Upper and lower limb injuries

Question 1

What is the most common cause of a sternoclavicular joint dislocation?

Answer 1

Direct blow to the chest or shoulder

Sprain most common. Anterior dislocation more common than posterior

Question 2

What is the management of a posterior sternoclavicular joint dislocation?

Answer 2

Less common than anterior, but there’s a risk of compression of posterior structures and can be life threatening → CT and orthodoxy referral

Question 3

What is the most common cause of a acromioclavicular joint dislocation?

Answer 3

Fall on outstretched hand

Fall on shoulder

Question 4

What is the Rockwood classification for acromioclavicular joint dislocations?

Answer 4

Type 1: ligament stretched and radiologically normal
Type 2: <1cm between clavicle and acromion
Type 3: >1cm between clavicle and acromion
Types 4-6: according to degree of displacement

Question 5

What is the management for a acromioclavicular joint dislocation?

Answer 5

Types 1&2: sling 1-2w, RICE
Types 3: sling, orthopaedic
referral
Types 4-6: sling, orthopaedic
referral, likely surgery

Question 6

What are common causes of clavicular fractures?

Answer 6

Fall on outstretched hand

Shoulder impact

Question 7

What are common locations for clavicular fractures?

Answer 7

80% middle third
15% lateral third:often associated with ruptured CC ligament

5% medial third: commonly missed and may be
associated with intrathoracic injury e.g. subclavian
vein/artery

Question 8

What is the most common type of shoulder dislocation?

Answer 8

Anterior (95-97%)

Question 9

What is the clinical presentation of an anterior shoulder dislocation?

Answer 9

a. Arm held in an abducted and ER position
b. Loss of normal contour of the deltoid and acromion prominent posteriorly and laterally
c. Humeral head palpable anteriorly
d. All movements limited and painful
e. Palpable fullness below the coracoid process
and towards the axilla
f. Elbow flexed

Question 10

What is the clinical presentation of a posterior shoulder dislocation?

Answer 10

a. Arm is abducted and IR
b. May or may not lose deltoid contour
c. May notice posterior prominence head of humerus
d. Tear of subscapularis muscle (weak or cannot internally rotate)

Question 11

What nerves can be damaged by an anterior shoulder dislocation?

Answer 11

Axillary mainly (shoulder numbness &
weakness)

Median
Radial

Axillary artery injury: absent radial pulse, lateral
chest wall bruising, axillary haematoma, axillary bruit

Question 12

How would you manage a shoulder dislocation?

Answer 12

Adequate analgesia and relaxation are usually essentia

Then a manipulation technique preferred by physician

Question 13

What techniques can be used for shoulder dislocations?

Answer 13

1. Hippocratic method:
   The clinician holds the patient’s affected arm by the wrist and applies traction at a 45° angle.
   At the same time, they provide countertraction by placing a foot on the patient’s chest wall or by having an assistant wrap a sheet around the patient’s torso

2.External rotation method:
The patient is in a supine position on the bed.
The affected arm is adducted and flexed to 90° at the elbow.
The arm is then slowly externally rotated.

3. Immediate reduction:
   The manoeuvre involves initial slight abduction and internal de-rotation of the affected arm. This can be done without applying a great deal of traction.

Question 14

What is the cause of an elbow dislocation?

Answer 14

Fall on an outstretched hand

Question 15

How does an elbow dislocation often present?

Answer 15

Elbow flexed at 45 degrees with prominent olecranon posteriorly

Question 16

What injuries are associated with elbow dislocation?

Answer 16

Children: medial epicondyle

Adults: coronoid, radial head, capitellum and olecranon

Brachial artery injury, ulnar, median and radial nerve injuries

Question 17

What are the different types of humerus fractures?

Answer 17

Proximal humeral fractures
Humeral shaft fractures
Distal humeral fractures

Question 18

What causes humerus fractures?

Answer 18

Usually after a fall on to an outstretched hand from standing height.

Can also result from a direct blow.

Question 19

What people often suffer from humerus fractures?

Answer 19

Middle age/elderly are most commonly affected. It is common in women. Many patients are osteoporotic.

