Upper Limb Fractures Flashcards
Management of midshaft clavicle #:
80% are middle third
Mostly conservative:
- Broad arm sling, 2-3 weeks
- Start moving it once comfortable
OT if:
- >100% overlapped
- >2cm shortened
- Skin tenting
- Associated injury +-
Associated injuries with clavicle #:
PTx/ lung laceration
Vascular
- Subclavian vessels
- Internal jugular
- Axillary
Brachial plexus
Other orthopaedic
- AC joint
- Shoulder disloc.
- Floating shoulder (concurrent scapula neck #)
- Ribs
Displaced MIDDLE thirds are at risk of NV injury:
–>CT chest + ortho
Displaced LATERAL thirds are at risk of coracoclavicular ligament injury:
–>Ortho
Scapula #
Uncommon
Associated with high-mechanism blunt trauma
Associated injuries common (80-90%) - CONSIDER CT
Types:
BODY
NECK
- Isolated
- With clavicle and/or AC disruption (‘floating shoulder’)
GLENOID
EXTRAS
- Acromion
- Coronoid
Management
- Check for: thoracic trauma (CT), floating shoulder
-Basically all are sling and conservative
- OT only if:
Displaced >1cm
Comminuted
Unstable glenoid
–> Intraartic, >4mm step-off, >25% involved
BANKART LESION
Tear of glenoid labrum
Result of anterior shoulder dislocation
Very, very commonly coexists with Hill-Sachs
Conservative Mx
Neer classification:
Proximal humerus fractures
Divides into 4 segments:
- Shaft
- Head
- Greater tuberosity
- Lesser tuberosity
How many parts displaced:
Ie.
>1cm
>45deg
1 part
= NO parts displaced
2 part
= ONE part displaced (segments)
3 part
= TWO parts displaced (3 segments)
4 part —> osteonecrosis and OT
= THREE parts displaced (4 segments)
Management of proximal humerus fractures based on NEER:
1 part
- Conservative
2 part
- OT if:
—> Tuberosities
—> Surgical neck (displaced OR angulated)
3 and 4 part
- OT
Risk of avascular necrosis of humeral head
Describe conservative Mx of proximal humeral fractures:
- Collar and cuff (or broad-arm, shoulder immobiliser)
- Early ROM (as soon as tolerated) to prevent frozen shoulder
- Ortho RF
Which nerve can be injured in proximal humerus #:
Axillary nerve
Supplies deltoid + teres minor in rotator cuff
ie. important!
Check:
- ’Badge’ area sensation
(Probs too sore for motor check)
Coronoid process #
Often along with radial head displacement or #
Check for “terrible triad!”
OT if >50% of process involved
What is a Monteggia injury:
ELBOW!! (‘A’ is proximal)
# of proximal ulna
PLUS
Dislocation of radial head
Associated with posterior interosseous nerve injury:
- Wrist drop
- Weak finger extension (at MCP)/ thumbs up
Types 1-4:
1- ANT displ radial
2- POST displ radial head
3- LAT “ “
4- Radius FRACTURED’
What is a Galleazi injury:
WRIST! (‘Z’ is distal)
# of distal radius
PLUS
Dislocation of DRUJ
ALL need ortho
All adults needs OT, kids can have CRPP
Isolated ular shaft #
AKA Nightstick #- defensive
Always look for the Montegg (if prox
Displaced >50% may need OT
or angled >10deg, torsional.
APPROACH TO WRIST XRAY:
PA and Lateral
1- Lateral
- Ensure Apple-cup-saucer alignment of radius, lunate, capitate
- Look for triquetral flake
2- PA
- 3 even ‘rows’ of joint space
- All uniform
- All 1-2mm
3- Individual carpals
4- Distal radius/ ulnar
- If possible impaction: radial inclination/ height measurements
- If distal rad #, look for Galleazi (DRUJ dislocation)
5- Soft tissues
Describe reduction technique for this #:
Colles
AKA metaphyseal# of distal radius
Dinner Fork
_____________
REDUCTION
*Biers good option
-
1- Disimpact with traction
(in-line or extension) - 2- Push back down
- 3- Push back ulnar
-
4- Firm, moulded (Charnley) cast ‘down and out’
–> Full pronation
–> Full ulnar deviation
–> Slight palmar flexion
Not extreme- carpal tunnel risk.
Despite high reduction success, very unstable and often displace again (60%)
Acceptable post-reduction position for a Colles’
< 5mm shortening (radial height)
< 5deg dorsal angulation
<5deg change in radial inclination
<2mm step within joint
Describe reduction technique for this #:
Smith’s
AKA Reverse Colles
Garden Spade
Fall onto back of hand
Reduction and positioning same as Colles, in reverse.
PLASTER:
- Full above-elbow- very unstable
- Supination, slight dorsiflexion. (“Oh well” position)
Like Colles’, very likely to displace (even more so)
Barton’s
Front or back surface of styloid shaves off
Resulting in:
Volar or Dorsal displcement of the fracture
ALONG WITH the RADIOCARPAL JOINT
ie. “Volar Barton fracture with associated volar dislocation of RCJ”
Unstable
If <50% joint surface involved, can trial conservative
(Reduce same as Colles/Smith)
Radial styloid #
AKA Chauffer’s
Unless minor, fragment displaces and allows scaphoid to fall out sideways
–> Scapholunate widening is common.
Undisplaced- cast
Any displacement- usually OT
Anatomy of the radiocarpal joint
Radius
with
Scaphoid, Lunate, Triquetrum
Disrupted in Barton’s fracture
Differentiate Barton’s and Radial styloid (Chauffer’s) … kinda similar!
Barton’s:
- Volar or palmar aspect of styloid shaves off obliquely
- Displaces volar or palmar direction
- Radiocarpal joint dislocates along with it
Radial styloid:
- Transverse fracture across styloid
- RCJ remains intact
- BUT, scaphoid can slide out sideways, causing scapholunate widening
Both are potentially unstable.
Unar styloid #
Small avulsion at tip doesn’t matter
At base, risk of DRUJ instability
What are radial height, and radial inclination?
Normal inclination = 23degr 15 - 25
Normal height = 11mm 8-14
Outside can indicate:
- Presence of radial # (incl. impaction)
- Need for surgical Mx of known #
Hill-Sachs
Indent of humeral head secondary to being pressed against glenoid whilst out
Conservative but:
Predisposes to future dislocations/ causes shoulder instability
APPROACH TO SHOULDER XRAY:
-
Identify coracoid. Good landmark, most anterior.
—> Coracoclavicular distance <13mm (<5mm diff to other side). - AC distance <6mm F, <7mm M
-
Humeral head:
—> Lightbulb/walking stick
—> DIRECTLY BELOW CORACOID? Ant. disloc.
—> If inferior to coracoid but not directly: subluxation.
—> #, Hill Sachs - Neck and shaft
-
Glenoid
—> Bankart
—> Overlap with humeral head
—> Haemarthrosis
