Upper Limb Injuries

Question 1

In an acromioclavicular rupture which structures are damaged?

Answer 1

Caracoclavicular ligament

Acromioclavicular ligament

Question 2

In which demographic are AC joint injuries more common?

Answer 2

Younger people as it is a high energy injury.

Question 3

What are the different subtypes of AC injury? (6)

Answer 3

Type I: Sprain of AC ligament joint intact
Type II: AC ligament is torn other ligaments intact

(Types I and II are treated non operatively)

Type III: AC and CC ligaments tor joint dislocation
Type IV: As above with posterior displacement
Type V: Gross displacement
Type VI: Inferior displacement

(Types III to VI are treated operatively with a hook plate or synthetic ligament)

Question 4

What is the mechanism of proximal humeral #?

Answer 4

Fragility fracture caused by a FOOSH mechanism

Common accounts for 5% of all #

Question 5

How are proximal humeral # classified?

Answer 5

Describe the same as a long bone fracture.

Classified by number of pieces 2/3/4

Question 6

What is a major complication of proximal humeral fractures?

Answer 6

Avascular necrosis as blood supply to the head is carried in a singular distal branch. (risk if fracture is in anatomical neck)

Other complications are the standard:

• Bleeding
• Infection
• Non-union
• Rotator cuff damage (likely to be worn anyway as this injury is more common in elderly)
• Radial nn damage (if mid shaft)

Question 7

How are proximal humeral fractures usually managed?

Answer 7

Conservative management is most common with a collar and cuff.

If surgical a hemiarthoplasty may be done to avoid AVN.

Note: Arthroplasty of shoulder is not very successful in terms of function.

Question 8

What is the most common site of fracture in the elbow?

What X ray changes are a sign of this fracture

Answer 8

Radial head.

Difficult to see on X-ray often look for fat pad sign. Posterior fat pad is always abnormal. Anterior may be raised.

Question 9

What is the common mechanism of action in radial head fractures?

Answer 9

FOOSH

Question 10

How are radial head fractures classified?

Answer 10

Mason Classification:

I: Undisplaced
II: Minimally displaced
III: Comminuted and displaced

Question 11

How do you manage radial head fractures?

Answer 11

I: Undisplaced
II: Minimally displaced
III: Comminuted and displaced

I and II treat conservatively

III: Surgical management, attempt to reconstruct radial head if not possible can be excised providing medial ligament is intact.

Question 12

What is the terrible triad of the elbow?

Answer 12

Dislocation
Radial Head #
Coronoid Process #

Known as the terrible triad as it is very difficult to treat as all of the supporting structures of the capsule of the elbow are damaged. This can make treatment very difficult particularly if the radial head cannot be reconstructed.

Note: dislocation can also be caused by FOOSH and often accompanies medial collateral ligament damage

Question 13

What is the eponymous name given for a radial head dislocation + ulnar fracture?

Answer 13

Monteggia’s

Mon-teg-ee-a

Question 14

What is the eponymous name given for an ulnar head dislocation + radial fracture?

Answer 14

Galeazzi’s

Gal-ee-at-zees

Question 15

In which demographic is supracondylar fractures seen?

Answer 15

Paediatric fracture

Question 16

How are fractures of the supracondylar humerus classified?

Answer 16

Gartland classification:

I: no displacement
II: posterior cortex intact therefore periosteum is intact posteriorly
III: complete displacement

Note: In children the periosteum is very thick as it provides all the blood supply for growth therefore if to is intact provides a degree of stability

Question 17

What is the most common wrist fracture?

Answer 17

Colle’s (radial fracture) caused by a FOOSH on an outstretched wrist

Question 18

What are the main points regarding a colle’s fracture?

Answer 18

Extrarticular
Dorsally angulated
Radial shortening due to impaction

Question 19

What is a smith’s fracture?

Answer 19

Same as Colle’s except it is volarly angulated.

Question 20

What is a Barton’s fracture?

Answer 20

It is an intrarticular radial fracture which can have dorsal or volar angulation

Question 21

How are wrist fracture’s treated?

Answer 21

Dependent on stability.

Reduction and fixation with plastering. Repete X rays 1 / 2 weeks

OR

Open reduction and internal fixation with plates and screws.

In order of stability:
Colle’s
Smith’s
Barton’s (almost always need ORIF)

Question 22

What is tennis elbow?

Answer 22

Lateral epicondylitis.

Pain is over the lateral epicondyle and is increased by active or resisted extension of the wrist.

Question 23

What is golfers elbow?

Answer 23

Medial epicondylitis.

Pain over the medial epicondyle.

Worsened by grasping items and opening jars. Resisted flexion of the wrist.

Question 24

1. What is the mechanism of a schaphoid fracture?
2. What are the key examination findings of a schaphoid fracture?
3. Why are 4 X ray views of a potential schaphoid fracture done?
4. Describe the management of a schaphoid fracture
5. What are the risks associated with a schaphoid fracture?

Answer 24

1. FOOSH.
2. Pain maximal at anatomical snuff box, weak pinch grip
3. Notoriously hard to see on Xray
4. Immobilisation of thumb for 2 months.
5. 10% risk of non-union. Avascular necrosis common here

Question 25

Which nerves are at risk of damage in the following fractures:

1. Colle’s
2. Elbow and forearm (radius)
3. Humeral shaft
4. Shoulder dislocation/ head of humerus fracture

Answer 25

1. Median nerve damage
2. Anterior interosseus (branch of median nerve) OR posterior interosseus (branch of radial nerve) both purely motor
3. Radial nerve
4. Axillary nerve

Question 26

Describe the mechanism of action AND X-ray findings of:

1. Anterior shoulder dislocation
2. Posterior shoulder dislocation

Answer 26

90% anterior dislocations

1. add+ext rotation, FOOSH. Humeral head in inferior and medial
2. trauma to front of shoulder, electrocution.
   Humerus head looks like a light bulb as rotated inwards. Trough line

Question 27

What signs are associated with a poor prognosis of an anterior shoulder dislocation?

Answer 27

Bankart lesion = Part of the glomeral joint gets damaged during dislocation, gets broken off

Hill-sachs lesion = Posterolateral humeral head compression fracture, typically secondary to recurrent anterior shoulder dislocations- Chunk out of humeral head.

Question 28

What are the signs and symptoms of carpel tunnel syndrome?

Answer 28

• Numbness and tingling down the median nerve distribution
• Worse in the morning and may wake from sleep
• Thenar wasting
• Reduced abduction and opposition of thumb

Tinels and Phalens positive

Question 29

Name syndromes associated with Carpel tunnel

Answer 29

DM, RA, Hypothyroid, Acromegaly, Prgenancy, renal disease, menopause

Question 30

What is De Quesvains tenosynovitis

What symptoms does it cause

Answer 30

Inflammation of the sheath covering the abductor pollivis longus and the extensor pollicis brevis

Pain around anatomical snuffbox and radial styloid - especially when using thumb
tenderness over radial boarder
Finkelstein positive

Question 31

Describe the treatment of:

1. Dupuytrens contracture
2. Trigger finger

Answer 31

1. Fasciotomy

2. Conservative, tenosynovectomy