Upper limb

Question 1

What are the 6 grades of the Rockwood classification for Acromoclavicular joint disruption?

Answer 1

1- Essentially normal
2- <25% disruption
3- 25 - 100% disruption
4- Overt skin tenting and posterior fullness
5- > 100% + severe shoulder droop with no improvement on shrugging
6- Inferior dislocation of the lateral clavicle, usually associated other injuries (paraesthesias etc)

Question 2

What is the rough treatment based on the different Rockwood grades

Answer 2

1-2: Conservative Mx
3: Conservative Mx unless patient highly active/athlete
4-6: Surgical fixation

Question 3

What is an easy way to tell on Xray if the AC joint disruption is Rockwood 3 or greater?

Answer 3

If the lateral clavicle is entirely above the acromion (a straight lane in the horizontal plane does not transect them)

Question 4

What is a Hill-Sachs lesion and what is its significance?

Answer 4

A posterolateral humeral head depression fracture from anterior shoulder dislocation
It is associated with increase GH joint instability

Question 5

What is a Bankart lesion and what is its significance?

Answer 5

An anteroinferior glenoid depression fracture/labrum injury associated with anterior shoulder dislocations
It is associated with increased GH joint instability

Question 6

What is the lightbulb sign?

Answer 6

Seen in posterior shoulder dislocations when the head of the humerus rotates into the same axis as the glenoid

Question 7

What is the incidence and main causes of posterior shoulder dislocation?

Answer 7

2-4% of shoulder dislocation
FOOSH, high speed trauma, seizures (often bilateral) and ECT without paralysis

Question 8

What is the incidence of inferior dislocation and what are some of its features?

Answer 8

AKA luxatio erecta
<0.1%
Caused by sudden hyperabduction or load to proximal arm when arm is already abducted
Arm held in permanent hyperabduction

Question 9

How are fractures and dislocations described in terms of displacement or angulation?

Answer 9

Relative to the proximal bone
The proximal bone is said to be in anatomical position and the distal bone is displaced relative to this

Question 10

What is the elbow dislocation terrible triad and what is its significance?

Answer 10

Posterior dislocation + Coronoid process and radial fracture

Question 11

What do the sail sign and posterior fat pad sign represent?

Answer 11

An elbow joint haemoarthrosis with fat displacement, this may be obvious or occult
The most common occult cause is a non-displaced radial head or neck fracture

Question 12

What does the CRITOE mnemonic represent (Come Rub My Tree Of Love)

Answer 12

Capitellum 1yr
Radial Head 3yrs
Internal (medial) epicondyle 5yrs
Trochlea 7yrs
Olecranon 9yrs
External (lateral) epicondyle 11yrs

Question 13

In pediatric elbow injuries, what is the most common injury and what is the most common CRITOE injury

Answer 13

Supracondylar fractures overall
Internal (medial) epicondyle in the CRITOE system, often avulsed and should at least partially overlap with the humerus

Question 14

What is a Monteggia fracture? (MUGR)

Answer 14

A displaced midshaft ulnar fracture with an associated radial head dislocation

Question 15

What is a Galleazzi fracture? (MUGR)

Answer 15

A displaced radial fracture (usually distally) with an associated distal radioulnar joint dislocation

Question 16

What does the Terry Thomas/Madonna sign represent?

Answer 16

widened schapolunate space on wrist AP xray
Represents scapholunate dissociation with ligamentous injury and possible scaphoid subluxation/dislocation

Question 17

What do the “piece of pie” in AP and crescent sign in lateral represent on wrist xray

Answer 17

Lunate dislocation
This an orthopaedic emergency requires urgent relocation usually in theatre under GA

Question 18

What is the most sensitive test for Scaphoid fracture?

Answer 18

DEXA bone scan
Although MRI next base and much more practical/timely

Question 19

What are the features and importance of peri-lunate/Capitate dislocations?

Answer 19

This is an orthopaedic emergency
Often dorsal displacement of the capitate, difficult to spot in AP except for disruption of the normal radiocarpal lines

Question 20

Which upper limb bone is most likely to have pathological fractures from mets?

Answer 20

The Clavicle

Question 21

What is a typical shoulder xray checklist?

Answer 21

• Is the humeral head inferior to the coracoid? anterior dislocation
• Does the humeral head have a lightbulb appearance? posterior dislocation
• Is the humeral not parralel to the glenoid rim? posterior
• > 1.5cm coraco-clavicular distance? coracolavicular ligament injury
• Acromioclavicular distance wide?
• Fractures

Question 22

What is a mnemonic for determinig Hill-Sachs from Bankart lesion?

Answer 22

(H)ill Sachs is on the (H)humerus
(B)ankart is on the glenoid (B)rim