Week 6 - D - Regional Adult Trauma (3) - Humeral shaft, elbow, forearm, distal radius fractures

Question 1

Humeral shaft fractures can be caused by direct trauma (such as during an RTA) resulting in transverse or comminuted fractures, or by fall with or without twisting injury resulting in oblique or spiral fractures.

What nerve may be injured?

Answer 1

The radial nerve may be injured as it runs through the radial (spiral) groove

Question 2

If there was a radial nerve palsy in a humeral shaft fracture How would this show?

Answer 2

There would be a loss of sensation in the first dorsal web space and a wrist drop would be present (loss of innervation to the extensors)

Question 3

Most cases are treated non-operatively with a functional humeral brace which compresses the fragments into acceptable alignment and provides some stability. What will be used if there is non-union?

Answer 3

Use internal fixation with an intramedullary nail or plates

Question 4

What age group does supracondylar fractures usually occur in? What are complications?

Answer 4

Usually occurs in childen

Can result in injury to the brachial artery and the median nerve

Brachial artery rupture can lead to haemorrhage causing compartmnet syndrome and this can lead to volkmann’s ischaemic contracture

Question 5

How is an intra-articular fracture of the distal humerus treated?

Answer 5

Treat with open reduction and internal fixation

Question 6

Olecranon – common and occur when falling onto the point of the elbow with a contracted triceps Where to the triceps insert distally?

What is the treatment?

Answer 6

Onto the olecranon process of the ulna

Treatment is open reduction internal fixation

Question 7

Radial head and neck fractures usually occur due to a fall onto the outstretched arm. Some undisplaced fractures may not show up on x‐ray other than a posterior fat pad sign on the lateral x‐ray (a triangle like a sail anterior to the distal humerus - due to a raised anterior fat pad) with lateral elbow pain on supination / pronation.

What is the treatment of the undisplaced radial head and neck fractures?

Answer 7

Conservative treatment with a sling for comfort

Patients often lose 10‐15° of terminal extension

Question 8

What is given if it is an intraarticular fracture of the radial head?

Answer 8

Would give ORIF

Question 9

The forearm consists of the radius and ulna bones which are connected proximally and distally by strong ligaments around the proximal and distal radio‐ulnar joints where supination and pronation occur. Because of these strong ligaments, the forearm acts as a ring

If there is one fracture therefore, what happens?

Answer 9

There tends to be another fracture also or a dislocation

Question 10

Isolated fractures of the ulna can occur after a direct blow. What is a nightstick fracture properly known as?

Answer 10

Ulnar shaft fracture

Question 11

What must you make sure there is no associated of in an isolated ulnar shaft fracture?

Answer 11

No associated of a Monteggia fracture dislocation

Question 12

What is the management of an isolated ulnar shaft fracture?

Answer 12

Many cases are dealt with by conservative management however ORIF may afford earlier return to function and may reduce the risk of non‐union.

Question 13

What is a monteggia fracture dislocation?

Answer 13

This is where there is a fracture of the ulna with a dislocation of the radial head at the elbow MUGGER

MU - ulnar fracture monteggiA (A for proximal where the radial head is disocated at elbow)

Question 14

When the radius dislocates from the humerus at the elbow joint, what is the joint?

Answer 14

This is the radio-capitellar joint - supination and pronation

Question 15

Which of the elbow joints cause flexion and extension?

Answer 15

This would be the ulnohumeral joint - the trochlea of the humerus inserts into the trochlear notch of the ulna

Question 16

What is a galeazzie fracture dislocation?

Answer 16

This is where there is a radial fracture with an ulnar dislocation at the distal radioulnar joint MUGGER

GR - radial fracture galeaZZi (Z for distal - dislocation at distal radioulnar joint)

Question 17

It is advisable to form elbow xrays in monteggia fractures to make sure the radius is dislocated What is the mandatory xray view for galeazzia fractures?

Answer 17

Mandatory to have a lateral xray view

Question 18

What is the treatment of monteggia and galeazzia fractures? How is an isolated ulnar fracture treated? Describe both fractures again?

Answer 18

Monteggia and galeazzi fractures are treated with open reduction internal fixation

Isolated ulnar fracture - conservative management

Monteggia - fracture of the ulnar accompanied by dislocation of the radius at the elbow

Galeazzi - fracture of the radius accompanied by dislocation of the ulnar at the distal radioulnar joint

Question 19

Describe a Colle’s fracture

Answer 19

Extraarticular fracture of the distal radius within an inch of the articular surface with dorsal angulation or displacement of the radius due to a fall on outstrectched hand (FOOSH)

Question 20

How does a colle’s fracture usually occur?

Answer 20

Usually occurs due to FOOSH (fall on out-stretched hand)

Question 21

Fractures which heal with less angulation and shortening tend to have a better outcome in terms of pain, grip strength, ROM(range of motion), and function How will minimally displaced colles fractures be treated?

Answer 21

Reduce and splint

Question 22

In a Colle’s fracture, any angulation past neutral (the distal radius articular surface is normally 10° volarly angulated) is usually corrected by manipulation. How is it held together?

Answer 22

Held together by a plaster cast

Question 23

If the colle’s fracture is comminuted or particularly unstable after reduction What is carried out?

Answer 23

ORIF + Kwiring (percutaneous pins) may be required

Question 24

What nerve can be compressed in colle’s fracture and what are signs of this?

Answer 24

Can have median nerve compression, causes an ape like hand deformtiy and loss of sensation /sometimes pain in 1st,2nd and 3rd digits

Question 25

What is a late complication of colles fracture that will require tendon transfer?

Answer 25

This is rupture of the extensor pollicis longus

Question 26

What is the function of the extensor pollicis longus?

Answer 26

Causes extension of the thumb

Question 27

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. What is this fracture?

Answer 27

This is a Smith’s fracture - falling onto flexed wrist

Question 28

How should all Smith’s fractures be treated?

Answer 28

All smith’s fractures should be treated with ORIF usuing a plate and screws as they are highly unstable

Question 29

Intra-articular fractures of the distal radius with carpal bone subluxation

They can be classified as volar Barton or dorsal Barton fractures

What are volar and dorsal barton fractures also able to be called?

Answer 29

Volar Barton fracture - intra-articular Smith’s fracture

Dorsal Barton fracture - intraarticular Colle’s fracture

Question 30

As bArton’s fracture is intra-articular, what is the treatment?

Answer 30

This would require ORIF

Question 31

Some distal radius fractures are so comminuted (due to high energy or poor bone quality) that stable fixation of the joint fragments is not possible. What is used as treatment for these?

Answer 31

External fixation, wires for big fragments