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MSK block > Upper Limb Fractures > Flashcards

Upper Limb Fractures Flashcards

1
Q

Define Fracture

A

Fracture is the (local) separation of an object or material into two, or more, pieces under the action of stress

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2
Q

List the 4 ways we classify fractures + what each means

A
  1. Open/Closed: communication with skin
  2. Complete/Incomplete: fragments 2 or more
  3. Simple/Comminuted: all cortex disrupted
  4. Direction
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3
Q

Apposition and alignment are defined in relation to ______ fragments

A

distal

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4
Q

List 5 terms used to describe apposition and alignment of fragments in a fracture

A
  1. displacement (medial lateral, posterior, anterior)
  2. angulation (medial, lateral, posterior, anterior)
  3. rotation (internal, external)
  4. overriding: overlap of fragments
  5. distracted: separated fragments
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5
Q

What type of fracture is shown

A

Complete fracture

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6
Q

What type of fracture is shown + define

A

Green Stick Fracture

Break of one cortical margin. Only with intact periosteum due to tension on soft growing bone

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7
Q

What type of fracture is shown + define

A

Torus Fracture

Buckling of cortex due to compression

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8
Q

Are smokers at an increased risk of fractures? Explain your answer

A

Smokers generally have lower bone density than non- smokers, so have a much higher risk of fractures.

Smoking also delays bone healing

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9
Q

Define a pathologic fracture + give 4 causes

A

Fracture at site of pre-existing osseous abnormality

Causes: tumor, osteoporosis, infection, metabolic disorder

(Image shows lucency at fracture site)

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10
Q

Compare a Stress vs Insufficiency fracture

A

(Fatigue) Stress Fracture are produced as a result of repetitive prolonged muscular action on bone that has not accommodated itself to such actions, activity related pain abating with rest

Insufficiency fractures occur when normal physiologic stress is applied to bone with abnormal elastic resistance/deficient mineralization

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11
Q

List 4 X-rays findings which may be seen with a stress fracture

A
  1. subtle blurring of trabecula margins
  2. sclerotic band (due to trabecular compression usually perpendicular cortex)
  3. gray cortex sign (subtle ill definition of cortex)
  4. Intra-cortical radiolucent striations (early)
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12
Q

What is seen on the X-ray below and therefore what type of fracture is this?

A

blurring of trabecula margins ➞ stress fracture

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13
Q

List 2 investigations to do if you suspect a stress fracture? (in additon to an X-ray)

A
  1. Bone Scan (gold standard)
  2. MRI
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14
Q

What may be seen on a bone scan in a patient with a stress fracture?

A

Stress fracture will appear as an area of increased uptake of tracer. Abnormal uptake is seen within 6-72 hours of injury ➞ prior to radiographic abnormality

If less intense (prefracture), ususally termed as stress reaction (focus of subtly increased uptake)

Abnormal uptake persists for months

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15
Q

Give 4 common sites for stress fractures to occur

A
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16
Q

Give 4 causes of an Insufficiency fracture

A
  1. osteoporosis
  2. paget/FD
  3. osteopetrosis
  4. osteomalacia/Rickets
  5. radiation
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17
Q

Give 3 X-ray findings indicative of an insufficency fracture

A
  1. Cortical lucency
  2. Periosteal reaction
  3. Sclerosis
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18
Q

List an MRI finding indicative of a Insufficiency Fracture

A

Marrow edema (low T1 High T2)

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19
Q

What type of fracture is this and why

A

Pelvic Insufficiency Fracture

  • Fracture line
  • Callus formation
  • Honda sign: asymmetric incomplete H-shaped pattern of sacral uptake
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20
Q

Pathological Fractures are based on what 4 characteristics?

A
  1. tumor location
  2. associated pain
  3. type of lesion (either lucent, mixed, or blastic)
  4. lesion size
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21
Q

How are tumours scored?

A

1-3

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22
Q

If tumour is scored an 8+ what is advised surgically?

A

Fixation

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23
Q

What is Salter Harris?

