Upper Arm and Hands Trauma

Question 1

what is the most common cause of proximal humerus fracture?

Answer 1

low energy fall onto outstretched hand in osteoporotic bone or directly onto shoulder

Question 2

what is the most common pattern of fracture in the humerus?

Answer 2

fracture of surgical neck with medial displacement of humeral shaft due to pull of pectoralis major

Question 3

other fracture patterns in humerus?

Answer 3

avulsion of greater and lesser tuberosities due to attachment of rotator cuff muscles
isolated fractures of greater tuberosity
head splitting intra-articular fractures

Question 4

treatment of humeral neck fracture?

Answer 4

conservative - sling and gradual mobilisation - if minimally displaced
internal fixation if persistently displaced

Question 5

when is a shoulder replacement used?

Answer 5

3 or 4 part comminuted fracture

head splitting fractures

Question 6

how does a scaphoid fracture present and how is it diagnosed?

Answer 6

occur after FOOSH
tenderness in anatomical snuff box
pain on compressing the thumb metacarpal
difficult to diagnose on X ray so 4 views taken but sometimes still invisible until healing starts

Question 7

what views are taken of scaphoid fracture?

Answer 7

AP
lateral
2 oblique views

Question 8

what is a clinical scaphoid treatment?

Answer 8

if scaphoid fracture is clinically suspected but X ray fails to show it so wrist is splinted and further clinical assessment and X ray arranged in 2 weeks time

Question 9

how is a scaphoid fracture managed?

Answer 9

plaster cast for 6-12 weeks if undisplaced
compression screw sunk into bone to avoid non-union if displaced
screw fixation and grafting if non-union
partial/total wrist fusion of AVN

Question 10

complications of scaphoid fracture?

Answer 10

non union

AVN of proximal pole

Question 11

what structures are at risk in penetrating injuries to the hand?

Answer 11

volar injury = damage to flexor tendons and digital nerves/arteries
dorsal injury = damage to extensor tendons
- beware on examination a tendon can function even if partially ruptured

Question 12

when is surgical repair used in penetrating hand injuries?

Answer 12

tendon rupture
digital nerve injury proximal to DIP joints
injury to both digital arteries to a digit

Question 13

how are extensor tendon divisions managed if more than 50%?

Answer 13

surgical repair with splintage in extension for 6 weeks

Question 14

what is mallot finger and what causes it?

Answer 14

avulsion of the extensor tendon from its insertion into the terminal phalanx
caused by forced flexion of the extended DIP, often from a ball during sport

Question 15

how does mallot finger present and how is it treated?

Answer 15

pain
drooped DIP and inability to extend at DIP
treatment = mallot splint holding DIP in extension for 4 weeks

Question 16

why do injuries in flexor tendons cause problems?

Answer 16

as they need to run smoothly within tendon sheath and under the pulleys
run adjacent to digital nerves and arteries so are at risk of injury

Question 17

how are flexor tendon injuries managed?

Answer 17

partial divisions with a flap of tendon = smoothed out
significant partial lacerations or complete divisions = repair
fingers splinted in flexed position

Question 18

considerations with tendon repair?

Answer 18

tendon sheath requires careful repair to preserve pulleys to prevent bowstringing of the tendon

Question 19

what structures are at risk with flexor tendon injury?

Answer 19

interdigital nerves
radial and ulnar arteries
volar forearm injury = wrist, fingers and thumb flexors
median and ulnar nerves

Question 20

fracture of which metacarpals are treated conservatively?

Answer 20

3rd 4th and 5th

Question 21

what usually causes 5th metacarpal fracture and how is this managed?

Answer 21

punching injury (boxers fracture)
neighbour strapping
early motion
manipulation and neighbour strapping or wire stabilization of rotational alignment

Question 22

how are phalangeal fractures managed?

Answer 22

neighbour strapping
splintage
manipulation under anaesthetic or nerve block if displaced/angulated
K wiring or fixation with screws if unstable or intra-articular

Question 23

what is the most common cause of distal radial fractures?

Answer 23

fall onto outstretched hand

Question 24

what is a colles fracture?

Answer 24

extra articular fracture of distal radius within an inch of the articular surface and with dorsal displacement or angulation

Question 25

what injury are colles fractures associated with?

Answer 25

fall onto outstretched hand

Question 26

how are colles fractures treated?

Answer 26

depends on degree of displacement/angulation and dorsal comminution
minimal displacement = splintage
displacement >10 degrees volar = manipulation
fracture held with plaster case
- if comminuted or unstable = wires or ORIF + plate and screws

Question 27

what other injuries are colles fractures associated with?

Answer 27

ulnar styloid fracture
median nerve compression due to stretch or bleed into carpal tunnel
rupture of extensor pollicis longus tendon (late)

Question 28

how is median nerve compression associated with colles fracture managed?

Answer 28

reduction can relieve pressure and fracture stabilised with fixation
carpal tunnel can be surgically decompressed if needed

Question 29

what is a smith’s fracture?

Answer 29

volarly displaced/angulated extra-articular fracture of the distal radius

Question 30

what commonly causes smith’s fractures?

Answer 30

falling onto the back of a flexed wrist

Question 31

how is a smith’s fracture managed?

Answer 31

all undergo ORIF with plate and screws as V unstable

Question 32

what is a bartons fracture?

Answer 32

intra articular fractures of the distal radius involving dorsal or volar rim where the carpal bones sublux with the displaced rim fragment

Question 33

how are bartons fractures classified and how are they managed?

Answer 33

volar = intra articular smiths fracture
dorsal = intra articular colles fracture
all require ORIF

Question 34

what causes comminuted intra articular distal radius fracture and how is it managed?

Answer 34

high energy injury or poor bone quality
external fixation
sometimes supplementary wires used to pin large fragments