Upper Limb Flashcards
What is osteology of the clavicle?
S shaped bone- Flat laterally
Tubular centrally
Prism medially
Sup surface smooth
Inf surface rough
What are the muscular and ligamentous attachements of the clavicle
SCM medially
Pec major- when fractured pulls clavicle medially
Deltoid
Subclavius
Sternohyoid
Traps
Ligaments
Medially- sternoclavicular joint- sternoclavicular/interclavicular/costoclavicular
Laterally- ACJ
Acromioclavicular ligament
Coracoclavicular ligament- medially Conoid, laterally trapezoid
What type of joints are involved in the clavicle?
Sternoclavicular- synovial joint
ACJ- fibrocartillagenous joint
Describe the Allman’s classification of clavicles?
Into 1/3s
Medial- 5%
Middle- 80%
Lateral- 15%
Describe the Neer classification of clavicles
Lateral 1/3 clavicle fractures- all in relation to CC ligaments
Type 1- extra-articular, lateral to CC, non op
Type 2A- Medial to CC, operative due to high non union rate- 56%
Type 2B- Torn conoid +- Trapezoid lig, operative non union rate 30-45%
Type 3- intra-articular, lateral to CC, ACJ arthritis, non op
Type 4- physeal fracture- non op
Type 5- comminuted ##, intact CC ligs, operative
Important points in examination of clavicle?
Open?
Skin tenting- is the skin freely mobile?
Brachial plexus injury?
Suprascapular nerve injury?- jobe’s test negative
SCJ dislocation/mediastinal injury in medial 1/3 clavicle #s- if posterior displacement need CT + Cardiothoracic referral- emergency
Listen to Chest!!
Indication for operation on a clavicle?
Absolute:
Open/threatened
Polytrauma- floating shoulder
Subclavian A/V injury
Symptomatic non union
Relative:
Unstable # patterns- Neer 2a/b/5
Bilateral displaced #
Brachial plexus injury
Rib #s
Young sports injuries for quicker return to play
Reasons for operation?
Reasons again operation
on clavicles that is
Faster time to uninon, fewer non/symptomatic malunions, increased satisfaction
RCT 2007 Canadian OTS
Infection, NVI (supraclavicular nerve- sensation only- important in breast feeding)
Removal of metalwork very likely- ~30%
Pneumothorax
Frozen shoulder
What is the non operative management of clavicle fractures?
Sling- polysling
ROM exercises at 2 weeks
Strength exercises at 6 weeks
Sport at 4-6 months
How to assess any trauma patient?
ATLS
A2E
AMPLE
Allergies
Medication
PMHx
Last ate
Events
What is the most common nerve injury for shoulder discloation?
Axillary nerve injury- 5% of cases
Transient neuropraxia
How to assess axillary nerve function?
Deltoid and teres minor strength
Regimental patch
Axillary nerve course?
C5,C6 of posterior cord of brachial plexus
Through quadrangular space (with post circumflex humeral A)
What are the theoretical spaces in the axilla and what runs through them and boarders?
Fingers together
Quadrangular space- Axillary N, post circumflex A +V
Triangular space- circumflex scapular
Triangular interval- radial N, profunda brachii A
Boarders- Teres minor/major, medial/long head triceps
What are the associated bony/ligamentous injuries with a shoulder dislocation?
Bankart lesion-avulsion of the anterior labrum
Bony bankart- # of the ant.inf glenoid labrum
Hills sachs defect- chondral impact injury, present in 80-100% of dislocations
Rotator cuff injuries- 30% of those >40 years old, >80% of those greater than 60 years old
Superior labral tears from ant to post (SLAP lesions)
How to examine a shoulder dislocation?
A2E AMPLE
Nerves/vascular injury
Isolated injury?
Age
Hypermobility?
Imaging- Scapula Y, AP, modified trauma axial
How to manage a shoulder dislocation
Relocate in ED with sedation
My technique- traction counter traction with bed sheet in axilla
Avoid any rotation- can lead to a associated neck fracture
May need abduction in the axilla to unstick from hills sachs lesion
Other techniques:
Kocher’s,
Milch’s (supine + ER + ABDuction)
Stimpson’s (Prone + hanging on bed, traction + ER)
Dowson et al. for modified approach
Sedation in ED
Penthrox
Propofol
If un reducible, attempt reduction under GA
Assess for instability post reduction
Open reduction as back up
Once reduced- immobilise for 1 week and ensure has PT follow up for rehab
May need MRI if significant Rotator cuff injury- large tear in supraspinatus
Or if repeated dislocator
In my unit
<25 years old + symptoms for MRAtrhrogram to assess for labral injuries
> 40 years old for MRI to assess for rotator cuff injuries
Causes of posterior dislocation of shoulder?
