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Ortho/fracture > Upper Extremity > Flashcards

Upper Extremity Flashcards

0
Q

Division of axial load (%) supported by the distal radius and ulna/triangular fibrocartilage complex:

A

80% axial load by distal radius, 20% ulna/tfcc

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1
Q

Reversal of the normal palmar/voler tilt results in what in regards to axial load?

A

Reversal of the normal palmar tilt results in load transfer onto the ulna and TFCC. The remaining load is then borne eccentrically by the distal radius and is concentrated on the dorsal aspect of the scaphoid fossa

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2
Q

Which set of ligaments confer more stability to the radiocarpal articulation?

A

The volar ligaments are stronger and confer more stability than the dorsal ligaments

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3
Q

Most common mechanism of injury for distal radius fxs?

A

Fall onto an outstretched hand with the wrist in dorsiflexion

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4
Q

The radius initially fails in tension on the volar aspect, with the fx propagating _________.

A

Dorsally

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5
Q

Bending moment forces of the distal radius induce compression stresses resulting in _____ __________.

A

Dorsal comminution

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6
Q

Radiographic eval for distal radius

A

PA, lateral, oblique for further definition

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7
Q

Normal Radiographic relationship for radial inclination:

A

23 degrees (13-30)

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8
Q

Normal Radiographic relationship for radial length

A

11mm (8-18mm)

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9
Q

Normal radiographic relationship for Palmar (volar) tilt

A

Averages 11-12 degrees (range from 0 to 28)

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10
Q

Classification system for Colles fx based on intraarticular involvement

A

Frykman

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11
Q

Frykman classification system:

A

Extra-articular = type 1, + distal ulna fx = type 2
Intra-articular involving radiocarpal joint = type 3, + distal ulna fx = type 4
Intra-articular involving distal radioulnar joint (DRUJ) = type 5, + distal ulna fx = type 6
Intra-articular involving radiocarpal and DRUJ = type 7, + distal ulna fx = type 8

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12
Q

Mechanism based classification system for distal radius fx

A

Fernandez classification

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13
Q

Fernandez classification:

A

Type 1: metaphyseal bending fx with the inherent problems or loss of palmar tilt and radial shortening relative to ulna (DRUJ injury)
Type 2: shearing fx requiring reduction and often buttressing of the articular segment
Type 3: compression of the articular surface WITHOUT THE CHARACTERISTIC FRAGMENTATION; also the potential for significant interosseous ligament injury
Type 4: avulsion fx or radiocarpal fx-dislocation
Type 5: combined injury with significant soft tissue involvement owing to high energy injury

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14
Q

Extra-articular (original description) and intra-articular distal radius fx demonstrating various combinations of dorsal angulation (apex volar), dorsal displacement, radial shift, and radial shortening:

A

Colles fx

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15
Q

Exact mechanism of injury for Colles fx

A

Fall on hyperextended, radially deviated wrist with the forearm in pronation

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16
Q

Fx with volar angulation (apex dorsal) of the distal radius with a “garden spade” deformity or volar displacement of the hand and distal radius

A

Smith fx (reverse Colles)

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17
Q

Mechanism of injury for smith fx:

A

Fall onto flexed wrist with the forearm fixed in supination…produces unstable fx pattern

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18
Q

Shearing mechanism of injury that results in a fx-dislocation or subluxation of the wrist in which the dorsal or volar rim of the distal radius is displaced with the hand and carpus

A

Barton fx

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19
Q

Mechanism of injury for Barton fx

A

Fall onto a dorsiflexed wrist with the forearm fixed in pronation

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20
Q

An avulsion fx with extrinsic ligaments remaining attached to the styloid fragment

A

Radial styloid fx = chauffer’s fx, backfire fx, Hutchinson fx

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21
Q

Mechanism of injury for chauffeur fx

A

Compression of the scaphoid against the styloid with the wrist in dorsiflexion and ulnar deviation

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22
Q

Radiographic alignment parameters for acceptable reduction in an active, healthy pt

A

Radial length: within 2 to 3 mm of the contralateral side
Palmar tilt: neutral tilt, but up to 10 degrees dorsal angulation
Intra-articular step off less than two mm
Radial inclination less than five degree loss

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23
Q

How is carpal alignment measured on a lateral radiograph

A

By the intersection of 2 lines: one parallel and through the middle of the radial shaft and the other through and parallel to the capitate. If the two lines intersect within the carpus, then the carpus is aligned.

