Upper Limb Fractures and Dislocations Flashcards
Define surgical neck of humerus
Constriction below the greater and lesser tubercles, and above the deltoid tuberosity
Conservative management of proximal humerus fracture and when it is indicated
Sling immobilisation and progressive rehab
- minimally displaced (<5mm) of if the candidate is not suitable for surgery
Surgical management of proximal humerus fracture and when it’s indicated
Open reduction and internal fixation - normal management if fracture displaced
Severely comminuted fractured
- hemiarthropathy and soft tissue reconstruction
- total shoulder replacement for elderly patients
What radiological views are required for identification of a shoulder dislocation?
AP (antero-posterior)
Lateral
- only view a posterior dislocation can be seen on (light bulb sign)
Scapular ‘Y’ lateral view
Clinical assessment of an anterior shoulder dislocation
Empty glenoid fossa (palpable dent)
Humeral head palpable below the coracoid process
Arm held in external rotation
Clinical assessment of a posterior dislocation
Empty glenoid fossa (palpable dent)
Prominent posterior shoulder with anterior flattening
Prominent coracoid process
Arm held in internal rotation (outward rotation not possible)
Treatment of shoulder dislocations and when each is indicated
Emergency management
- immobilisation of joint (splint) and analgesia
Closed reduction
- performed in uncomplicated dislocations with no associated injuries (e.g. hill-Sachs lesion)’ no evidence of arterial injuries or any associated fractures
- continued, gentle, straight-line traction
Surgical management
- performed in complicated cases, recurrent dislocations or when close reduction is unsuccessful
Main complication of humeral shaft fractures
Risk of radial nerve injury because if the way the radial nerve wraps round the body of the humerus and over the lateral condyle
Treatment of a humeral shaft fracture
Conservative (most common)
- immobilisation by cast, followed by a brace
- allow movement of the elbow to prevent shoulder stiffness
Surgical management
- performed if open fracture, vascular injury, intra-articular fracture or a floating joint
- open reduction and internal fixation (plate and screws)
- intramedullary nailing (segmental/pathological fractures)
Clinical assessment of an elbow dislocation
Vascular assessment - brachial, radial and ulnar arteries
Inspection - ecchymosis, rubor and deformities
Disrupted triangle sign of the below may indicate a joint dislocation
What are the common neurovascular injuries associated with an elbow dislocation?
Ulnar nerve - damaged due to being stretched by the dislocation
Brachial artery - associated with open dislocations
Median nerve - associated with brachial artery injury
Treatment of an elbow dislocation
Non-operative
- closed reduction and splinting (90 degrees) for at least 5 days (X-Ray needed to see if reduction successful and to assess for any peri articular fractures)
- closed reduction done under GA
- rehab
Operative
- open reduction an internal fixation indicated in complex dislocations and unsuccessful closed reeducation
Complications of a forearm fracture/fracture dislocation.
Wrist and elbow required examination
- risk of nerve palsy causing loss of sensation and motor function
- risk of vascular injury (check pulses)
Compartment syndrome
- excessive bleeding and swelling
Types of fracture dislocations
Proximal (Monteggia) fracture-dislocation
- proximal ulnar fracture and associated proximal radial head dislocation
Distal (Galeazzi) fracture-dislocation
- fracture of a distal radius and dislocation of distal radio-ulnar joint and intact ulnar
Management of a forearm fracture/fracture dislocation in children
Greenstick fractures
- closed reduction and cast immobilisation
Correction of plastic deformities
Displaced fractures
- open reduction and internal fixation
Fracture-dislocations
- closed reduction and cast immobilisation
Management of forearm fracture/fracture dislocations in adults
Undisplaced
- cast immobilisation
Displaced - open reduction and internal fixation
Nightstick fracture
- undisplaced requires a brace, and displaced requires open reduction and internal fixation
Fracture dislocations
- open reduction and internal fixation
Complications of a distal radius fracture
Median nerve compression
- motor (thumb addiction)
- sensory (thumb, second and third digit)
More common in cases of malnutrition
Management of a distal radius fracture
Emergency manipulation - closed reduction (if required) with local anaaethestic (haematoma or Bier's block) Conservative - plaster immobilisation for 6 weeks - physiotherapy after surgery Surgical - indicated for significantly displaced/unstable fractures or complex intra-articular fractures - open reduction and internal fixation - K-wires - external fixation
What dislocations are associated with scaphoid fracture?
Lunate and perilunate
What’s the surface anatomy of the anatomical snuffbox?
Triangular depression found on lateral aspect of the dorsum of the hand at the level of the carpal bones.
What does the anatomical snuffbox contain?
Radial artery
Radial nerve
Cephalic vein
Clinical assessment of scaphoid fracture
Fullness in anatomical snuffbox = effusion
Tenderness over volar surface of the snuffbox
Painful wrist movement
- pronation and ulnar deviation
Pain on longitudinal compression of the thumb or on gripping
Scaphoid fracture X-Ray views required
Scaphoid view - 30 degree wrist extension and 20 degree ulnar deviation
AP
Lateral
45 degree pronation view
Complications of a scaphoid fracture
Non-union Avascular necrosis - risk in proximal and displayed fractures as the blood supply runs distal to proximal - 30% of cases Degenerative changes
Management of scaphoid fractures
Undisplaced
- cast immobilisation with thumb spica splint
Displaced or angulated
- open reduction and internal fixation
- often performed in all proximal fractures due to high risk
What is a perilunate vs lunate dislocation
Perilunate
- Dislocation of the carpus bones relative to the lunate (which remains in normal alignment with the radius)
Lunate
- dislocation of the lunate bone so it no longer has normal radiolunate articulation
What is a lunate or perilunate dislocation commonly associated with
Fracture dislocation of the radius, ulnar or carpal bones
- especially the scaphoid bones
Talk about rotational deformity of a metacarpal fracture
Rotational deformities are common and are unacceptable, so must be assessed for
What is a Boxers fracture
Fracture of the neck of the fifth metacarpal
What is a Bennett’s fracture dislocation
Base of thumb fracture caused by forced abduction of the first metacarpal (intracranial-articular two piece fracture)
Dislocated carpo-metacarpal joint
Small volar/ulnar fracture left behind to articulate with the trapezium
Treatment - closed reduction and K-wire fixation
What is a reverse Bennett’s fracture dislocation
Same as a Bennett’s fracture, but the 5th metacarpal base if affected, not the base of the thumb
- articulates with hamate
Treatment
- closed reduction and K-wire fixation
How is a Boxer’s fracture/metacarpal shaft fracture managed?
Neighbour strapping if undisplaced and minimally angulated
May need reduction and pinning or ORIF if significant angulation/displacement
What is the risk associated with a phalangeal fracture
Clinical rotational deformity - same as the concern with a metacarpal fracture
What is the Edinburgh position?
Prevents stiffness during immobilisation - stretches ligaments 90 degree flexion in metacarpal phalangeal joint (MCP joint) PIP joint extended 30 degree extension at the wrist
Management of phalangeal fractures?
Undisplaced - splint and immobilisation
Displaced (rotated/severely angulated/unstable)
- closed reduction and K-wire
- ORIF if needed
How are phalangeal fracture dislocations managed?
Dislocations require reduction under ring-block
- stable = extension blocking splint
- unstable +/- significant fracture = MUA and K-wire or ORIF if needed
