Upper limb injuries Flashcards
Features of SCJ dislocation:
FOOSH/direct blow to shoulder
Anterior > Posterior
Sprain more common
Complications of posterior SCJ dislocation:
Pneumothorax
Great vessel injury - subclavian veins, R brachiocephalic artery, L common carotid artery, L subclavian veins
Dyspnoea, stridor and dysphagia
CT mandatory
AC joint injuries: Rockwood classification:
1 = Radiographically normal
2 = Distance between clavicle and acromion <1cm
3 = Distance between clavicle and acromion >1cm
4-6 are defined by displacement
(1-2 = sling + rest, 3 = sling + referral, 4-6 = sling +surgery)
Difference in treatment between anterior and posterior SCJ dislocations?
Anterior requires broad arm sling and fracture clinic
Posterior requires orthopaedics referral
When do you refer a fracture?
Open fractures
Neurovascular compromise
Tenting of the skin
Clavicular fracture associations?
Middle - intra-thoracic injury
Distal - rupture of C-C ligament (floating fragment)
Medial - intra-thoracic injury to subclavian vessels
Most common type of shoulder dislocation?
Anterior: Subcoracoid, subglenoid, subclavicular, intrathoracic
Signs of shoulder dislocation:
Arm abducted and externally rotated with flexed elbow
“Squaring” loss of contours
Palpable head in the infra-clavicular fossa
Humeral head may appear falsely dislocated with…
Proximal humerus fracture due to bleeding into joint and displacement
What should you always check before manipulation of the dislocated shoulder?
Sensation of the deltoid and radial pulse
Complications of shoulder dislocation:
Axillary nerve/artery injury - badge sign
Bruising of lateral chest wall
Axillary haematoma/bruit
Fractures of humeral head, ant. glenoid lip, greater tuberosity
Rotator cuff injuries - pain and weakness after 2 weeks
Radial/medial/ulnar/musculocut/brachial plexus injury
Neer classification of fracture surgical neck of the humerus:
1 = one-part fracture - no displacement 2 = two-part fracture - displacement of one fragment 3 = three-part fracture - displacement of two fragments 4 = four-part fracture - displacement of all segments 5 = dislocation (ant. or post.) regardless of displaced segment
Management of fracture surgical neck of the humerus:
Broad arm sling, analgesia and refer
Early mobilisation to prevent capsulitis
Ortho referral for very comminuted fractures
Associations with fracture shaft of humerus:
Elderly/FOOSH
Middle 1/3
Elderly
Metastatic (e.g. pathologic fracture from breast cancer)
Osteoporosis
Radial nerve injury and wrist drop in 10-20%
Brachial artery injury
Management of fracture shaft of humerus:
Conservatively
Humeral brace - reduced risk of compartment syndrome
U-slab for minimally displaced +/- referral for displaced
Always X-ray elbow and shoulder
What is the positioning of a dislocated elbow?
Elbow flexed at 45 degrees and prominent olecranon posteriorly
Complications of elbow dislocation:
Injury to brachial artery, median, ulnar and radial nerves (10%)
Which fractures occur with elbow dislocation?
Fracture medial epicondyle in children
Fracture coronoid, radial head, capitellum and olecranon in adults
Signs of fracture of radial head:
Tender radial head
Tender on pronation and supination
FOOSH
Associated injuries with fracture of the radial head:
Fracture of capitellum, olecranon, coronoid, medial epicondyle
Treatment for simple clavicular fracture?
Either broad arm sling (BAS) or collar and cuff (C+C)
Management of shoulder dislocation:
7 weeks immobilisation to allow the surrounding structures to recover
Younger people need longer immobilisation
Need to move shoulder within 2 days of immobilisation
Normal shoulder vs posterior GH dislocation?
Normally the humeral head appears asymmetric on X-ray whereas with posterior GH dislocation it is symmetrical and looks like a lightbulb
What is chocolate therapy?
Midazelam and morphine - give for big muscley men
Management of elbow dislocation:
Manipulation under anaesthesia
Back slab for a week for swelling then full cast
Management of fracture of the radial head:
Broad arm sling for minimally displace
Ortho referral for grossly displaced
Which two lines should intersect within the capitellum?
