Upper Limb Trauma Flashcards
Are the majority of proximal humerus fractures high or low energy injuries?
The majority are low energy injuries in osteoporotic bone due to FOOSH or directly onto the shoulder!
Which is more common:
a) fracture of the surgical neck
or
b) fracture of the anatomical neck?
The fracture of the surgical neck…
with medial displacement of the humeral shaft due to pull of the pectoralis major muscle (must remember this bit to get the mark)
The consultant tells you about a patient with a minimally displaced proximal humerus fracture and asks you how best to manage them?
Conservatively
with a sling
and gradual return to mobilsation.
With displaced fractures the position often improves once muscle spasm settles.
A patient has a head splitting fracture of the humerus.
What are you going to tell them?
They probably will need a shoulder replacement
Unless the consultant thinks they’re young enough with good enough bone quality to avoid it.
Anterior shoulder dislocation is much more common than posterior dislocation
T/F
TRUE
posterior shoulder (gleno-humeral) dislocations only account for 2-5% of all shoulder dislocations
What movements would cause traumatic anterior shoulder dislocation?
- excessive external rotation force
- or a fall onto the back of the shoulder
- or a seizure (watch for bilateral dislocations
The senior registrar announces the patient who presented with unilateral shoulder pain after excessive external rotational force has a Bankart lesion.
What does this mean?
Anterior shoulder dislocation often results in detatchment of the anterior glenoid labrum and capsule
This is a.k.a. a Bankart lesion
How does a Hill-Sachs lesion occur?
The posterior humeral head can impact on the anterior glenoid producing an impaction fracture of the posterior head
What nerves and arteries can be affected by an anterior shoulder dislocation?
The axillary nerve can be stretched as it passes through the quadrilateral space
whilst other nerves of the brachial plexus
as well as the axillary artery can be stretched or compressed.
Patient presents with loss or roundness on the left shoulder. Their left arm is held in an adducted position and is supported by their right hand.
What is your current DDx?
Shoulder (gleno-humeral) dislocation
What investigation is required to confirm a suspected shoulder dislocation?
X-Rays confirm the diagnosis
if there is any doubt, X-Rays can be taken in two planes
What fractures are worth watching out for in a shoulder dislocation?
Fractures of the surgical neck and greater tuberosity
What patient group is likely to present late with a shoulder dislocation and therefore require open reduction rather than the standard closed reduction?
Alcoholics
What connective tissue disorders can cause generalised ligametnous laxity/hypermobility?
Ehlers-Danlos syndrome
Marfan’s syndrome
These patients tend to have atraumatic multidirectional dislocations which can be painful- some can voluntarily dislocate as a “party-piece”
What movement causes a posterior shoulder dislocation?
A posterior force
on the adducted
and internally rotated arm
A patient has the “light bulb” sign on X-Ray.
What has happened?
They’ve suffered a posterior shoulder dislocation
The excessively internally rotated humeral head looks symmetrical like a light bulb on an AP view
Very generally, how do you aim to manage shoulder dislocations?
- closed reduction
- sling
- physio
What is the most common mechanism of injury for an acromioclavicular joint injury?
a fall onto the point of the shoulder
(they’re a fairly common sporting injury)
How would you normally manage an ACJ injury?
Conservatively
with a sling for a few weeks
followed by physio
Who would get surgery for ACJ injury?
Those with chronic pain
althoguh some surgeons advocate early reconstruction for younger athletes with dislocation- it’s controversial
What are the three extents to which the ACJ can be injured?
- Sprained
- Subluxed (partially dislocated)
- acromioclavicular ligaments are ruptured
- Dislocated
- coracoclavicular ligaments (conoid and trapezoid ligaments) are also disrupted
What are the main MoI causing humeral shaft fractures?
And how do these MoI result in different humeral shaft fractures?
- direct trauma- e.g. RTA
- transverse or comminuted fractures
- fall +/- twisting injury
- oblique or spiral fractures
What nerve is at risk of becoming damaged in a humeral shaft fracture?
And how would this present?
-
radial nerve in the spiral groove
- presents with a wrist drop and loss of sensation in the first dorsal web space
How are most cases of humeral shaft fractures managed?
non-operatively
with a functional humeral brace which compresses the fragments into acceptable alignment & provides some stability
What is an important thing to remember about forearm anatomy when it comes to assessing forearm fractures?
Because of the strong ligaments at the p. and d. radio-lnar joints the forearm acts as a ring where if one bone is fractured there is sually a fracture or dislocation involving the other bone.
:. if an isolated displaced fracture of one of the forearm bones is identified, one should have a very high index of suspicion of a fracture or dislocation involving the other bone.
On which bone would you find a nightstick fracture?
ULNA
Isolated fractures of the ulna can occur after a direct blow (historically many cases occured after being hit by a truncheon/nightstick)
When assessing a nightstick fracture, what associated injury must you rule out?
A Monteggia fracture dislocation
What is a Motenggia fracture dislocation?
In an isolated fracture of the ulna there is also dislocation of the radial ehad at the elbow
:. with isolated ulna injuries it’s advisable to perform elbow X-Rays
What is a Galeazzi fracture dislocation?
A fracture of the radius
with dislocation of the ulna at the distal radioulnar joint
:. any isolated radial shaft fracture a lateral X-Ray of the wrist is mandatory
How distal radius fractures commonly acquired?
FOOSH
Define a Colles fracture
“A Colles fracture is an extra-articular fracture of the distal radius within an inch of the articular surface with dorsal displacement or angulation”
What fracture is often associated with a Colles fracture?
A fracture of the ulnar styloid
What nerve problems can accompany a Colles fracture?