Seizures/electric shock
Describe the anatomy of the proximal humerus?
GT and LT- LT is anterior, GT laterally facing
Head
Surgical neck- common site of fractures- more distal
Anatomical neck- site of old epiphyseal plate
What is the main blood supply for the head of the humerus?
Medially from the circumflex humeral Artery
How do you classify proximal humerus fractures?
Neer’s classification
Into parts- head, LT, GT and shaft
2o parts- fracture dislocation and head splits
When would you CT scan a proximal humerus fracture?
For pre op planning
if ?head split #
Or if GT/head position was uncertain
Intra-articular comminution
When would you MRI a proximal humerus fracture?
To assess for rotator cuff injury
Will guide your decision regarding a reverse vs total shoulder replacement
When would you operate on a fracture proximal humerus?
Patient and injury factors!!!
Absolute:
Open,NVI
GT fracture + >5mm displacement
Fracture dislocations
Head splits
Open
Vascular injury
Relative indications- Hurtle criteria
Young patients with 3/4 part #s
Failed non op management- non union/painful/traumatic osteoarthritis
RTSR better has less complications after failed non op management than failed operative management- Santana et al.
What did the Propher trial demonstrate?
Pragmatic trial
Surgical vs non surgical treatment of displaced proximal humerus #s
Mean age 66
No significant difference in outcomes between outcomes at 2 or 5 years
Cost analysis significantly worse for surgery
What is a pragmatic trial?
Evaluates the performance of treatment options in a real world clinical setting with a focus on patient centred outcomes. It aims to situations where there are clinical equipoise.
Describe the deltopectoral approach?
Internervous and intermuscular approach between axillary nerve (deltoid) and medial/lateral pectoral nerve (pec major)
Patient is position in beach chair + bolsters + head support
Landmarks are coracoid process/acromion/clavicle/humerus
Incision is along the deltopectoral groove
Skin, fat
Identify the cephalic vein overlying fascia- take laterally and divide medial perforators
Incise deltopectoral fascia
Deep dissection between deltoid and pec major
Identify conjoint tendon
Incised subscapularis tendon and reflect medially to access the joint capsule
Dangers are: Cephalic vein
musculocutaneous nerve 5-8cm distal to the coracoid process
Axially NVI all lie medial to the coracoid along with the brachial plexus
What are the cardinal signs of a flexor sheath infection?
Knavel’s signs
Sausage digit
Fixed flexion position
Pain on passive extension
Tenderness on palpation of the flexor sheath
Describe the function and the anatomy of the flexor sheaths?
Protect and nourishes tendons
Lots of variation but traditionally:
In index, middle and ring finger run from DIPJ to A1 pulley
Thumb runs from IPJ to radial bursa
LF runs from DIPJ to ulna bursa
what is the aetiology of a flexor sheath infection?
Penetrating trauma to the sheath
Direct spread from a felon/septic joint/ deep space infection
What are the common bugs causing a flexor sheath infection and the high risk groups?
Staph A/MRSA
Staph Epi
Beta haemolytic strep
Pseudomonas
Polymicrobials
High risk groups- immunocomprimised/Animal/human bits/DM/PVD/renal failure
What is the treatment of a flexor sheath infection?
Urgent washout + IV Abx + re washout
Incision is made over A1 and A5 pulleys + incision over flexor sheath
Insert cannula into sheath + gentle washout
Aspirate pus + send for samples
If there is purulent pus + ischaemic digit there is a 59% amputation rate as per Pang et al.
8% if just purulent and no ischaemia
Describe the anatomy of the flexor compartment of the forearm?
Superficial- FCU, Palmaris longus, FCR and pronator teres
Intermediate- FDS
Deep- FPL, FDS, Pronator quadratus
What is the nerve supply of FDP?
Radial 1/2 is medial
Ulna 2 fingers is ulna
Describe the pulley anatomy in the fingers?
Annular ligaments- prevent bowstringing
A1-A5
A1- MCPJ- trigger finger commonest
A3 PIPJ
A5 over DIPJ
A2- proximal phalanx
A4 middle phalanx
Cruiciate ligaments- prevent sheath collapse during flexion
C1 between A2 and A3
C2 between A3 and A4
C3 between A4 and A5
What is the blood supply of the scaphoid bone?
