ortho - 1 Flashcards
what is the classification of clavicular fractures?
Allman classification system
type 1 - fracture of middle of the clavicle (most common) - generally stable
type 2 - fractures involving the lateral third of the clavicle - if displaced often are unstable
type 3 - medial third (least common) - can be associated with neurovascular compromise, pneumothorax and haemothorax
clinical features of clavicular fracture?
sudden onset localised severe pain made worse on active movement of arm
nearly always following trauma
focal tenderness and deformity
look for open injuries and threatened skin
ensure to check neurovascular status of upper limb
investigations for clavicular fracture?
plain film AP and modified axial radiographs
CT is rarely indicated
how are clavicle fractures managed?
most can be treated conservatively
initial treatment is with a sling
early movement of shoulder is recommended to prevent frozen shoulder - healing time is usually 4-6 weeks
open fractures need surgical intervention
if fractures fail to unite and ORIF will be needed - usually 2-3 months post injury
what muscles make up the rotator cuff?
supraspinatus (abduction) infraspinatus (external rotation) teres minor (external rotation) subscapularis (internal rotation)
what joint does the rotator cuff muscles support and rotate?
glenohumeral joint
how are rotator cuff tears classified?
either acute (lasting <3 months) or chronic (lasting >3 months) tears.
either partial thickness or full thickness tears.
> Full thickness tears can be further classified into small (<1cm), medium (1-3cm), large (3-5cm), or massive (>5cm or involves multiple tendons) tears.
risk factors for rotator cuff tears?
age trauma overuse repetitive overhead shoulder motions BMI>25 smoking DM
what are the clinical features of rotator cuff tears ?
pain over the lateral aspect of the shoulder
inability to abduct arm above 90 degrees
tenderness over the greater tuberosity and subacromial bursa regions
what are the specific tests to look for rotator cuff tears and elucidate which tendons are affected?
Jobe’s test (the ‘empty can test’; tests supraspinatus)
Gerber’s lift-off test (tests subscapularis) – internally rotate the arm so the dorsal surface of hand rests on lower back.
Posterior cuff test (tests infraspinatus and teres minor) – the arm positioned at patient’s side, with the elbow flexed to 90°. The patient is instructed to externally rotate their arm against resistance.A positive test is present if there is weakness on resistance.
differentials for rotator cuff tears?
fracture
persistent glenohumeral subluxation
brachial plexus injury
radiculopathy
investigations for rotator cuff tears ?
plain XR to exlude fracture
USS to establish presence of tear and size of tear
MRI can also be used
management of rotator cuff tears?
conservative management is preferred in patients who are not limited by pain or loss of function or if they are unsuitable for surgery - analgesia and physiotherapy, corticosteroid injections into the subacromial space can be trialled
Surgical - large and massive tears or if they remain symptomatic despite conservative
prognosis with surgical repair is very good
what is the main complication of rotator cuff tears?
adhesive capsulitis -leading to stiffness of the glenohumeral joint
what is the most common site of shoulder fracture?
the proximal humerus
(occurs usually in elderly when they fall onto and outstretched hand - usually in the context of osteoporosis)
if in younger patients and high energy traumatic injury there may be associated soft tissue or neurovascular injuries
RF for shoulder fracture?
osteoporosis female gender early menopause prolonged steroid use recurrent falls frailty
clinical features of shoulder fracture?
pain around upper arm and shoulder
restriction of movement - inability to abduct arm
swelling and bruising of shoulder
due to close proximity of axillary nerve and circumflex vessels it is important to check the neurovascular status of the arm
what would damage to the axillary nerve result in?
loss of sensation of the lateral shoulder (regimental badge area)
loss of power in deltoid muscle
investigations for shoulder fracture?
any trauma - urgent bloods including a coagulation and group and save
plain XR
work up bloods to look for cause. - serum calcium and myeloma screen
CT may be done for pre-operative planning
what classification is used for shoulder fractures?
the Neer classification system (used to characterise proximal humeral fractures) - based on the relationship between 4 main segments of the proximal humerus:
Greater tuberosity
Lesser tuberosity
Articular segment (anatomical neck)
Humeral shaft (surgical neck)
what is the management for shoulder fractures?