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24
Q

Factors associated with redisplacement following closed manipulation of a distal radius fx

A

1: the initial displacement of the fracture
2: the age of the patient
3: extent of metaphyseal comminution
4: displacement following closed reduction

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25
Q

Primary Nonoperative tx for distal radius fx

A

Closed reduction: accentuate, traction, opposite. Long arm “sugar tong” splint with the wrist in neutral or slight flexion. Leave the MCP joints free. 6 weeks or until Radiographic evidence of union

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26
Q

Primary operative tx for extra-articular fractures or 2 part intra-articular fxs of distal radius

A

Percutaneous pinning: 2 or 3 kirschner wires placed across the fx site, generally from the radial styloid directed proximally and from the dorsoulnar side of the distal radial fragment directed proximally

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27
Q

Technique of trapping the distal fragment by buttressing to prevent displacement by inserting wires radially and dorsally directly into the fx site, then levering up and directing into the fx site

A

Kapandji “intrafocal” pinning

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28
Q

Options for ORIF of distal radius

A

1: dorsal plating - fixation is on the compression side, avoids neurovascular structures on palmar side, associated with extensor tendon complications
2: volar nonlocked plating - primary indication is a buttress plate for the shear fx of the volar Barton
3: volar locked plating - stabilizes distal radius fxs with dorsal comminution

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29
Q

Position of the proximal humerus relative to the epicondylar axis

A

35-40 degrees retroverted

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30
Q

4 osseous segments of the humerus (Neer)

A

Humeral head, greater tuberosity, lesser tuberosity, humeral shaft

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31
Q

Deforming muscular forces on the osseous segments:

A

The greater tuberosity is displaced superiority and posteriorly by the supraspinatous and external rotators
The lesser tuberosity is displaced medially by the pull of subscapularis
The humeral shaft is displaced medially by pec major
Proximal segment abducted by deltoid insertion

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32
Q

Major blood supply to the proximal humerus

A

Anterior and posterior humeral circumflex arteries. Humeral head supplied by arcuate artery (continuation of the ascending branch of the anterior humeral circumflex

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33
Q

Nerve that you must watch out for in proximal humerus fxs 2/2 it’s course just anteroinferior to the glenohumeral joint

A

Axillary nerve

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34
Q

Most commonly used surgical approach for the proximal humerus

A

Deltopectoral

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35
Q

Classification system used for proximal humerus fractures

A

Neer

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36
Q

Neer classification of proximal humerus fxs

A

Four parts: greater and lesser tuberosities, humeral shaft, humeral head.
A part is defined as displaced if: >1 cm of fracture displacement or >45 degrees of angulation
Fracture types include:
One part fxs - no displaced fragments regardless of the number of fx lines
Two part fx - any displaced piece (anatomic neck, surgical neck, greater tube, lesser tube
Three part fx - surgical neck with greater tube, surgical neck with lesser tube
Others: four part, fx dislocation, articular surface fx

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37
Q

Tx of minimally displaced fractures (one part)

A

Sling immobilization or swathe for comfort. Pendulum exercises, passive range of motion exercises, then active ROM exercises at 6 weeks

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38
Q

Treatment of two part anatomic neck fx

A

ORIF or prosthesis (elderly). High incidence of osteonecrosis

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39
Q

Tx of two part surgical neck fx

A

If fx is reducible and good bone quality, can consider fixation with Percutaneous pins or cannulated screws

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40
Q

Tx for Two part greater tuberosity fx

A

If displaced more than 5 to 10 mm (5 for superior translation), require ORIF with or without RCR

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41
Q

Tx of two part lesser tube fx

A

Tx closed unless inhibiting internal rotation

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42
Q

Tx of three part prox humerus fxs

A

Unstable 2/2 opposing muscle forces, ORIF or hemi

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43
Q

Tx of four part proximal humerus fxs

A

ORIF with locking plate and screw fixation, suture, and/or wire fixation

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44
Q

Recommended tx for anatomic neck fx-dislocations

A

Hemi arthroplasty - high incidence of osteonecrosis. These injuries may be associated with a higher incidence of myositis ossificans with repeated attempts at closed reduction

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45
Q

Percentage breakdown of humeral shaft fxs

A

60% middle third of diaphysis, 30% proximal third of diaphysis, 10% distal third of diaphysis

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46
Q

Vascular supply to the humeral diaphysis

A

Arises from perforating branches of the brachial artery, with the main nutrient artery entering the medial humerus distal to the midshaft

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47
Q

Mechanism of injury to humeral shaft resulting in comminuted or transverse fx

A

Direct (most common mechanism overall)