A

Classification for Epiphyseal plate Injury

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24
Q

State the following regarding Epiphyseal plate Injurys

  • peak age
  • most common location
  • upper vs lower limb prognosis
  • shear force/compression
A

Peak age: 12 y

Radius most common (30%) others incl phalanges, distal tibia, humerus, ulna

Lower limb = worse prognosis

80% shearing force; 20% compression

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25
Q

List the 5 Salter Harris classifcations and explain each

A
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26
Q

State the following about a Type I fracture on the SH classification

  • What/why
  • Location
  • Prognosis
A
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27
Q

State the following about a Type II fracture on the SH classification

  • What/why
  • Location
  • Prognosis
A
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28
Q

State the following about a Type III fracture on the SH classification

  • What/why
  • Location
  • Prognosis
A
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29
Q

State the following about a Type IV fracture on the SH classification

  • What/why
  • Location
  • Prognosis
A
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30
Q

State the following about a Type V fracture on the SH classification

  • What/why
  • Location
  • Prognosis
A
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31
Q

State the following about the SH classification:

  1. Type _____ is most common
  2. Types _____ & _____ are more prone to chronic disability
  3. Type _____ associated with growth disturbances and has a poor functional prognosis
A
  1. II
  2. III & IV
  3. V
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32
Q

List the 3 features of a Triplane Fracture

A
  1. vertical fracture of epiphysis
  2. horizontal cleavage plane within physis
  3. oblique fracture of adjacent metaphysis
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33
Q

List 2 complications of a Triplane Fracture

A
  1. progressive deformity from segmental arrest of germinal zone growth with formation of a bone bridge across physis = “bone bar”
  2. limb length discrepancy from total cessation of growth
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34
Q

What is meant by “ulnar variance” in a hand fracture?

A

Ulnar variance refers to the relative lengths of the distal articular surfaces of the radius and ulna.

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35
Q

What are the 3 types of ulnar variance and explain each

A

Neutral: both articular surfaces the same length

Positive: ulnar surface longer

Negative: ulnar surface shorter

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36
Q

What disease is associated with a positive vs negative ulnar variance

A

Positive ulnar variance is associated with Ulnar Impaction Syndrome.

Negative ulnar variance is associated with Kienbock disease

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37
Q

What is shown on the X-ray below?

What may a loss of these arcs indicate

A

Carpal Arcs: X-ray shows 3 arcs carpus intact

Loss of the arcs may indicate carpal dislocation

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38
Q

What are the 2 types of Intra-articular thumb metacarpal fractures?

A
  1. Bennett
  2. Rolando
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39
Q

What is a Bennett Fracture and how does it occur?

A

Intra-articular fracture-dislocation of base of 1st metacarpal due to forced abduction of thumb

Forced abduction causes fracture ➞ small fragment of 1st metacarpal, attached to anterior oblique ligament, continues to articulate with trapezium

Pull of AbPL causes dislocation ➞ displaced proximally

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40
Q

What is a Rolando Fracture and how does it occur?

A

Intra-articular Y/T shaped comminuted fracture through the thumb metacarpal

Mechanism: forced abduction of thumb

41
Q

Compare a Bennet vs Rolando Fracture

A

Both are intra-articular fractures at the base of the first metacarpal

BUT Bennet is not dislocated vs Rolando which is. Rolando is also comminuted (worse prognosis)

42
Q

What is a Boxer’s Fracture and where does it most commonlv occur?

A

Fracture of the MCP neck with volar angulation and often external rotation of the distal fragment

(Most commonlv 5th MCP)

43
Q

What is the most common fracture of carpus and how does it usually occur?

A

Scaphoid Fracture usually due to a fall on outstretched hand in young adults

44
Q

Give the 3 ways we classify a Scaphoid fracture based on location + state how common each is

A

Waist 70%

Proximal pole 20%

Distal pole, 10%

45
Q

A scaphoid fracture at which location are we most concered about and why?

A

The proximal pole

This is because blood supply to the proximal pole enters at the waist therefore the proximal pole is at high risk for nonunion and osteonecrosis

46
Q

A Scaphoid Fracture may be difficult to detect on plain film, what may we be able to see?

A

Loss of navicular fat stripe on PA view

47
Q

If a fracture is clinically suspected but not Radiographically detected what 3 things can we use

A
  1. Bonescan
  2. MRI
  3. Cast and repeat plain films in two week.
48
Q

Give the prognosis of a scaphoid fracture at each location

A

Waist fracture: 90% heal evenfually, 10% nonunion or proximal avascular necrosis (AVN)

Proximal fracture: high incidence of nonunion or AVN

Distal fracture: usually heals without complications

49
Q

Give 2 types of Carpal Fractures

A
50
Q

What fracture is shown below + explain

A

Baseball (mallet) finger

Dorsal avulsion of the extensor mechanism at the DIPJ ➞ results in inability to flex the DIPJ

(Can be with or without avulsion fragment)

51
Q

What fracture is shown below

A

Volar plate fracture: avulsion at base of middle phalanx resulting in hyperextension

52
Q

What is a Barton’s Fracture?