In younger people, the same injury mechanism can cause fracture with co-existing shoulder dislocation

Question 20

How would you manage humerus fractures?

Answer 20

1. Immobilise fracture
2. Most proximal humeral fractures can be treated non-operatively. This involves the use of a sling or a shoulder immobiliser

If displaced, surgery may be needed

Question 21

What causes humeral shaft fractures?

Answer 21

Usually direct trauma or torsion injury to an upper limb. Occasionally, a fall on to an outstretched abducted arm. Blunt injury/bending forces usually cause transverse fractures. Torsional force tends to result in spiral fracture.

Question 22

What is a comminuted fracture?

Answer 22

This injury happens when your bone breaks into three or more pieces

Question 23

What is a Galeazzi fracture?

Answer 23

radial shaft fracture

Question 24

What is the cause of a radial shaft fracture?

Answer 24

Commonly caused by a fall on to an extended, pronated wrist.

Question 25

How does a radial shaft fracture present?

Answer 25

Pain, swelling and deformity of the wrist and forearm. Tenderness and swelling at the distal radius and tenderness at the DRUJ.

Question 26

How would you manage a radial shaft fracture?

Answer 26

In adults, this requires surgical open reduction of the distal radius and DRUJ with internal fixation

In children, the fracture can often be treated by closed reduction with longitudinal traction and correction of radial angulation.

Question 27

What is the mechanism of injury for an ulnar shaft fracture?

Answer 27

Usually caused by a direct blow to the ulnar border, classically if someone receives a blow from an object whilst raising their arm in defence

Question 28

How does an ulnar shaft fracture present?

Answer 28

Point tenderness over the ulnar shaft, and forearm swelling.

Question 29

How would you manage an ulnar shaft fracture?

Answer 29

Orthopaedic referral

Non-displaced or minimally displaced fractures can be treated with a posterior splint

Question 30

What are Monteggia’s fractures?

Answer 30

These are fractures of the proximal third (usually) of the ulna with associated dislocation of the radial head

Question 31

What are the causes of Monteggia’s fractures?

Answer 31

Usually caused by a fall on to an outstretched, extended and pronated elbow, or by a direct blow

Question 32

What is pronator syndrome?

Answer 32

This is due to entrapment of the median nerve.

There is pain or paraesthesia over the median nerve distribution in the anterior proximal forearm. It is aggravated by throwing/swinging a racquet.

Question 33

What is the most common cause of radial head fractures?

Answer 33

These are most commonly caused by a fall on to an outstretched arm.

Radial head fracture is the most common fracture around the elbow joint in adults, whereas radial neck fractures occur more commonly in children.

Question 34

What is the most common cause of olecranon fractures?

Answer 34

Elderly - indirect trauma by pull of triceps and brachioradialis

Children - direct blow to elbow

Question 35

What is the olecranon?

Answer 35

The large, thick, curved bony eminence of the ulna

Question 36

How does a radial head fracture present?

Answer 36

The patient presents with swelling over the lateral elbow with limited range of motion, particularly forearm rotation and elbow extension ± elbow effusion and bruising. Pain is increased with passive rotation.

Question 37

How would you manage a radial head fracture?

Answer 37

Refer for urgent surgical treatment if there is elbow fracture, dislocation or evidence of nerve or vascular involvement.

Immobilise the elbow in a long arm posterior splint with the elbow at 90°.

Question 38

What is a Smiths fracture?

Answer 38

The definition is a fracture of the distal radius, with or without ulnar involvement, that has volar (anterior) displacement of the distal fragments.

Question 39

What is a greenstick fracture of the wrist?

Answer 39

Greenstick fracture is a fracture of children.

The bone is broken and may be considerably distorted but the periosteum remains intact.

Question 40

What are complications for supracondular fractures?

Answer 40

Nerves: radial (wrist drop), median, ulnar

Arteries: brachial (check radial pulse)

Pierced brachialis muscle (Pucker sign)

Compartment syndrome

Transphyseal separation: suspect non-accidental injury

Question 41

What is a Boxer’s fracture?

Answer 41

Fracture of the neck of the 5th metacarpal

Question 42

What is the mortality for neck of femur fractures?

Answer 42

30%

Question 43

What are the causes of neck of femur fractures?