48
Q

Mechanism of injury resulting in spiral or oblique midshaft humerus fxs

A

Indirect: fall on outstretched arm or rotational injury

49
Q

Type of force applied to produce the following fxs:

1: proximal or distal humeral fxs
2: transverse shaft
3: spiral shaft
4: oblique, often with butterfly fragment

A

1: compressive
2: bending
3: torsional
4: torsional and bending

50
Q

Descriptive classification of humeral shaft fxs

A

1: open vs closed
2: location - prox, mid, distal third
3: degree - displaced vs nondisplaced
4: direction and character - transverse, oblique, spiral, segmental, comminuted
5: intrinsic condition of bone
6: articular extension

51
Q

Percent of humeral shaft fxs that will heal with nonsurgical tx

A

90%

52
Q

Acceptable anterior angulation, varus angulation, and bayonet apposition that will not compromise function or appearance

A

20 degrees anterior angulation, 30 degrees varus angulation. 3 cm of bayonet appearance

53
Q

Indication for hanging cast nonoperative tx

A

displaced midshaft humeral fx with shortening, particularly spiral or oblique patterns

54
Q

Relative contraindications for hanging cast nonop tx

A

Short oblique or transverse

55
Q

Acute tx of humeral shaft fxs with minimal shortening, short oblique or transverse fxs that may displace with hanging cast

A

Coaptation splint

56
Q

Tx for minimally displaced or nondisplaced fxs that do not require reduction (shoulder/humerus)

A

Thoracobrachial immobilization (Velpeau dressing)

57
Q

Nonoperative tx indicated when the fx pattern necessitates significant abduction and external rotation of the UE (operative tx is usually performed for these indications)

A

Shoulder spica cast

58
Q

Preferred surgical approach for proximal third midshaft humeral fxs and the interval used. What nerve is identified between this interval?

A

Anterolateral, interval is between brachialis and brachioradialis. Radial nerve must be identified.

59
Q

Muscular interval of the anterior and posterior surgical approaches to midshaft humerus

A

Anterior: muscular interval between biceps and brachialis
Posterior: interval between the lateral and long heads of triceps. Medial head is split. Must ID radial nerve in spiral groove

60
Q

Surgical technique associated with the best functional results (does not violate the rotator cuff) and implant and fixation used

A

Open reduction and plate fixation with a 4.5 mm dynamic compression plate with 6-8 cortices of fixation proximal and distal to the fx. Lag screws used whenever possible

61
Q

Indications for IM nailing the humerus (3)

A

1: segmental fxs in which plate placement would require significant soft tissue dissection
2: extremely osteopenic bone
3: pathologic fxs

62
Q

2 types of IM nails and rationale for use of both in the humerus

A

1: flexible - fill the canal with multiple nails to achieve an interference fit. Use should be reserved for transverse or minimal comminution
2: interlocked - proximal and distal interlocking nails to provide rotational and axial stability.

63
Q

With antegrade nailing, what is at risk for injury while inserting the proximal locking screw?

A

Axillary nerve

64
Q

Distal locking of the humerus usually consists of a single screw in the AP plane. Why are these screws not inserted lateral to medial

A

Lateral to medial screws risk injury to the lateral antebrachial cutaneous nerve and the radial nerve

65
Q

The proximal aspect of an IM humerus nail should be countersunk to prevent what?

A

Subacromial impingement

66
Q

3 indications for external fixation of the humerus

A

1: infected nonunions
2: burn pts with fxs
3: open fx with extensive soft tissue loss

67
Q

Most common (overall uncommon) vascular injury in humerus fx? Locations? Amount of time preferred to reestablish arterial inflow?

A

Brachial artery at proximal and distal third. 6 hours

68
Q

Most common fx pattern of distal humerus fxs

A

Intercondylar

69
Q

The joint surface to shaft axis, or the trochlear axis compared with the longitudinal axis is how many degrees

A

4-8 degrees of valgus

70
Q

Rotation of the trochlear axis

A

3-8 degrees externally rotated

71
Q

The IM canal ends approximately where in the humerus?

A

2-3 cm above the olecranon fossa

72
Q

In nondisplaced fxs, an anterior or posterior “fat pad sign” may be present on the lateral radiograph, representing displacement of the adipose layer overlying the joint capsule in the presence of what?