Median nerve compression from stretch of the nerve of a bleed into the carpal tunnel
- reduction may relieve pressure on the nerve
- carpal tunnel may need surgically decompressed
What is the specific late local complication of a Colles fracture?
rupture of the Extensor Pollicis Longus tendon (which usually requires a tendon transfer)
Define a Smith’s fracture
This is a volarly displaced or angulated extra-articular fracture of the distal radius which usually occurs after falling onto the back of a flexed wrist
All Smith’s fractures should undergo _______ for management
ORIF using a plate and screws
(they are highly unstable injuries)
Define Barton’s fracture
Barton’s fractures are intra-articular fractures of the distal radius involving the dorsal or volar rim, where the carpal bones of the wrist joint sublux with the displaced rim fragment.
They can be classified as:
- volar Barton’s fractures (an intra-articular Smith’s fracture)
- or a dorsal Barton’s fracture (an intra-articular Colles’ fracture)
As with most intra-articular injuries, these injuries require ORIF.
How would a scaphoid fracture present?
Usually occur after a FOOSH. Signs:
- tenderness in the anatomic snuff box
- pain on compressing (telescoping) the thumb metacarpal
How many views must be taken of a suspected scaphoid fracture?
Four
AP, lateral and 2 obliques
A patient presents after FOOSH. They complain of pain in the anatomical snuffbox so you take an X-Ray (with four views of course).
The X-Ray doesn’t show any fractures.
What do you do?
Diagnose with a “Clinical Scaphoid Fracture”. Splint the wrist. Organise for them to come back for X-Rays in 2 weeks explaining that aprox 5% of scaphoid fractures are not visible on initial x‐rays but show up on radiographs 2 weeks later after resorption of the fracture ends as the first stage of fracture healing.
If they come back in 2 weeks and scaphoid fracture is confirmed it can be treated with a cast for 6-12 weeks
Describe a peri-lunate injury and its MoI
- simply meaning a dislocation of one of the carpal bones around the lunate (another carpal bone),
- is an uncommon but severe
- high energy wrist injury resulting from hyperdorsiflexion
The radiologist describes a “spilt cup” sign on X-Ray. What bone are they looking at? And what’s happened?
Luante bone
Lunate dislocation
The lunate is usually tilted volarly and empty like a spilled tea cup
Describe scapho-lunate dislocation on X-Ray
The gap between the scaphoid and lunate is larger than normal
(this dislocation occurs when scapho-lunate ligaments rupture)
Penetrating hand injuries are common.
What’s at risk with a volar penetrating hand injury?
- flexor tendons
- digital nerves
- digital arteries
Penetrating hand injuries are common.
What’s at risk with a penetrating dorsal hand injury?
- extensor tendons
Describe management of extensor tendon injuries in hand
Extensor tendon divisions of 50% or more usually require surgical repair with splintage in extension for 6 weeks as any flexion within this period may cause failure of the repair
What is this presentation known as?
What has happened to the finger?
Pic shows MALLET FINGER
…it’s an avulsion of the extensor tendon from its insertion into the terminal phalanx and is caused by
forced flexion of the extended DIPJ, often from a ball at sport
A patient presents after a hurling match. They have a painful finger. This finger has a drooped DIPJ. When you ask them to extend the DIPJ they can’t do it.
What do they have?
Mallet finger
(an avulsion of the extensor tendon from its insertion into terminal phalanx)
The injury may be a purely tendoninous avulsion or may have a bony fragment
How would you treat mallet finger?
A mallet splint holding DIPJ extended
Should be worn continuously for a minimum of 4 weeks
What is the management for “partial divisions with a flap of tendon” of flexor tendon injuries?
Should be smoothed
The fingers are then splinted in a flexed position
What is the management of significant partial lacerations or complete tendon divisions of flexor tendons in the hand?
They require repair.
Need to avoid “bowstringing” of the tendon.
Fingers splinted in a flexed position, often with elastic traction to allow early active gentle extension and passive flexion to prevent stiffness and adhesions within the tendon sheath.
How are metacarpal fractures managed and why?
Fractures of the 3rd, 4th and 5th metacarpals are usually treated conservatively.
They have strong intermetacarpal ligaments proximally and distally giving stability to these fractures and usually minimal displacement.
What bone is fractured in a Boxer’s fracture?
A 5th metacarpal neck
Fractures of the 5th metacarpal often occur with a punching injury esp the neck.
How do you manage a metacarpal fracture?
Neighbour strapping of the affected digit to the adjacent finger and early motion to maintain function.
A drunk guy presents to A&E with his mates with a sore hand. One of his friends confides in you that he got in a fight and punched another guy. You already suspected this because he had a fracture of _______. You’ve noticed broken skin on his hand-
- what are you definitely not going to do (despite his requests)
- who ya gonna call
- and why?
- ______= (neck of) 5th metacarpal
- suture it closed in A&E
- surgeons
- it is a fight bite! Intra-oral organsims may cause an aggressive infection leading to septic arthritis and :. needs thoroughly washed out in theatre
You’ve got two patients in Beds 3, 5and 8 in A&E.
- Patient X has a undisplaced/minimally displaced phalangeal fracture, how are you going to treat him?
- Patient Y has a significantly displaced phalangeal fracture, how are you going to treat him?
- Patient Z has an intra-articular phalangeal fracture, how will you manage her?
- Many phalangeal fractures can be treated with neighbour strapping or splintage
- Significantly displace or angulated fractures may require manipulation under anaesthetic or digital nerve block (ring block). Unstable fractures may require K-wiring or fixation with small screws.
- Intra-articular fractures may be fixed with k-wires or small screws