How would we treat?

A

Intra-articular fracture of the volar or dorsal margin of the distal radius. The carpus usually follows the distal fragment.

Unstable fracture requiring open reduction and internal fixation and/or external fixation.

53
Q

What is a Chauffeur Fracture

A

Triangular fracture of radial styloid process.

54
Q

What fracture is shown below + give its mechanism of injury

A

Colle’s Fracture

Mechanism of injury: fall on the out streched hand with the forearm pronated in dorsiflexion (most common injury to distal forearm)

55
Q

Give 4 Radiographic features of a Colle’s fracture

A
  1. Extra-articular fracture
  2. Distal radius is dorsally displaced/angulated
  3. Ulnar styloid fracture also occur in 50%
  4. Foreshortening of Radius
56
Q

Compare a Colle’s vs Barton’s Fracture

A

Barton’s = Intra-articular fracture

Colle’s = Extra-articular fracture

57
Q

Give 3 complications of a Colle’s fracture

A
  1. Median nerve injury
  2. Ulna nerve injury
  3. Osteoarthritis
58
Q

What is a Smith’s fracture

A

Same as Colles’ fracture except there is volar displacement and angulation of the distal fragment

59
Q

Give the 3 types of Smiths fractures

A

Type 1: horizontal fracture line

Type2: oblique fracture line

Type 3: intraarticular oblique fracture

60
Q

Give the 3 features of a Essex-Lopresti Fracture

A
  1. comminuted displaced radial head fracture
  2. dislocation of distal radio-ulnar joint
  3. rupture of the interosseous membrane (radiopedia)
61
Q

Give the 2 features of a Galeazzi Fracture and where does it most commonly occur?

A
  1. radial shaft fracture (most commonly) at junction of distal to middle third with dorsal angulation
  2. dislocation of distal radio-ulnar joint
62
Q

Ulnar plus variance (radial shortening) in a Galeazzi Fracture implies what?

A

complete disruption of interosseous membrane (instability of radio-ulnar joint)

63
Q

What is a Monteggia-type Fracture

A

Fracture of ulnar shaft + dislocation of radial head (4 types)

64
Q

Describe the 2 features of a Type I (classic) Monteggia fracture

State the mechanism of injury

A
  1. Anterior dislocation of radial head
  2. Anteriorly angulated proximal ulnar fracture

Mechanism: direct blow to the forearm

65
Q

Describe 2 features of a Type II (reverse) Monteggia fracture

A
  1. Radial head displaced posteriorly
  2. Dorsally angulated proximal ulnar fracture
66
Q

Describe 2 features of a Type III Monteggia fracture

A
  1. Anterolateral dislocation of radial head
  2. Ulnar metaphyseal facture
67
Q

Describe 2 features of a Type IV Monteggia fracture

A
  1. Anterior displacement of radial head
  2. Fracture of proximal third of radius + ulna at the same level
68
Q

What is the Fat Pad Sign and when is it seen?

A

Fat Pad Sign is seen when there is displacement of either/ both of the Anterior fat pad or Posterior fat pad of the elbow

Clinically these indicate there is elbow joint effusion due to supracondylar/lateral condylar/proximal ulnar or radial fractures

69
Q

What 4 important questions must we ask ourself in a suspected elbow fracture?

A
  1. Joint effusion?
  2. Normal allignment?
  3. Normal ossification centres?
  4. Subtle fracture?
70
Q

What 2 lines are we looking at when assessing elbow ‘allignment’

What is considered normal for each in children?

A

Radio-Capitellar Line ➞ line drawn down radial neck should intersect the capitellum

Anterior Humeral Line ➞ line drawn down anterior surface of humerus should intersect middle third of the capitellum

71
Q

Describe 3 features of a Supracondylar Fracture and how it usually occurs

A
  1. Transverse fracture line
  2. Distal fragment posteriorly displaced/ tilted
  3. Anterior humeral line does not intersect middle third of capitellum ➞ distal fragment posteriorly displaced/tilted

Mechanism: Hyperextension with vertical stress

72
Q

What classification is used for Supracondylar fractures + give the 3 types

A

Gartland Classification

type I: minimally displaced

type II: displaced distil fragment with intact posterior cortex

type III: complete displacement (posteromedial 75%, posterolateral 25%)

73
Q

What are the 2 sites where an avulsion fracture of the elbow occurs?

A

Lateral and Medial condyle

74
Q

Elbow avulsion fractures and supracondylar fractures almost always affect what age group?

A

Children!!

75
Q

How do Radial Head Fractures usually occur?