A

Effusion or hemarthrosis

73
Q

Normal condylar shaft angle on lateral xray

A

40 degrees

74
Q

Operative tx for extra-articular supracondylar fxs

A

ORIF with plate fixation used on each column, either in parallel, 90 degrees or 180 degrees from one another

75
Q

Operative tx for transcondylar fxs of the distal humerus

A

Open reduction and plate fixation, usually with precontoured locking plates

76
Q

Mechanism of injury of most intercondylar fxs

A

Force is directed against the posterior aspect of an elbow flexed >90 degrees, thus driving the ulna into the trochlea

77
Q

Classification system for intercondylar humeras fxs

A

Riseborough and Radin

78
Q

Riseborough and Radin classification system

A

Type 1: nondisplaced condylar fx
Type 2: slight displacement with no rotation between the condylar fragments (T-condylar fx)
Type 3: displacement with rotation (T-condylar fx)
Type 4: severe comminution of the articular surface

79
Q

Indications and types of nonoperative tx for intercondylar fxs

A 
Nondisplaced, severe osteopenia and comminution, comorbid conditions. 
Cast immobilization (worst possible tx option-poor reduction and prolonged immobilization) or "bag of bones" to produce pseudoarthrosis
80
Q

Operative txs and indications for intercondylar fxs

A

ORIF- displaced reconstructive fx, use interfrag screw or dual plate fixation
Total elbow arthroplasty - markedly comminuted or osteoporotic bone

81
Q

Possible surgical approaches for intercondylar fx repair

A

1: tongue of triceps (Campbell’s)
2: olecranon osteotomy
3: triceps sparing extensive posterior approach (Bryan and Morrey)

82
Q

Mechanism of injury for most condylar fxs

A

Abduction or adduction with the elbow in extension

83
Q

2 classification systems used for condylar fxs

A

Milch and Jupiter

84
Q

Milch classification system

A

Key is lateral trochlear ridge:
Type 1: lateral trochlear ridge is left intact
Type 2: lateral trochlear ridge is part of the condylar fragment

85
Q

Nonoperative tx for condylar fxs (non or minimally displaced)

A

Posterior splinting with the elbow flexed to 90 degrees and the forearm in supination for lateral condylar fxs or pronation for medial condylar fxs

86
Q

Operative tx of condylar fxs

A

Screw fixation with or without collateral ligament repair

87
Q

Capitellum fx classification

A

Type 1: Hahn-steinthal fragment- large osseous component of capitellum, sometimes with trochlear involvement
Type 2: Kocher-Lorenz fragment - articular cartilage with minimal subchondral bone attached, “uncapping of the condyle”
Type 3: markedly comminuted (Morrey)
Type 4: extension into the trochlea (McKee)

88
Q

Nonop tx for capitellum fxs

A

For nondisplaced fxs - posterior splint for 3 weeks followed by ROM exercises

89
Q

Indication for operative tx and tx method for capitellum fxs

A

Indicated for type 1 displaced fxs via a posterolateral or posterior approach. ORIF

90
Q

Mechanism of injury for trochlea fxs (laugier’s fxs)? Nonop and op tx?

A

Mechanism: tangential shearing force resulting from elbow dislocation
Nondisplaced fxs get posterior splint for 3 weeks
Displaced get kirschner wires or screw fixation

91
Q

Operative indications for medial epicondyle fxs (4) with ORIF vs excision

A

1: displaced fragments with ulnar nerve symptoms
2: elbow instability to valgus stress
3: wrist flexor weakness
4: symptomatic nonunion of the displaced fragment

92
Q

Name for the fibrous arch connecting the supracondylar process with the medial epicondyle, and the structures that pass through this arch

A

Ligament of Struthers

Median nerve and brachial artery

93
Q

Provides valgus stability to the elbow? The anterior bundle is the primary stabilizer in what directions

A

Medial collateral ligament

Flexion and extension

94
Q

Structures that provide varus stability to the elbow joint

A

Static: lateral collateral ligament
Dynamic: anconeous muscle

95
Q

The capsuloligamentous structures of the elbow are injured in what direction of progression during dislocation of the elbow

A

Lateral to medial (Hori circle)

96
Q

Structures that usually require repair following dislocation of the elbow. Structure that doesn’t require repair and why

A

Trochlear notch, radial head, lateral collateral ligament.

