upper limb fractures and dislocations Flashcards
for the following images identify the fracture or dislocation
[55]
clavicle fracture
for the following images identify the fracture or dislocation [56]
proximal humerus fracture
for the following images identify the fracture or dislocation [57]
acromioclavicular joint dislocation
for the following images identify the fracture or dislocation[58]
anterior and posterior shoulder dislocation x ray
for the following images identify the fracture or dislocation[59]
elbow dislocation simple and complex
for the following images identify the fracture or dislocation[60]
radial head fracture
for the following images identify the fracture or dislocation[61]
forearm fractures
for the following images identify the fracture or dislocation[62]
distal radius fracture
for the following images identify the fracture or dislocation[63]
scaphoid and other carpal fractures and dislocations
for the following images identify the fracture [64]
metacarpal and phalangeal fractures
who gets clavicle fractues
young active patinets
where anatomically do clavicle fractures occur
80% middle third
15% lateral third
5% medial third
mechanism of injury in clavicle fracture 2
FOOSH- fall on outstreched hand)
direct blow to shoulder
-cyclist
treatment for clavicle injury 2
usually conservative
-broad-arm sling w follow up XRs at 6wks to ensure union
ORIF- open reduction internal fixation if displaced significantly
complications of clavicle fractures 4
deformity may lead to functional problems in adulthood
-palpable bump
stiffness, infection, malunion
who gets acromioclavicular joint dislocations
male athletes, contact sports
*-remeber this is clavicle dislocation not shoulder
mechanism of injury in acromioclavicular joint dislocations 2
direct blow to top of shoulder
fallowing onto shoulder
presenation of acromioclavicular joint dislocations 2
tender prominence over AC joint
adduction of arm across body will increase pain
imaging of acromioclavicular joint dislocations 1
on XR- chekc for congruity of underside of acromino with distal clavicle
classificaitons for acromioclavicular joint dislocations
Rockwood Type 1-6:
1 = AC sprain
2 = AC torn
3 = AC torn
4 = Posterior displacement of clavicle
5 = >100º superior displacement
6 = Inferior displacement of clavicle
treatment for grade 1-3 acromioclavicular joint dislocations 1
conservatievly with broad-arm sling and physio
-chronic sympatonitc grade 3 with reconstruction
treatment for grade 4-6 acromioclavicular joint dislocations 2
reconstruction
or
ORIF with hook plate
complications of acromioclavicular joint dislocations 2
cosmetic issues
-large bump, skin necrossi
ACJ arthitits or ongoing pain
state the two types of shoulder dislocation
anterior dislocation
posterior dislocation
which type of shoulder dislocaiton is more common
anterior dislocaiton
-accounts for up to 95% of shoulder dislocations
who gets anterior shoulder dislocations
typically young males after contact sport
elderly patients can have FOOSH
what movment causes a anterior shoulder dislocations from contact sports 3
forced arm into:
-abduction
-extension
-external rotation
what does anterior shoulder dislocations cuase a risk of
humeral fracture
signs of anterior shoulder dislocations 2
loss of shoulder contour
-flattening of deltoid
anterior bulge from head of humerus
-palpated in axilla
what needs to be checked before and after reduction in anterior shoulder dislocations 2
pulses and nerves
treatment for anterior shoulder dislocations 4
relieve pain - ENTONOX
simple reduction
Kocher’s method
support arm in internal rotation with broad arm sling and refer to fracture clinic for follow up
describe the simple reduction method for anterior shoulder dislocations
apply longitudinal traction to the arm in abduction
replace humeral head by gentle pressure
describe the Kocher’s method for anterior shoulder dislocations reduction 1
flex elbow to 90degree and externall rotate shoulder
-bring arm anteiorly and then internally rotate
overveiw of posterior shoulder dislocation 4
rare
presentes with limitation of extetrnal rotation
can be assoc w epileptic seizures or electrical shocks
hard to diagnose with AP XR
-‘light bulb’ appearance of humeral head
LATERAL XR ESSENTIAL
complications of shoulder dislocations 3
recurrent dislocation
-can cause further instability due to damaged joint capsule component s
