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
articulations of the elbow
Radioulnar- hinge
radiocapiellar- rotational
proximal Radioulnar joint- rotational
Normal ROM at elbow
0-150o flexion
80o pronation
85o supination
elbow stability
MCL primary medial stability- especially anterior band
- -full extension =30% of stability
- -90o flexion provides > 50% of stability
Mech of action
- posterior dislocation
- Anterior dislocation
post- elbow hyperextension, valgus stress, arm abduction, and forearm supination
Ant- force on posterior forearm with arm in flexed position
direction of injury to elbow capsule in dislocation
Most commonly Lateral to medial
–Hori circle
terrible triad of the elbow
- Posterior dislocation
- radial head fracture
- coronoid fracture
elbow reduction techniques
Parvin’s method
Meyn and Quigley’s method
per greg’s list
- Inline traction - corrects ant/post displacement
- -Supinate forearm - clears coronoid beneath trochlea
- -Flex elbow while placing pressure on tip of olecranon
operative indication for dislocation
- instability when placed in greater than 30o of flexion
- associated with unstable fractures
-address the LCL first with Suture anchors then reassess stability
Mechanism of injury of Olecranon fractures
Direct - Less common - fall on to the point of the elbow or direct trauma to the olecranon results in comminuted fractures
Indirect- more common- strong sudden eccentric contraction of the triceps upon a flexed elbow==> transverse or oblique fractures
Combination will produce displaced, commented fractures or fracture dislocations
Mayo classification based on what
1- fx displacement
2- comminution
3 ulnohumeral stability
-Guides treatment
olecranon fracture treatment
type 1- non operative
type 2A- tension band constructs
Type 2B- Plate fixation
Type 3- surgical treatment
Radial head fx mechanism of injury
- fall onto outstretched hand
- impaction with the capitellum
- –pure axial load, with post lateral rotatory force
- –with radial head dislocation in conjunction with Monteggia fx or post olecranon fx dislocation
- axial load at 0-35o = coronoid fx
- axial load at 0-80o = radial head fx
frequent association of ligamentous injury
Essex Lopresti fx
-radial head fracture- dislocation with associated interosseous ligament injury and DRUJ disruption
Fat pad sign - sensitivity anterior vs posterior
Posterior more sensitive
Greenspan View
45o Oblique Xray of the forearm with arm in neutral rotation to visualize the radiocapitellar articulation
Radial head fx operative indications
- Mason Type II with mechanical block
- -assessed with intraarticular lidocaine injection
- Mason Type III where ORIF feasible
- presence of other complex ipsilateral elbow injuries
Lateral kocher or kaplan approach- b/t anconeus and ECU
safe zone for hardware in radial head
Caputo - ~90 degree arc from radial styloid and Listers tubercle as intra operative guides
smith and hotchkiss- lines bisecting the radial head in full supination, full pronation, and neutral
Most common complications in olecranon orif
Symptomatic hardware in up to 80 % of patients
—hardware removal in 34 to 66 % of pts
Decreased ROM especially decreased extension but no functional decreases
Order of ossification of carpal bones
Capitate (then proceeds in counter clockwise fashionaccording to PA X-rays ) Hamate Triquetrium Lunate scaphoid Trapezium Trapazoid Pisaform
PA vs AP xray view of wrist
position of the ulnar styloid will determine which way film was taken;
- in standard PA view, the ulnar styloid is peripheral;
- in the standard AP position, the ulnar styloid points centrally
Gilula’s lines
First arc running along the proximal convexity of the scaphoid, lunate and triquetrum
Second arc running along the distal concavities of the scaphoid, lunate and triquetrum
Third arc running along the proximal curvatures of the capitate and hamate
treatment of non displaced condylar fx of elbow
milch type 1
immobilize in supination for lateral condyle fractures
immobilize in pronation for medial condyle fractures
non operative coronoid fx indications
regan Morrey classification types 1 2 and 3 that are minimally displaced with stable elbow
Operative indications for coronoid fx
ORIF with medial approach -indications ---Type I, II, and III with persistent elbow instability ---posteromedial rotatory instability ORIF with posterior approach -indications ---olecranon fracture dislocation ---terrible triad of elbow hinged external fixation -indications ---large fragments ---poor bone quality ---difficult revision cases to help maintain stability
Ossification centers and order of elbow
Capitellum (1 yr) Radial Head (2-3 yr) Medial epicondyle (5 yr) Trochlea (7yr) Olecranon (9 yr) Lateral epicondyle (11 yr)
Deforming forces of radial shaft fracture
- Weight of hand- causes dorsal angulation + sublet of distal radio ulnar joint
- Pronator quadratus insertion- pronation of distal frag
- brachioradialis-prox displacement and shortening
- thumb extensors and abductors-
Galeazzi fx mech
reverse galeazzi mech of onjury
- Galeazzi
- fall onto an outstretched hand with forearm pronation,
- -direct trauma to the dorsolateral aspect of the wrist
- Reverse
- fall onto an outstretched supinated wrist
Xray signs of DRUJ injury
- fracture at base of ulnar styloid
- widened DRUJ on AP xray
- Subluxed ulna on lateral Xray
- > 5mm radial shortening
Proximal radius fx treatment
any evidence of loss of radial bow or displaced fx = ORIF with 3.5 mm DC plate
Bennett fracture (type 1 fracture of thumb metacarpal base)
Intra articular fracture with proximal and radial dislocation of the first metacarpal. Triangular bone fragment is sheared off.
APL deforms the fracture
Rolando fx (type 2 fx of base of thumb metacarpal)
Intra articular fx with Y shaped configuration
Bennett fracture (type 1 fracture of thumb metacarpal base)
Intra articular fracture with proximal and radial dislocation of the first metacarpal. Triangular bone fragment is sheared off.
APL deforms the fracture
Rolando fx (type 2 fx of base of thumb metacarpal)
Intra articular fx with Y shaped configuration
Bennett fracture (type 1 fracture of thumb metacarpal base)
Intra articular fracture with proximal and radial dislocation of the first metacarpal. Triangular bone fragment is sheared off.
APL deforms the fracture
Rolando fx (type 2 fx of base of thumb metacarpal)
Intra articular fx with Y shaped configuration
