upper extremity Flashcards
indications for clavicle shaft fx surgical fixation
indications
absolute
▪ open fxs
▪ displaced fracture with skin tenting
▪ subclavian artery or vein injury
▪ floating shoulder (clavicle and scapula neck fx)
▪ symptomatic nonunion
▪ symptomatic malunion
▪ relative and controversial indications
▪ displaced Group I (middle third) with >2cm shortening
▪ bilateral, displaced clavicle fractures
▪ brachial plexus injury (questionable b/c 66% have spontaneous return)
▪ closed head injury
▪ seizure disorder
polytrauma patient
indications for clavicle distal 1/3 fractures fx surgical fixation
absolute
▪ open, or impending open, fractures
▪ subclavian artery or vein injury
▪ floating shoulder (e.g., distal clavicle and scapula neck fx with >10mm of displacement)
▪ symptomatic nonunion
relative
▪ unstable fracture patterns (Type IIA, Type IIB, Type V)
▪ brachial plexus injury (questionable b/c 66% have spontaneous return)
▪ closed head injury
▪ seizure disorder
polytrauma patient
Operative indications for SC joint dislocation
ORIF indications posterior dislocation with dysphagia shortness of breath decreased peripheral pulse
MEDIAL clavicle resection
chronic/recurrent SC dislocation (anterior or posterior)
persistent sternoclavicular pain
Indications for scapula ORIF
indications
glenohumeral instability
> 25% glenoid involvement with subluxation of humerus
> 5mm of glenoid articular surface step off or major gap
excessive medialization of glenoid
displaced scapula neck fx
with > 40 degrees angulation or 1 cm translation
open fracture
loss of rotator cuff function
coracoid fx with > 1cm of displacement
X-rayevaluation of Anterior shoulder dislocation
Trauma series- AP(true AP), scapular Y, axillary
- preproduction views in 1st time dislocater, age >40, high energy trauma - Velpeau - west point axillary-prone w/ beam 25o from midline and horizontal - hill sachs view( maximal internal rotation for post lat defect) - Stryker notch-post lateral humeral defects
shoulder reduction techniques
stimson
hippocratic
traction-counterttraction
Milch
surgical indications for ant shoulder dislocate
- first time dislocation in young active male
- soft tissue interposition
- Displaced Greater Tuberosity >5mm after reduction
- Glenoid rim fx >5mm
signs of posterior shoulder dislocation on true AP
- absence normal elliptical overlap of Humeral head and glenoid
- vacant glenoid sign-(space b/t ant rim and humeral head >6mm)
- trough sign-Impact fx of the ant humeral head caused bu post glenoid( reverse hill sachs)
- loss of humeral neck profile
- void inf and sup glenoid fossa
—however most readily noticed on axillary view
surgical indications for post shoulder dislocate
- major displacement of associated lesser tuberosity fx
- large post glenoid fragment
- irreducible/impaction fx on post glenoid preventing reduction
- open
- Reverse hill sachs
- 20-40% humeral head involve= modified McLaughlin procedure
- > 40% humeral head- Hemiarthroplasty
superior glenohumeral ligament
- from anteriosuperior labrum to humerus
- restraint to inferior translation at 0° degrees of abduction (neutral rotation)
- prevents anteroinferior translation of long head of biceps (biceps pulley)
middle glenohumeral ligament
resist anterior and posterior translation in the midrange of abduction (~45°) in ER
Coracohumeral ligament (CHL)
- from coracoid to rotator cable
- limits posterior translation with shoulder in flexion,adduction, and internal rotation
- limits inferior translation and external rotation at adducted position
Coracohumeral ligament (CHL)
- from coracoid to rotator cable
- limits posterior translation with shoulder in flexion,adduction, and internal rotation
- limits inferior translation and external rotation at adducted position
Xrays for proximal humerus fx
true AP, lateral Y view, axillary view best for glenoid articulation, velpeau (standing leaning 45o back with caudally directed beam)
- CT for intraarticular
- MRI non indicated, but good for cuff tear
Neer Classification
4 parts- greater tuberosity, lesser tuberosity, humeral shaft, humeral head
part define- >45o angulation or >1 cm displacement
one part- no displaced frags regardless of # of fx lines
2 part
3 part- sure neck w/ greater or surge neck w/ lesser
4 part
fx dislocation
Articular surface fx- impression or head split
Neer one part fx treatment
sling and swathe
early passive ROM at 7-10 days
Active ROM at 6 weeks
full ROM at 1 year
Neer 2 part fx treat
anatomic neck- rare- ORIF in young and arthroplasty in older
Surgical neck- IM Rod,
neer 3 part treat
need to finihs
near 4 part treat
need to finish
X-ray evaluation of humeral shaft fracture
AP and lateral X-rays (rotate the patient!!! not the arm b/c can cause rotation of the injury
- Traction views are helpful
- joint above and below
Acceptable reduction of Humeral shaft fx
> 20o anterior angulation
30o varus angulation
3cm shortening
Coaptation vs hanging cast
Coaptation splint for fx w/ minimal shortening and transverse or short oblique fx
Hanging arm cast for displaced mid shaft fx with shortening particularly spiral and oblique patterns
-both switched to functional bracing 1-2 weeks after injury
surgical indications for humeral shaft fx
Absolute indications for ORIF
- -open fracture
- -vascular injury requiring repair
- -brachial plexus injury
- -ipsilateral forearm fracture (floating elbow)
- -compartment syndrome
relative ORIF indications
- -bilateral humerus fracture
- -polytrauma or associated lower extremity fracture
- -pathologic fractures
- -burns or soft tissue injury that precludes bracing
Relative indications for IMN
- -pathologic fractures
- -segmental fractures
- -severe osteoporotic bone
- -overlying skin compromise limits open approach
- -polytrauma