Upper Limb Trauma: Fractures and Dislocations

Question 1

What are the key aspects to assess in the history of an injury?

Answer 1

• Event leading to injury
• Mechanism of injury
• Injuries sustained

Event examples include fight club injuries or motor vehicle accidents. Mechanisms can include falls on an outstretched hand or slamming onto a dashboard.

Question 2

What does a complete history follow as part of in the ATLS evaluation sequence?

Answer 2

The secondary survey

The history is crucial for making management decisions, including whether to operate.

Question 3

What should be looked for during a physical examination?

Answer 3

• Skin: open wounds, abrasions, blisters
• Soft tissues: swelling, bruises
• Bones: alignment, obvious deformities

This examination is part of the physical assessment of a fracture or dislocation.

Question 4

What is the purpose of the ‘Rule of 2’s’ in radiologic assessment?

Answer 4

• See joint above and below
• Detect dislocations and subluxations
• Two views: AP and Lateral view
• Two sides: Left and right sides
• Two occasions: before and after manipulation

This rule helps in evaluating bone alignment and detecting potential injuries, especially in children.

Question 5

Define the acronym LARA in the context of fracture alignment evaluation.

Answer 5

• Length
• Apposition
• Rotation
• Angulation

LARA is used to describe the alignment of fractures and dislocations.

Question 6

Describe the classification system is used for open fractures?

Answer 6

The Gustilo-Anderson classification is a system used to classify open fractures (fractures where the bone breaks through the skin). It helps guide treatment and predict the risk of infection and complications.

Gustilo-Anderson Classification of Open Fractures

1. Type I

Wound <1 cm

Clean wound with minimal soft tissue damage

Low-energy injury

2. Type II

Wound >1 cm but <10 cm

Moderate soft tissue damage

No extensive contamination or crush injury

3. Type III (Severe soft tissue damage, high-energy injury, and increased infection risk)

Type IIIA – Large wound (>10 cm), but soft tissue coverage is adequate

Type IIIB – Extensive soft tissue loss with periosteal stripping, requiring soft tissue reconstruction

Type IIIC – Open fracture with vascular injury requiring repair

This classification is important for choosing antibiotics, surgical management, and predicting outcomes.

This system assesses the severity of open fractures.

Question 7

What is the immediate treatment protocol for open fractures?

Answer 7

• Immediate IV antibiotics
• Immediate surgical debridement
• Stabilisation

The choice of antibiotics depends on the Gustilo and Anderson classification grade.

Question 8

What characterizes a Colles fracture?

Answer 8

• Typical distal radius fracture
• Common in elderly and osteoporotic patients
• Dinner fork deformity

Clinically, it presents with a swollen wrist and dorsal tilt of the distal fragment.

Question 9

What is the mechanism of injury for a Smith fracture?

Answer 9

Fall onto flexed wrist or fist

This type of fracture can be associated with conditions like osteoporosis and osteomalacia.

Question 10

What distinguishes a Galeazzi fracture?

Answer 10

Distal radius fracture with distal radio-ulna joint dislocation

It requires complex surgical treatment due to the nature of the injury.

Question 11

What is a Monteggia fracture?

Answer 11

Proximal ulna fracture with proximal radio-ulna joint dislocation

This injury often requires a high index of suspicion for diagnosis.

Question 12

What is the commonest type of shoulder dislocation?

Answer 12

Anterior dislocation

Anterior dislocation accounts for 95% of shoulder dislocations and is often post-traumatic.

Question 13

What is the Hippocratic method of shoulder reduction?

Answer 13

Traction/Counter-traction method using a towel or foot in the axilla

This method is used for the reduction of shoulder dislocations.

Question 14

What should be evaluated in an elbow dislocation?

Answer 14

• Complications
• Associated injuries

It is important to check for brachial artery injuries and nerve injuries, particularly median nerve injuries.

Question 15

What are the immediate management steps for elbow dislocation?

Answer 15

• Look for complications
• Immediate reduction
• Immobilisation in above elbow backslab

Associated fractures should also be assessed during this evaluation.

Question 16

Describe the antibiotics of choice for the different types of open fracture according to Gustilo and Anderson classification

Answer 16

Type 1 and 2
> 1st gen of cephalosporin, eg, Kefazoline (Kefzol)

Type 3
> Kefazoline plus Gentamycin