Upper Limb Ortho

Question 1

Mx clavicle fracture?

Answer 1

• Sling for comfort (2/52 initially)
• mobilisation asap
• warn about formation of lump at # site (fracture callus)
• Xray at 6/52 (callus, fracture line)
• No loading/contact sports for 3/12

Question 2

When to refer clavicle #?

Answer 2

ACUTELY:
-open #
-neurovascular compromise
->2cm shortening
-Lateral fractures
DELAYED:
-painful non unions
-symptomatic malunions

Question 3

Why is shortening an indication for clavicle # referral?

Answer 3

Fracture will still heal but shortening will move muscle down starling curve. Shoulder protracted with decreased power
-Pt unlikely to accept decreased function.

Question 4

Who gets anatomical NoH fractures?

Answer 4

• very uncommon

- Younger pt, high velocity trauma

Question 5

Structure at risk in NoH #?

Answer 5

Axillary nerve and vessels

Question 6

How is axillary nerve damage tested for?

Answer 6

Regimental badge distribution loss of sensation

Question 7

Mx SNOH #?

Answer 7

Depends on age and level of function (i.e. elderly can usually tolerate more displacement as less arm use)
Mild: non op (if ice cream on cone, leave it alone).
Mod: internal fixation
Severe: replacement
XR after 1-2/52

Question 8

Age of presentation of rotator cuff tears?

Answer 8

• Acute, traumatic, young pt

- Chronic, degenerative, older pt

Question 9

Major problem with acute rotator cuff injury (usually in younger pt)?

Answer 9

Weakness

Question 10

Major problem with chronic degenerative rotator cuff tears?

Answer 10

Pain from subacromial impingement and bursitis

Question 11

Ix of acute v chronic rotator cuff tears?

Answer 11

Acute: XR, MRI
Chronic: XR, US

Question 12

Rx acute v chronic cuff tear

Answer 12

Acute: surgical repair of cuff
Chronic:
-analgesia
-subacromial injections
-subacromial decompression +/- cuff repair

Question 13

XR features to look for in chronic rotator cuff tear?

Answer 13

• OA

- Spurs resulting in impingement of cuff tendon

Question 14

Types of shoulder instability?

Answer 14

ACUTE traumatic: UNIdirectional (anteroinferior or posterior)
CHRONIC: MULTIdirectional (habitual dislocated)

Question 15

Mx acute v chronic shoulder instability?

Answer 15

Acute: surgery
Chronic: PT/rehab

Question 16

What stabilises the shoulder?

Answer 16

1. Bone
2. Soft tissues:
   –labrum (negative pressure affect)
   –capsule
   –ligaments
   –muscles
   Can also consider as static and dynamic stabilisers

Question 17

Why does small tear to labrum cause severe shoulder instability?

Answer 17

Loss of negative pressure; shoulder relies on suction system

Question 18

What can be damaged with anteroinferior dislocation?

Answer 18

Glenoid: bankart fracture (also causes labral tear)
Humerus: Hills sachs lesion
Axillary nerve injury

Question 19

Who needs op with instability?

Answer 19

• Large bony bankart lesions

- Recurrent dislocation (chance of recurrence depends on age)

Question 20

Frozen shoulder diagnostic criteria?

Answer 20

1. Insidious
2. Painful restriction of active AND passive elevation
3. True shoulder pain
4. External rotation

Question 21

Mx frozen shoulder?

Answer 21

Based on clinical assessment of stage of pt.
Stage I and II (pre dec ROM):
-subacromial /glenohumeral joint injections
Stage III
-no steroid injections
-hydrodilation
-manipulation under anaesthesia (useless, blood clot formation, back in 3 months)
-surgical release (arthroscopy, cut through capsule, bloodless; pt returned to ROM)