Answer 43

Neck of femur fractures are typically caused either by low energy injuries (the most common type), such as a fall in frail older patient, or high energy injuries, such as a road traffic collision or fall from height and are often associated with other significant injuries.

Question 44

How are neck of femur fractures classified?

Answer 44

1. Intra-capsular – from the subcapital region of the femoral head to basocervical region of the femoral neck, immediately proximal to the trochanters
2. Extra-capsular – outside the capsule, subdivided into:
   2A. Inter-trochanteric, which are between the greater trochanter and the lesser trochanter
   2B. Sub-tronchanteric, which are from the lesser trochanter to 5cm distal to this point

Question 45

How is the blood supply to the neck of femur organised?

Answer 45

The blood supply to the neck of the femur is retrograde, passing from distal to proximal along the femoral neck to the femoral head

This is predominantly through the medial circumflex femoral artery, which lies directly on the intracapsular femoral neck.

Consequently, displaced intra-capsular fractures disrupt the blood supply to the femoral head and, therefore, the femoral head will undergo avascular necrosis. Patients with a displaced intra-capsular fracture therefore require joint replacement (arthroplasty), rather than fixation.

Question 46

What is the Garden classification for intracapsular hip fractures?

Answer 46

1. Non-displaced incomplete
2. Non-displaced complete
3. Displaced complete, partial displacement
4. Displaced complete, full displacement

Question 47

What is the clinical presentation for neck of femur fractures?

Answer 47

On examination, the leg is characteristically shortened and externally rotated, due to the pull of the short external rotators, with pain on pin-rolling the leg and axial loading.

Question 48

How would you manage neck of femur fractures?

Answer 48

Ensure adequate analgesia is provided, as hip fractures are very painful

1. Displaced subcapital → hip Hemiarthroplast
2. Inter-trochanteric and Basocervical → Dynamic Hip Screw (or short IM nail)
3. Non-displaced intra-capsular → Cannulated hip screws
4. Sub-trochanteric → Anterograde Intramedullary Femoral Nail

Question 49

For what neck of femur fracture would you perform Hip Hemiarthroplast?

Answer 49

Displaced subcapital

Question 50

For what neck of femur fracture would you perform Dynamic Hip Screw (or short IM nail)?

Answer 50

Inter-trochanteric and Basocervical

Question 51

For what neck of femur fracture would you perform Cannulated hip screws?

Answer 51

Non-displaced intra-capsular

Question 52

For what neck of femur fracture would you perform Anterograde Intramedullary Femoral Nail?

Answer 52

Sub-trochanteric

Question 53

What are complications of neck of femur fractures?

Answer 53

Long term complications following repair include joint dislocation, aseptic loosening, peri-prosthetic fracture, and deep infection/prosthetic joint infection.

Question 54

What are risk factors for hip fractures?

Answer 54

Increasing age.
Osteoporosis.
Osteomalacia
Falls
Instability

Question 55

What is the cause of a femoral shaft fracture?

Answer 55

Fractures of the femoral shaft are caused by a high-energy injury, such as a road traffic accident, unless a pathological fracture in a patient with osteoporosis or metastatic disease.

They are often associated injuries to the hip, pelvis, knee and other parts of the body.

Question 56

What are supracondylar fractures?

Answer 56

Fractures of the distal third of the femur are termed supracondylar fractures and can affect the knee joint

Question 57

How do femoral shaft fractures present?

Answer 57

Severe pain, with supporting history of injury.
Tense, swollen, tender thigh.
Inability to bear weight.
Deformity and shortening on the affected side.

Question 58

How would you manage femoral shaft fractures?

Answer 58

Patients are usually treated with open or closed reduction. The limb is immobilised with a plaster or splint and possibly also with internal or external fixings. X-rays are used to verify the alignment of the bone and assess progress towards healing

Intramedullary nailing is the most common fixation method. This involves placing a rod in the femoral bone marrow, crossing the fracture site, with intramedullary nails screwed to the bone at both ends.

Question 59

How long does it take for femoral shaft fractures to heal?

Answer 59

Most femoral shaft fractures take 4-6 months to heal completely.

Open fractures and complex comminuted fractures can take longer.

