually with volar displacement
Symptoms are pain, swelling, & deformity
Exam reveals tenderness at 5th MC head, flattening of the knuckle, edema, & inability to fully extend at the 5th MCP joint
Always check for rotation
Treatment is closed reduction with ulnar gutter splint & flexion of the MCP joint to 90 degrees

Question 48

Finger Dislocations
Most Common?
Treatment?

Answer 48

PIP is the most commonly dislocated finger joint
Dorsal PIP is the most common
PIP dislocations are described as dorsal, volar or lateral depending on the direction of the PIP in relation to the proximal phalanx
Reduction should be attempted asap
MCP is most common in the thumb
Are usually dorsal
DIP dislocations are often accompanied by fx
Are usually dorsal
Treatment for all is closed reduction & splinting
Dislocation with fx may require closed reduction & surgical pinning or ORIF

Question 49

Tuft Fractures
MOI?
Treatment?

Answer 49

MOI is most commonly a crush injury
Most common type of DP fx
Subungual hemorrhage/hematoma is common
Trephination is indicated for subungual hematoma
Nail bed lacerations require removal of the fingernail & repair of the nail bed laceration with absorbable sutures
& then replace the nail back under the eponychium & suture in place to ensure new nail grows in smooth

Question 50

Mallet Finger Fracture

Treatment

Answer 50

Occurs at the insertion of the terminal finger extensor mechanism into the dorsal portion of the DP
Caused by axial loading to the tip of the finger leading to forced flexion at the DIP joint
Usually causes an avulsion type fx
Treatment includes splinting in full extension at the DIP joint for 8 weeks & must be maintained at all times as any flexion can disrupt the healing
Surgical repair is recommended for fxs > 30% of the intra-articular surface & those associated with volar subluxation of the distal phalanx

Question 51

Flexor Digitorum Profundus Avulsion Fracture
MOI
Xray finding
Treatment

Answer 51

Inserts at the volar surface of the DP
MOI results from forced hyperextension of the flexed DIP joint
Commonly referred to as a jersey finger
Exam reveals inability to flex the DIP joint
Xray shows an avulsion fx
Surgical referral is indicated to prevent retraction of tendon as flexion is functional