Retrograde- 80% from dorsal carpal branch of radial A
What are the boarders and contents of the anatomical snuffbox?
Ulnar (medial) border: Tendon of the extensor pollicis longus.
Radial (lateral) border: Tendons of the extensor pollicis brevis and abductor pollicis longus.
Proximal border: Styloid process of the radius.
Floor: Carpal bones; scaphoid and trapezium.
Roof: Skin.
Radial A
Superfiscial radial N
Cephalic vein- hosueman’s
When would you get a MRI for ?scaphoid fracture
If clinical concerns of scaphoid fracture but no sign on xray
What are the risk factors for AVN in scaphoid fractures?
Displaced
Multifragmentary
Proximal 1/3- 33%
Proximal 1/5- 100%
Patient factors- DM, smoking, PVD
What is the management of scaphoid injuries?
As per SWIFT study Undisplaced waist #s <2mm displacement- cast for immobilisation for 6 weeks- if non union for immediate fixation
> 2mm displacement at waist needs fixation
If proximal fracture/associate #s/scapolunate dissocation for fixation
Screw fixation - either percutaneous or ORIF
What is carpal tunnel syndrome?
Compressive neuropathy of the median nerve at the level of the wrist
What are the risk factors for carpal tunnel syndrome?
Pregnancy
Women
Obesity
Hypothyroidism
RA
Reptitive motion activities
What are the contents and the boundary of the carpal tunnel?
Contents- FDS, FDP, FPL and median nerve
Boundaries-
Formed laterally by the scaphoid and trapezium tubercles
Formed medially by the hook of the hamate and the pisiform
Flexorretinaculum sueprfiscially
What are the symptoms of carpal tunnel syndrome?
Numbness/tingling in radial 3.5 digits
Pain/parasthesia at night
Clumsiness
What are the signs of carpal tunnel syndrome?
Thenar atrophy
Hand diagram of symptoms- most specific test
Durkan’s test- compression for 30s
Phalen’s- reverse prayer for 30-60s
Tinnel’s tapping for 30s
Why may some patients get sparing of sensation over the thenar eminence?
Palmar cutaneous branch given off pre tunnel- so not affected compression
How do you investigate/diagnose carpal tunnel syndrome?
Clinical diagnosis
Nerve conduction studies are useful.
Corticosteroid injection
What is the management of carpal tunnel syndrome?
Conservative- non op, activity modifications
Medical- NSAIDs
Corticosteroid injection- 80% have transient improvement. 20% of these symptom free at 1 year. Can be diagnostic in equivocal cases
Operative- carpal tunnel decompression
How do you perform a carpal tunnel decompression?
M + C
WHO Checklist
Supine
Arm board
LA + Tourniquet + Abx at induction
Standard Ortho set
Pre and drape
Incision is from intersection of Kaplan’s line with radial boarder of index finger to distal wrist crease- if needing to cross wrist crease zig zag
Skin fat
Identify the flexor retinaculum
Macdonalds beneath to protect medial nerve
Cut as ulnarly as you can to avoid possible recurrent motor branch injury
Check flexors freely moving post release
Caution- palmar cutaneous branch- comes off between PL and FRC
Recurrent motor branch off median nerve- 50% extraligamentous (post CT), 30% subligamentous (given off within CT), 20% transligamentous (pierces CT)
What is the difference between a perilunate and a lunate dislocation?
Mayfield stage 3 vs stage 4
Perilunate- lunate stays in the correct position and the carpal bones dislocate
Lunate dislocation- lunate dislocates
How do you classify lunate dislocations and correlate this with the pathoantomy?
Mayfield stages
Stage 1- scapholunate dissociation
Scapholunate ligament disrupted
Stage 2- perilunate dislocation
Disruption of capitolunate articulation
Stage 3- Midcarpal dislocation
Disruption of Luniotriquetral articulation
Stage 4- lunate dislocation
Failure of dorsal radiuocarpal ligament
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Associated injuries in lunate/perilunate dislocation?
Scaphoid- v common
Other carpal bones
Radius/ulna #s
What common neurovascular injury is associated with a lunate dislocation?
Median nerve symptoms in ~25%
How do you manage the perilunate/lunate dislocation?
Emergent closed vs open reduction
Fingertraps- 15mins +2-4kg hanging weight
Pull carpus up and over- extension traction + flexion.
With applied dorsal pressure
Good sedation needed
Open reduction- ligamentous repair, fixation +/- carpal tunnel release
Describe the anatomy of the median nerve?