-those <25yrs have higher risk of recurrent events
bankart lesions
-avulsion of glenoid labrum from glenoid
Hill-sachs lesions
-impaction fracture of humeral head following anterior dislocation
who gets proximal humerus fractures 2
elderly population FOOSH
high energy
describe the neer classification for proximal humerus fractures
divides promixal humerus into 4 parts
-humeral head
-greater tuberosity
-lesser tuberosity
-femoral shaft
what is defined as displaceemnt in a proximal humerus fractures
if angulation >45˚ or >1cm
treatment for proximal humerus fractures 4
depends on no of fragments and displacement
2 parts, displaced= ORIF
severely comminuted, 4 parts= conservative
if unable to fix and rotator cuff defunctioned due to tuberosity involvement
-reverse shoulder replacement
young patients with fracture not suitable for fixation
-hemiarthroplasty
cause of humeral shaft fracture 1
typically fall onto arm
classification for humeral shaft fracture
location by proximal, middle or distal 1/3
define a hollstein-lewis humeral shaft fracture fracture
spiral fracture of distal 1/3
-assocaited with radial nerve palsy (wrist drop)
what does a radial nerve palsy cause
wrist drop
treatment for humeral shaft fracture
usually conservatie with humeral brace
-collar and cuff sling
-immobilise for 8-12wks
ORIF if:
-open
-vascular injury
-forearm fracture
-polytrauma
*ORIF involves locking or compression plating
management of radial nerve palsy in humeral shaft fracture
surgery if still fucked after intervention or manipulation of fracture
msot common elbow fracture
radial head fracture
cause of radial head fracture
FOOSH with pronated forearm
features of radial head fracture 2
elbow swollen and tender over radial head
flexion and extension may be possible
-supination and pronation will HURT
XR findings in radial head fracture
shows effusion
minor fractures often missed
classiication for radial head fracture
mason type 1-4 [65]
define an essex-lopresti injury regarding radial head fracture
interosseous membrane disruption and DRUJ injury
treatmet for radial head fracture 4
Mason I- conservative
Mason II- conservative unless block to rotation
Mason III&IV- ORIG, excision or replacement
depends on how stable the elbow is
complications of radial head fracture 3
soft tissue injuries in 1/3rd of patients
loss of forearm movements
terrible triad
-elbow dislocation
-coronoid fracture
-radial head fracture
angle of elbow dislocation that is most common
posterolateral
mechanism of elbow dislocation
axial loading
supination
valgus force
posterior ulnar displacement on the humerus, fixed in flexion
imaging of elbow dislocation 3
look for anterior humeral line and radiocapitellar line
posterior fat pad is ALWAYS abnormal
classfications of elbow dislocation
anatomical location of olecranon in relation to humerus
simple vs complex
define simple vs complex elbow dislocations
he simple dislocation is characterised by the absence of fractures, while the complex dislocation is associated with fractures
treatment for elbow dislocation 3
closed reduction ± GA
post-reduction image needed to exclude fractures
immobolise on back slab for 10 days
describe a closed reduction of elbow dislocation
stand behind patient, flex elbow
-fingers around epicondyls
=PUSH FORWARD ON OLECRANON with thumbs and down on forearm
-hear a clunk- success
complications of elbow disocations 3
stiffness
instability
neurovascular injuries
2nd most common open fracture after the tibia
forearm fractures
cause of forearm fractures
direct trauma to forearm
what are patinets with forearm fractures at risk of 2
comparment syndrome
can also have damage to radial, ulner or median nerves (anterior interosseous branch)
treatment for forearm fractures 4
ATLS, compartments thorough neurovascular assessment
open fracture?- NEEDS OPERATIVE MANAGEMENT
minimally displaced/isolated ulna fracture- conservative
radial shaft fracture or proximal 1/3 ulna- ORIF
define moteggia fracture
proximal 1/3 ulna fracture with assocaited dislocation of radial head
-remembered by ‘monty loses his head’
peak incidence 4-10yrs
4types
define galeazzi fracture
distal radius shaft fractue and assoc DRUJ injury
-stbaility depends on proximity to joint lin e
all require reduction ± operative fixation
define nightstick fracture
isolated ulnar shaft fracture
typically assoc w direct blow to forearm held up in self-defence
