upper limb and hand trauma Flashcards
what are the main causes of shoulder injury?
pretty common
usually due to falls and sporting injuries
who gets humeral neck fractures?
proximal humerus fractures are common
majority low energy injuries in osteoporotic bone
fall onto outstretched hand or directly onto the shoulder
most common type of humeral neck fracture?
usually fracture of the surgical neck (rather than anatomical neck) with medial displacement of the humeral shaft - due to pull of the pectoralis major muscle
greater and lesser tuberosities may also be avulsed (affects rotator cuff muscles)
can get isolated fractures of the greater tuberosity and head-splitting intra-articular fractures
how are humeral neck fractures?
Minimally displaced: conservative treatment with sling (position often improves once muscle spasm settles)
Persistently displaced: internal fixation (plates, screws, wires or IMN), stiffness, chronic pain and failure of fixation can occur esp. in older people
IF 3/4 part comminuted proximal humerus fractures: treatment is difficult and usually unsuccessful, may need shoulder replacement - may get rotator cuff dysfunction, range of motion is often limited
Head splitting fractures: usually require shoulder replacement unless patient is young with very good bone quality
which direction of gleno-humeral (shoulder) dislocation is more common?
Anterior dislocation - much more common than posterior (2-5% of all shoulder dislocation)
who is at risk of recurrent shoulder dislocation?
80% in patients under 20
20% in patients over 30
recurrent dislocations can be stabilised by a Bankart repair with reattachment of the torn labrum and capsule (open/arthroscopic)
what causes an anterior gleno-humeral dislocation?
usually excessive external rotational force/fall onto the back of the shoulder
what accompanying damage can an anterior gleno-humeral joint cause?
Bankart lesion (detachment of the anterior glenoid labrum and capsule)
posterior humeral head can impact on the anterior glenoid and cause a Hill-Sachs lesion (impaction fracture of the posterior head)
axillary nerve can be stretched as it goes through the quadrilateral space (other nerves of the brachial plexus/axillary artery can be stretched/compressed)
rotator cuff tears in older people
what is the presentation of an anterior gleno-humeral dislocation?
loss of symmetry
loss of roundness of the shoulder
arm held in adducted position supported by patients other arm
loss of sensation in the regimental badge area - axillary nerve injury
can also get fractures of the surgical neck and greater tuberosity
how is an anterior dislocation of the gleno-humeral joint diagnosed?
x-rays to confirm (if doubt) do 2 planes
how is an anterior gleno-humeral dislocation managed?
closed reduction under sedation/anaesthetic
do x-ray to cnfirm reduction
full distal neurovascular assessment (before and after reduction)
sling for 2-3 weeks
physiotherapy
may need an open reduction for delayed presentation dislocations e.g. alcoholics
how are fracture-dislocations which involve the surgical neck of the humerus managed?
usually require surgery (fractures of the greater tuberosity are usually sorted along with the closed reduction but if persistent dislocation then do ORIF)
what is the management of shoulder dislocation due to patient’s marked ligamentous laxity?
treatment is physiotherapy to strengthen the rotator cuff muscles (which are secondary retstraints to dislocation)
who gets posterior shoulder dislocations?
tends to be people with seizures (watch for bilateral dislocations, usually due to the muscle spasms, not necessarily the fall)
caused by posterior force on the adducted and internally rotated arm
may palpate the humeral head posteriorly
how is a posterior shoulder dislocation investigated and managed?
light bulb sign on AP X-ray
closed reduction and perios of immobilisation followed by physiotherapy
what causes acromioclavicualr joint (ACJ) injuries?
usually a fall onto the point of the shoulder
pretty common sporting injury
injuries in the ACJ?
sprained
subluxed or dislocated
in subluxations - acromioclavicular ligaments are ruptures
in dislocations - acromioclavicular ligaments and coracoclavicular ligaments (conoid and trapezoid ligaments) are ruptured
how are the ACJ injuries treated?
mostly conservative (sling for few weeks followed by physio surgery - for those with chronic pain and maybe in young athletes with dislocation (controversial) surgery is reconstruction of the coracoclavicular ligaments
what causes humeral shaft fractures?
can be caused by direct trauma (e.g. RTA) resulting in transverse/comminuted fractures
can be caused by fall with/without twisting injury - resulting in oblique/spiral fractures
how does a humeral shaft fracture heal?
union rates are high (90%)
angulation can be accepted due to the mobility of the ball and socket shoulder joint and elbow joint
what are the accompanying injuries that can be caused by a humeral shaft fracture?
can injure the radial nerve
- causes wrist drop
loss of sensation i the 1st dorsal web space
how is a humeral shaft fracture managed?
mostly non-operative - functional humeral brave
quicker recovery - internal fixation with IMN/plate and screws
polytrauma - IMN
non-unions require plating and bone grafting
what are the different elbow injuries?
supracondylar fractures
intra-articular distal humerus fractures
olecranon fracture
radial head and neck fractures
elbow dislocation and fracture dislocation
who gets supracondylar fractures of the elbow?
usually children
how are intra-articular distal humerus fractures managed?
ORIF
if highly comminuted fractures in the elderly - can consider elbow replacement
how are olecranon fractures managed?
common and usually occur with fall onto the point of the elbow with contraction of the triceps muscle
mostly treated with ORIF