From lateral and medial cord of brachial plexus- C5-T1
C5-C7 lateral contributors provide sensation to hand and motor to PL and PT
C8-T1 medial contributors supply long flexors + intrinsics
Runs lateral to brachial artery in the arm crossing to medial at the mid humerus
Crosses into antecubital fossa- R TAN- from lateral to medial:
Radial nerve, biceps tendon, brachial artery, median nerve
Exits fossa by passing through 2 heads of pronator teres
Gives AIN which supplies PQ , FPL and radial half of fdp
Runs between FDP and FDS
Gives off palmar cutaneous branch 5cm proximal to wrist crease
Runs under the carpal tunnel
Recurrent motor branch given off- may be extra, trans or sub ligamentous
Terminates in digital cutaneous branch
Describe the anatomy of the musculocutenaous nerve?
Comes from lateral cords C5-C7
Pierces coracobrachialis
Runs between biceps and brachialis
Lateral to biceps tendon at the elbow
terminating in lateral cutaneous nerve of the forearm
Supplies Biceps brachii, coracobrachialis and brachialis
Describe the anatomy of the ulnar nerve?
Comes from medial cord C8-T1
Runs along posteromedial aspectof brachial artery and humuer
us
Pierces intermuscular septum at atcade of struthers 8cm proximal to medial epicondyle
Runs in cubital tunnel- post to medial epicondyle
Exits through 2x heads of FCU
Travels under FCU between FDP with ulnar a
Enters the hand through guyon’s canal
What is the ulnar paradox?
The more distal the lesion the more severe the clawing the of the hand
Due to the fact that a high ulnar lesion will cause paralysis of the ulnar half of FDP as well as intrinsic muscles
Whereas in low lesions FDP is not paralysed so there is unopposed action of it leading to clawing
Describe the course of the radial nerve?
From posterior cord- C5-T1
Exitrs through the triangular interval with profunda brachii giving off motor supply to triceps
Runs in the spiral groove along the posterior aspect of the humerus between medial and lateral heads of triceps
Pierces lateral intermuscular septum 8cm proximal to lateral epicondyle
Runs anterior to lateral epicondyle along lateral boarder of antecubital fossa
Divides into Superfiscial radial nerve- runs betweemn brachioradialis and FPL
Posterior interosseous nerve- runs through supinator
Arcades of frohse run over the nerve at this point (supinator arch)
What is Hertle’s criteria for prox humeral #s?
Predicts humeral head ischaemia
Increased # complexity
Displacement >10mm
Angulation of >45o
>8mm of calcar length attached to articular segment
Medial hinge disrupted
When to consider operative vs non operative treatment of olecranon #s?
Non op- non op if undisplaced in low demand + good ROM
R/V at 1 week + early ROM exercises
Operative if displaced (Tension band wiring)
ORIF if comminuted/monteggia’s/fracture dislocation/coranoid inolvement
What is the terrible triad of elbow injuries?
Elbow dislocation (posterolateral)
Coranoid process #
Radial head #
Ix of choice for a medial 1/3 clavicle fracture and scenarios where it is essential?
CT scan
Assess posterior displacement
Esp if
Hoarse voice
SOB
Hypotension
SCJ dislocation
Describe the flexor zone of injury?
1- FDP to FDS insertion
2- FDS to A1 pulley
3- A1 pulley to carpal tunnel
4-Carpal tunnel
5- carpal tunnel to forearm
What are the extensor compartments at the wrist?
Radial to ulna
1- APL + EPB
2- ECRB + ECRL
3- EPL
4- EI + EDC
5- EDM
6- ECU
When to consider operative fixation for distal radius fractures?
Unstable fractures- volar
Irreducible intra-articular fractures
If under 65 years old and non reducible
What xray parametres may you consider when thinking about operative fixation in distal radius fracutres?
Dorsal tilt (normal is 11o of volar tilt, acceptable is 5o of dorsal angulation)
Ulna variance (radial height in reality- but official neutral is when the ulna is level with the lunate fossa)
Intra-articular step >2mm
When to operate on distal radius fractures?
As per BOAST
Within 72 hours for intra-articular fractures
Within 1 week for all extra-articular
How to decide between K wires and ORIF for distal radius fractures?
ORIF if unstable fracture pattern
K wires if able to reduce the fracture closed
What evidence is there for distal radius fracture management?