most managed conservatively
immobilization initially with early mobilisation including pendular exercises at 2-4 weeks post injury
a sling that allows their arm to hang - the gravity on arm will aid the reduction of the fragments of most humeral fractures
surgery - needed when displaced, open or neurovascularly compromised fractures
multiple segment injuries - they may have open reduction internal fixation (ORIF) or intramedullary nailing
hemiarthroplasty or reverse shoulder arthroplasty are options
complicaitons of shoulder fractures?
reduced range of motion
avascular necrosis of the humeral head - in such cases a hemiarthroplasty or reverse shoulder arthroplasty may be required
scapular fractures?
very rare
almost always due to high energy trauma - 2-5% mortality due to their concurrent sevre injuries
treated non-operatively
ORIF is indicated in patients with glenohumeral instability, displaced scapular neck or complex fracture patterns
what are the different types of shoulder dislocation ?
An anterior dislocation is classically caused by force being applied to an extended, abducted, and externally rotated humerus - most common
A posterior dislocation is typically caused by seizures or electrocution, but can occur through trauma (a direct blow to the anterior shoulder or force through a flexed adducted arm) - often missed
what are the clinical features of shoulder dislocation?
painful shoulder acutely reduced mobility feeling of instability asymmetry of the contralateral side loss of shoulder contours anterior bulge from head of humerus
what are the bony injuries associate with shoulder dislocation ?
Bony Bankart lesions are fractures of the anterior inferior glenoid bone, most commonly present in those with recurrent dislocations
Hill-Sachs defects are impaction injuries to the chondral surface of the posterior and superior portions of the humeral head, present in approximately 80% of traumatic dislocations
Fractures of the greater tuberosity and the surgical neck of humerus can also occur
what are the ligamentous injuries associate with shoulder dislocation ?
(Soft) Bankart lesions are avulsions of the anterior labrum and inferior glenohumeral ligament
Glenohumeral ligament avulsion
Rotator cuff injuries occur frequently in anterior dislocations; in younger patients, around a third have at least one tear
what investigations should you perform for suspected shoulder dislocation ?
XR
how are shoulder dislocations managed?
analgesia
closed reduction using the hippocratic method
*ensure to assess the neurovascular status pre and post reduction
immobilisation - with a braod-arm and rehabilitation with physio
what are the clinical features of humeral shaft fractures?
pain
deformity
due to the location of the radial nerve within the spiral groove there is a high risk of injury to it - if it is involved the patient may also complain of reduced sensation over the dorsal 1st webspace and weakness in wrist extension
**ensure to assess and document neurovasular status and assess for open wounds
what is a holstein lewis fracture?
A Holstein-Lewis fracture is a fracture of the distal third of the humerus resulting in the entrapment of the radial nerve.
The resultant neuropraxia to the radial nerve will result in loss of sensation in the radial distribution and a wrist drop deformity. Surgical management is indicated in such cases.
what investigations for humeral shaft fracture ?
XR
in severe cases - CT may be needed for pre-operatively planning
how is humeral shaft fracture managed?
re-alignmenet of the limb - usually done conservatively in a functional humeral brace
Fractures that are <20o anterior angulation, <30o varus or valgus angulation, and with <3cm of shortening are typically deemed suitable for conservative management, requiring regular follow-up with repeated plain film imaging. Around 90% of patients will go on to full union within 8-12 weeks.
surgical management: surgical fixation - open reduction and internal fixation
Intramedullary nailing may be indicated in the presence of pathological fractures, polytrauma, or severely osteoporotic bones.
what is tendinopathy?
Tendinopathy is a broad term used to encompass a variety of pathological changes that occur in tendons, typically due to overuse. This results in a painful, swollen, and structurally weaker tendon that is at risk of rupture
where can bicep tendinopathy occur?
proximal and distal bicep tendons
what are the clinical features of bicep tendinopathy?
pain - made worse with stressing the tendon and alleviated through rest and ice therapy
weakness (flexion and supination)
stiffness
loss of muscle bulk due to disuse atrophy
what specific tests can be performed for bicep tendinopathy?
Speed test (proximal biceps tendon) – The patient stands with their elbows extended and their forearms supinated. They then forward flex their shoulders against the examiners resistance Yergason’s test (distal biceps tendon) – The patients stands with their elbows flexed to 90 degrees and their forearm pronated. They actively supinate against the examiners resistance