Question 60

What are complications for femoral shaft fractures?

Answer 60

Neurovascular damage from sharp bone ends.
Closed fractures may be involve a large volume of blood loss before becoming obvious with swelling of the thigh.
Acute compartment syndrome.
Fat embolism.
Deep vein thrombosis.
Pulmonary embolism.
Infection

Question 61

What are the ligaments of the knee (tibiofemoral joint)?

Answer 61

1. Medial collateral ligament (MCL) - prevents lateral movement of the tibia on the femur when valgus (away from the midline) stress is placed on the knee
2. Lateral collateral ligament (LCL) - prevents medial movement of the tibia on the femur when varus (towards the midline) stress is placed on the knee
3. Anterior cruciate ligament (ACL) - controls rotational movement and prevents forward movement of the tibia in relation to the femur
4. Posterior cruciate ligament (PCL) - prevents forward sliding of the femur in relation to the tibial plateau.

Question 62

What are the grades of knee ligament injuries?

Answer 62

Grade I: a few fibres are damaged or torn. This will usually heal naturally. It is often referred to as a sprain.

Grade II: more fibres are torn but the ligament is still intact. This may be referred to as a severe sprain.

Grade III: the ligament is completely disrupted. The knee joint is unstable and surgery may be indicated.

Question 63

What is the most common cause of medial collateral ligament injuries?

Answer 63

A direct blow to the lateral aspect of the knee or a twisting injury

It will often occur in association with cruciate and meniscal injuries.

Question 64

How would you manage medial collateral ligament injuries?

Answer 64

PRICER (Protect, Rest, Ice, Compression, Elevation, Rehabilitation) and non-weight-bearing restriction with the use of crutches (often only required for a few days) are recommended

Bracing and non-weight-bearing may be sufficient for mild injury.

Question 65

What is the most common cause of lateral collateral ligament injuries?

Answer 65

A direct blow to the medial aspect of the knee, which is rare due to the protective effects of the other knee, but may also be due to a varus stress such as a runner twisting on to the side of the planted foot

Question 66

How would you manage lateral collateral ligament injuries?

Answer 66

PRICER and non-weight-bearing restriction with the use of crutches are recommended.

Knee bracing with the knee locked in full extension for 4-6 weeks with weight bearing as tolerated. Active and passive range of movement exercises in the prone position are essential to prevent stiffness.

Achilles allograft reconstruction may be used with acute grade III and chronic posterolateral injury

Question 67

What is the most common cause of anterior cruciate ligament injuries?

Answer 67

ACL tears most often occur in younger patients during football and basketball; in older patients, they occur most often from skiing injuries

Substantial anterior tibial shear forces that stress the ACL are produced from quadriceps contraction, especially in 0-30° of extension.

Typically, the ACL is torn in a non-contact deceleration or change of direction with a fixed foot that produces a valgus twisting injury. This usually occurs when the athlete lands on the leg and quickly pivots in the opposite direction. Meniscal tears are often associated with ACL injury

Question 68

How would you manage anterior cruciate ligament injuries?

Answer 68

Most tears are managed surgically

In conservative management, after initial control of pain and effusion (using the PRICER method), hamstring and quadriceps activation/disinhibition and protected weight bearing in a hinged brace should be recommended

Question 69

What is the prognosis for anterior cruciate ligament injuries?

Answer 69

Surgery does not guarantee a return to previous level of sporting activity. The risk of a second ACL injury is high, especially in the short term. In the long term there is a significant risk of osteoarthritis, regardless of surgical intervention; this is even higher if revision surgery is required

Question 70

What is the most common cause of posterior cruciate ligament injuries?

Answer 70

Hyperflexion is the most common mechanism for an isolated PCL injury typically from a direct blow to the proximal tibia with the knee in flexion (eg, from a fall on to a flexed knee or where the proximal tibia hits the dashboard in an accident)

Question 71

How would you manage posterior cruciate ligament injuries?

Answer 71

PRICER

Axillary crutches and a long leg brace are recommended for more severe injury.

Indications for operative treatment include PCL avulsion fractures, tears associated with other knee ligament injuries and isolated tears that have failed conservative management.