-high force
LOOK FOR OTHER INJURIES
who gets distal radius fractures
bimodal distribution
young-high energy
old-low energy- FOOSH
osteoporotic fracture predictor
treatment for distal radius fractures 6
depends on 3 things (rulle of 11s)
-radial height-11mm
-inclination- 22˚
-tilt 11˚
MUA (manipulation under anaesthetic) and plaster
K-wires (extra-articular with little comminution)
ORIF
-complex, intra-articular, shortened & comminuted fractures
volar fractures are unstable and require ORIF
define colles fracture
extra-articular fracture of distal radia with DORSAL displacement
-described as a dinner fork deformities
-can get avulsions of ulna styloid process
3 features of colles fracture
transverse fracture of radius
1 inch proximal to radio-carpal joint
dorsal displacement and angulation
define smiths fracture
AKA reverse colles
extraarticular fractuer of distal radius with VOLAR displacement
-garden spade deformity
caused by falling backwards on outstreched hand
fixation is needed more commonly than in colles
-fragure fragments tend to migrate palmarly
define bartons fracture
INTRA-artiuclar involving the dorsal aspect of the distal radius
define chauffeurs fracture
fratue of radial styloid
when is a reduciotn of a distal radius needed
commonly in colles
describe reduction of the distal radius 4
ensure analgeisa
traction applied to hand with an assistant to provide counter-traction at the elbow
fractue can often be felt to disimpact with a clunk
correct dorsal and radial angulation
acceptable radiographic angle after distal radius reduction 5
dorsal tilt <10˚
radial shortening <2mm
radial inclination >15˚
articular step <2mm (between radius and ulna)
distal radio-ulnar joint congruence
where abouts in the scaphoids are commonly affected in fractures
65% are in the ‘waist’ of the scaphoid
25% proximal third
10% distal third
what is at risk with scaphoid fractures
blood supply is retrograde from branches of radial artery
-THEREFORE RISK OF AVASCULARNECROSIS INCREASES WITH PROXIMITY OF FRACTURE
features of scaphoid fractures 4
tender in anatomical snuff box and over scaphoid tubercles
pain on axial compression of thumb
pain on ulnar deviation of wrist pronation
pain on supination against resistantce
imaging of scaphoid fractures
request deticated scaphoid series
if negative and fracture suspected request MRI
-CT is alternative
treatment for scaphoid fractures
usually non-operative
if negative XR repeat in 10-14 days
ORIF for proximal pole fractures or waist fractures displaced >2mm
tubulercles, distal poles & undisplaced waist fractues= conservative
carpal bones and mneomonic
[66]
complications of scaphoid fracture
SNAC wrist- scaphoid nonunion advanced collapse
AVN- avascular necrosis
describe perilunate dislocation
injuries that involve traumatic rupture of the radioscaphocapitate (RSC) ligament, the scapholunate interosseous (SLI) ligament, and the lunotriquetral interosseous (LTI) ligament.
always high energy with poor functional outcome
diagnosis of perilunate dislocation
image with lateral xray of wrist
mechanism of injury of perilunate dislocation
wrist extended with ulnar deviation
-leads to intercarpal supination
classification of perilunate dislocation
Stage I = Scapholunate dissociation
Stage II = Perilunate dislocation
Stage III = Midcarpal dislocation
Stage IV = Lunate dislocation
treatment for perilunate dislocatiron
urgent reduction and fixation with K-wires
ligament reconstruction ± carpal tunnel release
most common metacarpal fracture
5th MC- often from a punch
-‘Boxers fracture’
management of 5th metacarpal fracture
stable- closed fracture
-mangaed in split/ cast for 2wks
-wrist in partial extension MCPJ in 70-90˚ flexion with fingers in extension
unstable fractues
-may need K-wires or ORIF
describe bennets fracture
intra-articular fracture of first carpometacarpal joint
impact on flexd MC, caused by fist fights
XR shows triangular fragment at ulnar base of MC
define proximal phalanx fractures
spiral or oblique fractuers occurrring at this site are likely to have a rotational deformity
-must be corrected
ORIF- with a single compression screw
define middle phalanx fractues
manipulate these
-split flexion over a malleable metal splint
-buddy strap
aims to control rotation
define distal phalanx fractures
may be caused by crush injuries often OPEN
if closed syx may be relieved by trephining the nail (hole in nail)