MCL: will usually heal properly with active motion, repair not necessary for stability

97
Q

Classification of elbow dislocation (2, not specific names)

A

Simple vs complex (associated with fx)
According to the direction of the ulna in relation to the humerus: posterior, posterolateral, posteromedial, lateral, medial, anterior

98
Q

Fx classification name and system used for fx-dislocations of the coronoid process

A

Regan and Morrey - based on size of fx fragment
Type 1: avulsion of the tip of the coronoid process
Type 2: a single or comminuted fragment involving 50% or less of the coronoid process
Type 3: single or comminuted fragment involving >50% of the coronoid process

99
Q

Terrible triad of elbow injuries

A

Posterior dislocation with fxs of the radial head and coronoid process

100
Q

Most common vascular structure injured in elbow dislocations

A

Brachial artery

101
Q

Mechanism of injury and predictable fx pattern associated with each (2) for olecranon fxs

A

Direct: fall on point or direct trauma results in comminuted olecranon fx (less common)
Indirect: strong, sudden eccentric contraction of the triceps upon a flexed elbow typically results in a transverse or oblique fx

102
Q

Classification name for olecranon fxs and 3 factors taken into consideration

A

Mayo classification

1: fx displacement
2: comminution
3: ulnohumeral stability

103
Q

Mayo classification of olecranon fxs

A

Type 1: nondisplaced or minimally displaced; 1A is noncomminuted, 1B is comminuted. Tx is nonoperative
Type 2: displacement of the proximal fragment without elbow instability. Require operative tx. 2A are noncomminuted, tx by tension band wire fixation. 2B are comminuted and may require plate fixation
Type 3: instability of the ulnohumeral joint. Require surgery

104
Q

Fx classification of olecranon fxs based on fx pattern

A

Schatzker: transverse, transverse-impacted, oblique, comminuted, oblique-distal, fx-dislocation

105
Q

Nonoperative tx for olecranon fxs (reserved for nondisplaced mainly)

A

Immobilization in long arm cast or splint with elbow in 45-90 degrees flexion. May consider posterior splint

106
Q

Operative indications for olecranon fx (2), tx of choice, and other tx options

A

1: disruption of the extensor mechanism (any displaced fx)
2: articular incongruity.
TOC = tension band wiring in combo with 2 parallel kirschner wires. Indicated for avulsion type fxs.
Other: IM fixation: 6.5 mm cancellous lag screw fixation. Plate and screw fixation. Excision

107
Q

Tenderness to palpation or stress at the distal radioulnar joint, in association with a radial head fx, may indicate the presence of what lesion?

A

Essex-lopresti: radial head fx-dislocation with associated interosseous ligament and DRUJ disruption

108
Q

Radiographic eval for radial head fxs

A

AP, lateral, and oblique (Greenspan view)

109
Q

Radial head classification system name

A

Mason

110
Q

Mason classification system

A

Type 1: nondisplaced fx
Type 2: marginal fx with displacement (impaction, depression, angulation)
Type 3: comminuted fx involving entire head
Type 4: associated with dislocation of the elbow (Johnston)

111
Q

Relative indications (2) for operative tx of partial radial head fxs? Exposure used? Describe the safe zone in this tx?

A

Displacement of a large fragment >2 mm without a block to motion, or fx with block of motion. Kocher exposure. Safe zone is within 90 degree arc between the radial styloid and Lister tubercle

112
Q

Optimal fx for ORIF of radial head fxs and tx

A

Three or fewer articular fragments without impaction or deformity, each should be of sufficient size and quality to accept screw, little or no metaphyseal bone loss. Reconstruct with screws and place plate posteriorly with arm supinated.

113
Q

Eponym for Spiral fx of the distal radius resulting in compression/laceration of the radial nerve

A

Holstein-Lewis fracture

114
Q

Fracture-dislocation of elbow with associated coronoid process is secondary to:

A

Avulsion by brachialis muscle

115
Q

Types of Elbow Instability

A

Posterolateral rotatory instability, Varus posteromedial rotation instability, Olecranon fx-dislocations

116
Q

Instability scale (Morrey) for elbow dislocations

A

Type 1: Posterolateral rotatory instability, positive pivot shift test, lateral ulnar collateral ligament disrupted.
Type 2: Perched condyles, varus instability, lateral ulnar collateral ligament, anterior and posterior capsule disrupted.
Type 3a: Posterior dislocation, valgus instability, lateral ulnar collateral ligament, anterior and posterior capsule, and posterior MCL disrupted.
Type 3b: Posterior dislocation, grossly unstable, lateral ulnar collateral ligament, anterior and posterior capsule, anterior and posterior MCL disrupted

117
Q

Three general approaches to failed nonop tx of elbow dislocations:

A

Open reduction and repair of soft tissues back to the distal humerus, hinged external fixation, cross-pinning of the joint

Ortho/fracture (4 decks)

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