Anterior humeral line and radiocapitellar line
Features of supracondylar fractures:
Direct blow to posterior aspect of the flexed elbow
Open fractures
Management of supracondylar fractures:
Splint for non-displaced
If displaced then ortho referral and admission for displacement and soft tissue swelling
Complications of supracondylar fractures:
Radial nerve (posterior-medial displacement) Median nerve (posterior-lateral displacement) High incidence of anterior interosseous nerve injuries so test 'OK' sign for the motor component Vascular entrapment of the brachial artery Non-union/mal-union and loss of mobility
Associations of fracture olecranon:
Other fracture in 30% (radial head)
Ulnar nerve injury
Triceps rupture
Management of fractured olecranon:
Undisplaced (<2mm in flexion) = conservative management
Majority require operative fixation
What should you rule out in fracture of forearm bones?
Compartment syndrome
What is the Galeazzi fracture?
Fracture to the distal radius which distal radio-ulnar dislocation
Caused by FOOSH/direct blow to back of wrist
Complication of Galeazzi fracture?
Ulnar nerve injury
Treatment of Galeazzi fracture?
Open reduction and internal fixation (ORIF)
What is the Monteggia fracture?
Fracture to the proximal 1/3 of ulnar with dislocation of the radial head
Caused by FOOSH/direct blow to the posterior aspect of the ulnar
Complication of Monteggia fracture?
Radial nerve injury
Treatment of Monteggia fracture?
ORIF and closed reduction/splinting
What is the Colles’ fracture?
Transverse fracture of distal radius with dorsal displacement of distal fragment
Impaction, radial deviation, ulnar angulation and rotation
Signs of Colles’ fracture:
FOOSH
Age >50
Dinner fork deformity
Associated injuries of Colles’ fracture:
Ulnar styloid fracture
Median nerve injury
What makes an unstable Colles’ fracture?
> 20 degrees of angulation
Intra-articular involvement
Comminuted
1cm of shortening
Treatment of Colles’ fracture:
Non-displaced = Sugar tong splint and refer to trauma clinic Displaced = Reduction: finger traps and manipulation under sedation or with haematoma block then sugar tong splint and ortho referral
Differential in the history between Colles’ and Smith’s fractures?
Colles’ fracture is due to falling onto wrists in extension
Smith’s fracture is due to falling onto wrists in flexion
What is Smith’s fracture?
Fracture of the distal radius with solar (palmar) displacement and angulation
What is Barton’s fracture?
Fracture of the distal radius which extends through the dorsal aspect of the articular surface with associated dislocation of radoiocarpal joint
What differentiates Barton’s fracture?
No disruption of radoiocarpal ligaments and the fractured articular surface of the distal radius remains in contact with the carpal row
What is Hutchinson’s fracture?
Intra-articular fractures of the radial styloid process
Radial styloid is within the fracture fragment
Fragments can vary markedly in size
Complications of Hutchinson’s fracture:
Median nerve injury Carpal tunnel syndrome Mal-union Reflex sympathetic dystrophy Rupture of extensor policis tendon Osteoarthritis of the wrist
When should you reduce although the fracture is not grossly displaced?
> 20 degrees angulation
1cm shortening
Intra-articular involvement
Marked comminution
What is Bier’s block?
Prolocaine or lignocaine
What is Haematoma block?
Adrenaline and bupivacaine
What is Conscious sedation?
Midazolam, morphine an cyclizine
Management of distal radius fractures:
Smith and Barton fracture = refer to ortho
Distal radius fracture in young = refer to ortho
Otherwise back-slab and follow up in fracture clinic
Above elbow injuries…
Usually managed in a sling
Always assess what?
The joint immediately proximal and distal (might tell you the wrong joint e.g. if dementia)
Which fractures do you always refer?
Smith’s
Barton’s
Hutchinson’s
Protocol for palmarly displaced fracture e.g. Smith’s?
Urgent ortho referral
Management for articular step-off >2mm?
Urgent ortho referral
Risk with large ulnar styloid fractures with displaced fragments at the styloid base?
Increased risk of distal radioulnar joint instability
Urgent ortho referral
Management of fracture dislocations?
Urgent ortho referral
What are distal radial fractures associated with?
Scaphoid fractures or scapholunate ligament injuries
Require urgent ortho referral
Problem with near-anatomic reduction of comminuted/displaced fractures?
Need urgent ortho referral as they are unstable even if reduction is near-anatomic and are likely to lose position
