Upper Limb Injuries

Question 1

What are some common examples of trauma that may lead to a clavicular fracture? Which portion of the clavicle is most commonly fractured?

Answer 1

Fall onto outstretched hand / fall onto shoulder

Middle 1/3 clavicle is most commonly fractured&raquo_space;> lateral 1/3 > medial 1/3

Question 2

Management of clavicular fractures?

Answer 2

• Vast majority unite without intervention
• Analgesia
• Sling for 3-4 weeks, progressive mobilization from 2 weeks

Question 3

When would you need to operate on a clavicular fracture?

Answer 3

• If the fracture is largely displaced
• Open fractures / fracture threatens the skin
• Neurovascular complications
• Polytrauma

Question 4

What sort of trauma tends to lead to injury of the AC joint? What signs on the patient indicate an injured AC joint?

Answer 4

• Fall onto the shoulder

- Can see the clavicular prominence bulging at the top of the shoulder as the acromion no longer holds it inferiorly

Question 5

Treatment of AC joint injuries?

Answer 5

Depends on severity of injury, sprain or complete dislocation of the joint?

• Sprain: sling for 3-4 weeks, progressive mobilization from 2 weeks
• Complete dislocation: may benefit from surgical fixation if clavicle is significantly displaced

Question 6

What type of trauma tends to cause proximal humerus fractures?

Answer 6

In young patients - high impact injuries

In the elderly - osteoporotic injuries

Question 7

What are the treatment options for proximal humeral fractures? What determines the type of treatment given?

Answer 7

Conservative:
- Sling, mobilize after 6 weeks

Operative:

• Fixation with plate
• Joint replacement

Age and severity of injury (more operation on younger individuals, extent of displacement may require surgery)

Question 8

In which direction does the shoulder tend to dislocate? What is an important test to conduct on the dislocated shoulder patient?

Answer 8

Anterior&raquo_space;» Posterior > Inferior (locks under glenoid)

Test sensation over the regimental badge area - tests axillary nerve function.

Question 9

What X-Ray views are used to confirm the diagnosis of a dislocated shoulder?

Answer 9

AP view

Y view - along the line of the scapula (lateral)

Question 10

Treatment of shoulder dislocation? How likely are these injuries to recur?

Answer 10

Treatment: reduction of joint +/- anaesthetic

Quite likely to recur, if the patient is young, male and participates in contact sports there can be a 90% recurrence rate

Question 11

What type of trauma can result in a posterior dislocation of the shoulder? What is the cardinal sign of this type of dislocation? How does this type of dislocation appear on X-Ray?

Answer 11

Seizures, electrocution, occasionally a direct blow to the shoulder such as boxing

• Loss of external rotation of the shoulder joint

Light bulb sign on AP view - head of the humerus shaped like a lightbulb due to incorrect orientation of articular surface

Question 12

What is the commonest fracture in elderly patients? What type of trauma commonly causes this injury?

Answer 12

Distal radial fracture (Colles fracture)

Falling onto outstretched hand

Question 13

Treatment options for distal radial fractures?

Answer 13

Conservative:

• Splints
• Casts (+/- wires)

Operative:

• Plate insertion
• External fixator

Question 14

What are some possible complications of distal radial joint treatment?

Answer 14

Malunion (can heal shortened or dorsally angulated)

DRUJ (distal radial ulnar joint) pain if heals shortened

Extensor policis longus rupture

Carpal tunnel syndrome

CRPS (Chronic regional pain syndrome)

Question 15

Investigations for scaphoid fractures?

Answer 15

X-Ray - can be difficult to see, patient often put in cast and X-Ray repeated at 2 weeks

MRI

Question 16

What is a relatively common complication of scaphoid fracture?

Answer 16

Non-union and avascular necrosis if the fracture is in the proximal third

• Due to retrograde blood supply

Question 17

What type of trauma results in scaphoid fractures? What are the symptoms of scaphoid fractures?

Answer 17

Falling onto outstretched hand

• Pain at base of thumb
• Tenderness in the anatomical snuff box
• Pain telescoping thumb

Question 18

Treatment of scaphoid fractures?

Answer 18

Cast for around 6 weeks

Surgery done if:

• Bones are significantly displaced
• There is non-union of the bones `

Question 19

What is the function of the ulnar collateral ligament of the thumb? What type of trauma can result in injury of the ligament?

Answer 19

Stops the thumb overextending radially

Trauma that moves the thumb radially - can injure just the ligament or have an associated avulsion fracture

Question 20

Symptoms of ulnar collateral ligament of the thumb injury?

Answer 20

• Weak pinch grip
• Pain, esp. tender on ulnar side of thumb MCPJ
• Joint opens up when radial pressure is applied on examination

Question 21

Treatment of ulnar collateral ligament of the thumb injuries?

Answer 21

Conservative:
- Splinting / cast

Surgery:

• Repair ligament
• Reduce avulsion fragment if needed

Question 22

What type of fracture is a Bennett’s fracture? What sort of trauma causes this fracture?

Answer 22

Intra-articular fracture at the base of the first metacarpal

Pressure moving the slightly flexed joint proximally causes shearing fracture

Question 23

Treatment of Bennett’s fracture?

Answer 23

Reduction of bones - due to pull of APL the bones are often displaced

Then:

• Plaster cast +/- wire to maintain reduced position
• Screw fixation

Question 24

What are some important signs to look for on a person who has been in a bare knuckle fight?

Answer 24

Swelling of hand - boxers fracture

“Fight bites” - if the patient has punched someone in the mouth they may have bits of broken tooth lodged in their hand. If this occurs over the MCP joint can lead to septic arthritis

Question 25

Which fingers tend to be affected by a boxers fracture? Management?

Answer 25

• Usually a fracture of the metacarpal neck of the little finger. May also be ring finger
• Usually managed conservatively: bind two fingers and let it heal
• Reduction may be necessary if there is significant angulation

Question 26

What type of trauma tends to precede flexor tendon injuries? What is the approach to management of these injuries?

Answer 26

• Usually knife lacerations
• Need to repair surgically and early, if the injury is left untreated the muscle will pull the flexor tendon proximally making reduction much more difficult

Question 27

How are flexor tendon injuries repaired surgically? What is a major concern in the repair of these injuries?

Answer 27

Repaired by the Kessler Technique: secure low profile sutures

• Main complication post surgery is adhesion of the flexor tendon to tendon sheaths or other tissue causing reduced movement. This is avoided by allowing early movement of the tendons