Draft 1 and 2
Draft 1
Extra-articular dorsally displaced DRs
K wires vs ORIF
Pragmatic, multi centred
No difference in primary outcome
K wires quicker and cheaper
Kwire had increased rates of loss of position
Draft 2
Dorsally displaced DRs
Non reducible, close intra-articular #s excluded
No difference in outcomes between k wires and cast
Significant number of patients lost position in cast so needed reoperation
Describe the FCR approach the wrist?
Appropriately marked and consented patient
GA
Supine + arm board
Tourniquet vs LA + adrenaline
Upper limb pre and drape
Internervous incision- AIN (FPL) and Median nerve (FCR)
Mark on FCR, 10cm incision, if crossing wrist crease then z across
Superfiscial
Skin, fat
Find FCR tendon + expose, retract ulnarly
Incise through muscle belly of FPL + take ulnarly
Watch out for radial artery- v close
Expose PQ
L shaped incision to take off- dont go into joint
Watch out for median nerve Ulna
Periosteal elevator to expose fracture site
Stryker Variax plate
Can release BR to help reduction
Watch out for
Radial A- radial to FCR
Median N- between FDS and FDP
Palmar cutaneous branch- Ulna to FCR, 5cm proximal to wrist crease
Volar wrist capsule
Volar approach to the forearm explain?
Marked + consented
Supine + arm board
GA + tourniquet to 250mmHg
Internervous approach between radial and median nerve
(BR + FCR)- take radial artery ulnarly, SPN laterally
Incision
Lateral to biceps tendon and elbow crease to radial styloid
Superfiscial
Incise fascia between BR and PT/FCR
Deep
prox 1/3- supinated position, remove supinator from radius
middle 1/3- pronate bring PT insertion into view on lateral radius- release
distal 1/3- retract FCR and incise PQ
Watch out for PIN- between superfiscial and deep supinator heads- take supinator off subperisoteally
Radial A
SRN- runs under BR/lateral to radial A
How to perform forearm fasciotomies
M+C
WHO sign/time out
Supine arm board
Tourniquet
Standard ortho set
VAC
10 + 15 blade
Incisions
Volar
S shaped incision from medial epicondyle to radial to FCU, can extend into Carpal tunnel decompression. Retract FCU ulnarly to expose deep compartment.
Dorsal
2cm distal to lateral epicondyle + to mid wrist
1 compartment + mobile wad
EDC + ECRB interval
What are you looking for when assessing compartments during faciotomies?
Do the compartments ping open?
Assess for
Colour
Consistency
Contractility
CRT
Debride
VAC
relook in 48 hours
Delayed 1o closure
How to do hand fasciotomoies
Carpal tunnel release
Dorsal incision over 2nd and 4th MCP
Radial side of 1st MCP
Ulna side of 5th MCP
What are the deforming forces in a midshaft clavicle fractures
Main ones
SCM pulling medial aspect superior
Weight of arm pulling lateral part inferior
Pec major also pulling inferior part medially to shorten
Classification system for olecranon fractures?
Mayo classification
A vs B (simple vs comminuted)
1- Non displaced
2- Displaced
3- Unstable (fracture dislocation)
Indications for non operative management of olecranon #s?
Non displaced with intact extensor mechanism
Low demand elderly frail
1 week of cast then rehab
What are the stabilisers of the elbow?
Primary static:
Ulnohumeral joint- coronoid
MCL
Lateral collateral lig complex
Secondary static:
Joint capsule
Common flexor and extensor origins
Radiocapitellar joint
Dynamic stabilisers:
Muscles crossing the elbow joint
Brachialis, Aconeus, triceps and biceps
How to manage a humeral shaft fracture with a radial nerve palsy?
Seen in 8-12% of closed fractures. Increased in distal 1/3 fractures.
BOAST guidelines for PNI
Neuropraxia is commonest in closed #s
Neurotmesis is commonest in open #s
Management options:
Conservative- 90% recover at 3 months. Perform EMG at 2 months for prognosis
Surgical- Open fracture with palsy, closed fracture failing to improve, fibrillations on EMG
Complications of scaphoid #s?
Avascular necrosis
Non union
Mal union
SNAC- scaphoid non union advanced collapse (chronic scaphoid non union- arthritis- options include stylectomy + stabilisation, proximal row carpectomy)
Commonest organisms in animal and human bites?
Ekinella for humans
Pasturella for animals
Associated injuries with clavicle fractures?
Pneumothorax
Rib #s
Mediastinal injury if medial 1/3 #
ACJ injury
Coracoclavicular injury
Scapula #- scapulothoracic dissociation
NVI
