Upper limb fracture/dislocations Flashcards
Describe the Stimson technique for shoulder relocation
Patient lies prone on bed with affected shoulder over the edge. Weight 2-3kg suspended from wrist. Gentle continuous traction overcomes muscle spasm. Most reduce within 20-25 minutes.
Describe Scapula manipulation technique for shoulder manipulation
Set up patient in the Stimson manoeuvre. Rotate inferior border of the scapula medially while stabilising superior aspect of scapula with other hand. Add some external rotation of the humerus if needed.
Describe the FARES method for shoulder reduction
Patient supine. Traction on the arm. Small Anterior and posterior oscillating movements whilst slowly abducting arm. When abducted to 90 degrees add external rotation.
Describe the Milch manoeuvre for shoulder reduction
Patient supine. Downward traction at the elbow with gentle abduction and external rotation
Describe the Spaso technique for shoulder reduction
Patient supine. Vertical traction with the shoulder flexed to 90 degrees. Add small external rotation. (Pulling arm up and away). Add pressure on humeral head from axilla if required.
Describe the Cunningham method for shoulder reduction
Patient sitting with back straight. Shouder adducted with elbow flexed. Kneel down and gently put patients hand on your shoulder. Loop your forearm through and place your forearm on the forearm/cubital fossa of patient. Apply gentle constant traction with the weight of your forearm. Massage traps, deltoid and biceps. Repeat massage. Will reduce in 10 minutes. Pick you patient- calm and cooperative.
Contraindications to shoulder reduction in ED
-associated humeral neck fracture
-nerve injury/deficit
-suspected vessel injury
-Delayed presentation > 48 hours
Injuries associated with anterior shoulder dislocation
-greater tuberosity fracture
-hill Sachs lesion- compression lesion of the posterolateral aspect of the humeral head
-bankart lesion-fracture of anterior lip of glenoid fro impaction of humeral head during dislocation
What is a Hill Sachs deformity?
Wedge shaped defect on the posterolateral aspect of the humeral head from impaction on the anterior glenoid rim during dislocation.
What is a Bankart lesion?
-occur with anterior shoulder dislocation where humeral head is compressed against labrum. Can be a soft tissue lesion i.e. Labral tear. Can be a boney Bankart lessor which is an avulsion fracture anterior inferior aspect of the glenoid rim. Usually coexists with hill ash defect.
Which nerve is commonly injured with shoulder dislocation?
Axillary nerve- patch test
What is happening in this XR?
Intraarticular fracture of the humeral head with associated lipohaemarthrosis
What is happening in this XR?
Anterior shoulder dislocation
-humeral head sitting below the coracoid process on first view
-humeral head sitting anteriorly (towards the ribs) on the scapula Y view (not in middle of Mercedes benz)
-Hill Sachs defect on the Y view
What does the light bulb sign in this picture suggest?
Posterior shoulder dislocation.
Should be a walking stick shape.
Check the y view to confirm
What is this XR suggestive of?
Posterior shoulder dislocation
What mechanisms are most commonly associated with posterior shoulder dislocation?
-electrocution
-seizures
-high impact trauma- outstretched hand with internal rotation of shoulder
What are the complications of posterior shoulder dislocation?
-avascular necrosis of the humeral head
-acute recurrent dislocation
-posterior instability and recurrent dislocations
-functional incapacity
-post traumatic osteoarthritis
Associated with reverse Hill Sachs deformity- anteromedial surface of humeral head
often accompanied by fracture neck of humerus or tuberosity fracture
What is the method for relocation of a posterior shoulder dislocation?
Traction counter traction
Discharge advice for shoulder dislocations?
Anterior
-sling for 1-2 weeks
-avoid external rotation movements for 4-6 weeks
-follow up with physio
-may need stabilisation procedure if recurrent
Posterior
-sling in neutral or external rotation for 4 weeks
-avoid internal rotation
-follow up with physio +/- ortho
-may need stabilisation procedure for recurrent
What is the classification system for AC joint injury?
What is the discharge advice/management for the different grades of AC joint injury?>
-Grade 1- broad arm sling for 2 weeks
-Grade 2 board arm sling for 2 weeks and avoid heavy lifting and contact sports for 6 weeks
-Grade 3- conservative or surgical
-Grade 4 and 5 and 6- surgical
What is the Neer classification for humeral head fractures?
-Fracture classification of proximal humeral fractures
-Works on displacement and how many parts to the fracture
What structures are most likely to be damaged with proximal humeral fractures?
-axillary artery
-axillary nerve
-brachial plexus
What is the treatment of proximal humerus fractures?
One or two part fractures
-discharged
-early Ortho follow up- may need fixation
-collar and cuff
-early mobilisation and physion
3 and 4 part need immediate Ortho review
What structures damaged with mid shaft humeral fractures?
-brachial artery and vein
-ulnar median and radial nerve
Which structure is most likely damaged in a mid shaft humeral fracture and how do you test it?
-radial nerve
-wrist drop
-altered sensation first dorsal web space
How are midhsaft humerus fractures manages?
-U shaped plaster
-functional humeral brace
-surgery
CRITOE- what ages doe the ossification centres match up to?
C-1
R-3
I- 5
T-7
O-9
E-11
How old is this child?
2
How old is this child?
4
How old is this child?
5-6
How old is this child?
9-10
How old is this child?
11 +
What is happening with this 12 year olds elbow?
-Internal epicondyle avulsion
-Most common ossification centre avulsed
-I before T- internal epicondyle ALWAY ossifies before the Trochlear. So if you can see the trochlear but the Internal epicondyle is missing, it has moved somewhere.
Describe the Gartland Classification of Supracondylar fractures
Gartland 1- undisplaced fracture. no separation of the cortex
Gartland 2- separation of the anterior cortex, and angulation of distal segment. posterior cortex remains intact
Gartland 3- disruption of the anterior and posterior cortex- no cortical contact
What is the Gartland Classification of Supracondylar fractures
What is the treatment of Gartland fractures based on classification?
What are the reasons for immediate orthopaedic referral with supracondylar fractures?
-arterial compromise
-nerve compromise
-open fracture
-associated forearm injury on same arm
-Gartland 2 or 3
-unable to reduce and maintain position in ED
-flexion type (rare) where the distal fragment is displace anteriorly
What are the long term complications of Supracondylar fracture
-volkmanns ischaemic contracture of the forearm- can be avoided with treatment- missed compartment or brachial artery injury
-malunion- gun stock deformity
-nerve injury
Which structures are most commonly compromised with Supracondylar fractures?
-Median nerve- 50% (posterolateral displacement)
unable to complete OK sign, sensation loss molar surface of index finger
-Radial nerve- 30% posteromedial displacement
weakness risk extension and sensory loss dorsal them web space
-Brachial artery
reduced radial pulse
Early complications of Supracondylar fractures
-median nerve injury
-radial nerve injury
-Brachial artery injury
-compartment syndrome
Which nerve is most commonly injured with fractures to distal radius?
median
How do radial head fractures present?
-pain
-restricted movement of the elbow
Injuries to what other structures are associated with radial head fractures?
-distal radial ulnar joint subluxation
-elbow dislocation
What classification system is used for radial head fractures?
Mason Hotckiss
-1-< 2 mm displacement with no mechanical block
-2-may have mechanical block
-3- comminuted
-4- associated with elbow dislocation
What is the ED treatment of radial head fractures?
Sling
referral to orthopaedics- mechanical block difficult to assess in acute phase