Question 72

What is the prognosis for posterior cruciate ligament injuries?

Answer 72

Conservatively managed patients do well, with 80% of people in one study reporting satisfactory knee function and the majority returning to sport after non-operative treatment with a six-year follow-up

Question 73

What are the Ottawa Knee Rules?

Answer 73

The Ottawa Knee Rules can be used to decide whether an X-ray is indicated. An X-ray should be performed if any of the following are present:

1. Age over 55 years (because of the risk of osteoporosis).
2. Tenderness over the fibular head.
3. Discomfort confined to the patella upon palpation.
4. Inability to flex the knee to 90°.
5. Inability to bear weight, immediately and in the emergency department, for at least four steps

Question 74

What are the functions of menisci?

Answer 74

The main functions of the menisci are tibiofemoral load transmission, shock absorption, lubrication of the knee joint and to improve the stability of the knee joint

The two menisci in each knee are crescent-shaped pads of cartilage tissue

Question 75

What are the causes for meniscus injuries?

Answer 75

The mechanism of injury is typically twisting or pivoting. Acute meniscal tears occur in young, active people.

No or minimal force can be sufficient to cause a degenerative meniscal tear in middle-aged and older people

Question 76

What is the presentation for meniscus injuries?

Answer 76

There may be acute pain, especially following obvious trauma or if a fragment of meniscus becomes trapped.

Often patients cannot remember the exact nature of an injury but complain of popping, catching, locking (usually in flexion) or buckling, along with joint line pain

There may be slow onset of swelling (over 2-36 hours) due to an effusion

Question 77

How would you manage meniscus injuries?

Answer 77

PRICER

Refer

Physio for mild to moderate symptoms

Surgery:

1. Menisectomy
2. Meniscal transplantation

Question 78

What is Segond’s fracture?

Answer 78

An avulsion fracture of the tip of the lateral tibial condyle.

he fracture is a consequence of knee joint injury

Question 79

What causes tibial shaft fractures?

Answer 79

Tibial shaft fractures are often caused by high-energy trauma with severe concomitant soft tissue injuries.

Question 80

How would you manage tibial shaft fractures?

Answer 80

Undisplaced transverse tibial shaft fractures:

1. Analgesia and immobilisation in a long leg plaster of Paris (POP) backslab.
2. Spiral and oblique fractures: immobilised in a long leg POP backslab. They are potentially unstable.

Displaced fractures: surgery

Question 81

What is a pilot fracture?

Answer 81

Distal tibial fracture

Question 82

What is a Toddler’s fracture?

Answer 82

Undisplaced spiral fractures of the tibial shaft in children under 7 years old often follow minimal trauma and may not be visible on initial X-ray.

Question 83

What nerve may proximal fibular fractures injure?

Answer 83

Common peroneal nerve, causing weakness of ankle dorsiflexion and reduced sensation of the lateral aspect of the forefoot.

Question 84

What is Maisonneuve fracture?

Answer 84

Transmitted forces may fracture the proximal fibula following an ankle injury.

This usually involves fracture of the medial malleolus and fracture of the proximal fibula or fibular shaft.

Question 85

How do ankle fractures present?

Answer 85

Immediate, severe pain, which may extend from foot to knee.
Swelling, localised or along the leg.
Bruising.
Tenderness.
Inability to weigh bear, although patients do sometimes walk on ankle fractures.
Joint deformity.

Question 86

How would you manage ankle fractures?

Answer 86

Treatment is determined by the stability of the ankle joint

Conservative treatment (in a cast) can be considered for:

1. Non-displaced fractures or anatomically reduced fractures - although functional outcome may be better if treated operatively.
2. Patients with serious comorbidities who are not fit for surgery.

Question 87

What is the most common type of foot fracture and how is it classified?

Answer 87

1. Proximal avulsion fracture:
   Fractures at the proximal tuberosity are very common and termed pseudo-Jones or tennis fractures (mid-shaft and distal fractures are much less common). They are usually associated with a lateral ankle strain and often follow inversion injuries of the ankle.
2. Jones fracture:
   Less common; this is a transverse fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal. Treatment involves an individualised approach tailored to the level of activity and time to union.