A

fall on outstretched hand

76
Q

On an X-ray of a radial head fracture the fracture line may be difficult to see. What other radioghraphic feature may be present?

A

Positive fat pad sign

77
Q

Give the 3 treatment options for a Radial Head Fracture and when each would be used

A

No displacement: splint, cast

More than 3 mm displacement on lateral view: open reduction and internal fixation

Comminuted: exicision of radial head

78
Q

Who do Humeral Head Fractures usually occur in?

A

common in osteoporotic elderly patients secondary to fall on outstretched hand

79
Q

What is meant by the ‘4-segment Neer classification’ for Humeral Head Fractures

A

Classified based on number and type of displaced segments.

4 segments: anatomical neck, surgical neck, greater tuberosity, lesser tuberosity.

80
Q

Give 2 Radiographic features of a Humeral Head Fracture

A
  1. Fracture lines according to Neer classification
  2. Pseudosubluxation: inferior displacement of humeral head due to hemarthrosis
81
Q

Clavicle Fractures are common in ______. The distal fragment is displaced ______ and ______.

A

children, inferior, medial

82
Q

What are the 3 sites of a clavicle fracture + how common each is

A

Lateral third: 15%

Middle third: 80%

Medial third: 5%

83
Q

What type of fracture is shown below?

A

Fracture to the lateral 1/3 of the clavicle

84
Q

What can be said about the acromium and clavicle radiologically in a normal person?

A

In the normal patient, the inferior surfaces of the acromion and clavicle are aligned

85
Q

What are the 3 grades of an Acromio-Clavicular dislocation

A

Grade I are radiographically normal

Grade II show widening of the joint with upward displacement of the clavicle

Grade III have a widened coraco- clavicular space 13 mm

86
Q

What fracture is shown on the X-ray below?

A

Acromio-clavicular dislocation

87
Q

How common are Scapula Fractures and how do they usually occur?

A

Uncommon, often caused by motor vehicle accident, fall from height (direct impact injuries).

88
Q

What is the best radiographic view to investigate a scapula fracture?

A

Transscapular view (Y-view), CT often helpful

89
Q

What is a Scapho-lunate Dissociation?

Give 2 radiological signs associated with this

A

Rupture of scapho-lunate ligament

  1. 3-mm gap between lunate and scaphoid - Terry-Thomas sign
  2. Ring sign on PA view secondary to rotary subluxation of scaphoid
90
Q

How are elbow dislocations defined and which is the most common

What fractures are often associated with this injury?

A

Defined by the relation of radius/ulna to distal humerus ➞

Posterior dislocations of both the radius and ulna are the most common type (90%).

Often associated with coronoid process or radial head fractures

91
Q

Compare a shoulder dislocation vs subluxation

A

Dislocation: separation of articular surface of glenoid fossa and humeral head that will not reduce spontaneously.

Subluxation: transient incomplete separation that reduces spontaneously

92
Q

Dislocation is divided into two large categories, what are these?

A
  1. TUBS (Traumatic, Unidirectional, Bankart, requires Surgery)
  2. AMBRI (Atraumatic, Multidirectional, Bilateral, Recurrent Instability)
93
Q

What does the X-ray below show?

A

Shoulder dislocation

94
Q

What are the 2 directions of shoulder dislocation?

How does each occur and which is most common?

A

Anterior dislocation (95%) and Posterior dislocation (5%)

Mechanism of injury

  • Anterior ➞ usually a blow to an abducted, externally rotated and extended arm
  • Posterior ➞ usually due to direct or indirect force
95
Q

On an X-ray of an anterior shoulder dislocation, the humeral head lies ______ and ______to glenoid

A

inferior, medial

96
Q

In anterior shoulder dislocation, 2 lesions can occur as the humeral head strikes the glenoid.

What is the name of these lesions and on which view are they most visible?

A
  1. Hill-Sachs lesion (posterior-superior and lateral) of humeral head, (best seen on Ap view with internal rotation)
  2. Bankart lesion (antero-inferior) of glenoid (may require CT)
97
Q

On an X-ray of a posterior shoulder dislocation, the humeral head lies ______ to glenoid. Posterior displacement is best seen on ______ view.

A

superior, axillary

98
Q

Give 3 Radiographic signs seen in a posterior shoulder dislocation + explain each

A

Trough sign: compression fracture of the anterior humeral surface

Light bulb sign: circular appearance of humeral head, due to arm fixed in internal rotation

Rim sign (66%): distance between medial border of humeral head + anterior glenoid rim >6 mm (widened)

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