Upper Limb Fractures and Dislocations

Question 1

Define surgical neck of humerus

Answer 1

Constriction below the greater and lesser tubercles, and above the deltoid tuberosity

Question 2

Conservative management of proximal humerus fracture and when it is indicated

Answer 2

Sling immobilisation and progressive rehab

- minimally displaced (<5mm) of if the candidate is not suitable for surgery

Question 3

Surgical management of proximal humerus fracture and when it’s indicated

Answer 3

Open reduction and internal fixation - normal management if fracture displaced
Severely comminuted fractured
- hemiarthropathy and soft tissue reconstruction
- total shoulder replacement for elderly patients

Question 4

What radiological views are required for identification of a shoulder dislocation?

Answer 4

AP (antero-posterior)
Lateral
- only view a posterior dislocation can be seen on (light bulb sign)
Scapular ‘Y’ lateral view

Question 5

Clinical assessment of an anterior shoulder dislocation

Answer 5

Empty glenoid fossa (palpable dent)
Humeral head palpable below the coracoid process
Arm held in external rotation

Question 6

Clinical assessment of a posterior dislocation

Answer 6

Empty glenoid fossa (palpable dent)
Prominent posterior shoulder with anterior flattening
Prominent coracoid process
Arm held in internal rotation (outward rotation not possible)

Question 7

Treatment of shoulder dislocations and when each is indicated

Answer 7

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

Question 8

Main complication of humeral shaft fractures

Answer 8

Risk of radial nerve injury because if the way the radial nerve wraps round the body of the humerus and over the lateral condyle

Question 9

Treatment of a humeral shaft fracture

Answer 9

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)

Question 10

Clinical assessment of an elbow dislocation

Answer 10

Vascular assessment - brachial, radial and ulnar arteries
Inspection - ecchymosis, rubor and deformities
Disrupted triangle sign of the below may indicate a joint dislocation

Question 11

What are the common neurovascular injuries associated with an elbow dislocation?

Answer 11

Ulnar nerve - damaged due to being stretched by the dislocation
Brachial artery - associated with open dislocations
Median nerve - associated with brachial artery injury

Question 12

Treatment of an elbow dislocation

Answer 12

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

Question 13

Complications of a forearm fracture/fracture dislocation.

Answer 13

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

Question 14

Types of fracture dislocations

Answer 14

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

Question 15

Management of a forearm fracture/fracture dislocation in children

Answer 15

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

Question 16

Management of forearm fracture/fracture dislocations in adults

Answer 16

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

Question 17

Complications of a distal radius fracture

Answer 17

Median nerve compression
- motor (thumb addiction)
- sensory (thumb, second and third digit)
More common in cases of malnutrition

Question 18

Management of a distal radius fracture

Answer 18

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

Question 19

What dislocations are associated with scaphoid fracture?

Answer 19

Lunate and perilunate

Question 20

What’s the surface anatomy of the anatomical snuffbox?

Answer 20

Triangular depression found on lateral aspect of the dorsum of the hand at the level of the carpal bones.

Question 21

What does the anatomical snuffbox contain?

Answer 21

Radial artery
Radial nerve
Cephalic vein

Question 22

Clinical assessment of scaphoid fracture

Answer 22

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

Question 23

Scaphoid fracture X-Ray views required

Answer 23

Scaphoid view - 30 degree wrist extension and 20 degree ulnar deviation
AP
Lateral
45 degree pronation view

Question 24

Complications of a scaphoid fracture

Answer 24

Non-union 
Avascular necrosis 
- risk in proximal and displayed fractures as the blood supply runs distal to proximal 
- 30% of cases 
Degenerative changes

Question 25

Management of scaphoid fractures

Answer 25

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

Question 26

What is a perilunate vs lunate dislocation

Answer 26

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

Question 27

What is a lunate or perilunate dislocation commonly associated with

Answer 27

Fracture dislocation of the radius, ulnar or carpal bones

- especially the scaphoid bones

Question 28

Talk about rotational deformity of a metacarpal fracture

Answer 28

Rotational deformities are common and are unacceptable, so must be assessed for

Question 29

What is a Boxers fracture

Answer 29

Fracture of the neck of the fifth metacarpal

Question 30

What is a Bennett’s fracture dislocation

Answer 30

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

Question 31

What is a reverse Bennett’s fracture dislocation

Answer 31

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

Question 32

How is a Boxer’s fracture/metacarpal shaft fracture managed?

Answer 32

Neighbour strapping if undisplaced and minimally angulated

May need reduction and pinning or ORIF if significant angulation/displacement

Question 33

What is the risk associated with a phalangeal fracture

Answer 33

Clinical rotational deformity - same as the concern with a metacarpal fracture

Question 34

What is the Edinburgh position?

Answer 34

Prevents stiffness during immobilisation
- stretches ligaments
90 degree flexion in metacarpal phalangeal joint (MCP joint)
PIP joint extended
30 degree extension at the wrist

Question 35

Management of phalangeal fractures?

Answer 35

Undisplaced - splint and immobilisation
Displaced (rotated/severely angulated/unstable)
- closed reduction and K-wire
- ORIF if needed

Question 36

How are phalangeal fracture dislocations managed?

Answer 36

Dislocations require reduction under ring-block

• stable = extension blocking splint
• unstable +/- significant fracture = MUA and K-wire or ORIF if needed