Ortho upper limb: FOREARM, ELBOW, HUMERUS, SHOULDER Flashcards
(111 cards)
1
Q
Why do you test motor function of the radius by both wrist extension and finger extension?
A
Wrist extension tests proximal portion of radius
Finger extension tests the deep branch ( posterior interosseous nerve)
2
Q
When assessing motor function of the median nerve, how can you assess the anterior interosseous nerve and recurrent branch?
A
Anterior interosseous: “OK sign”
Recurrent branch: thumbs up
3
Q
A fun way to test all the nerves of the hand is children is to play “rock, paper scissors” then “OK” and thumbs up. What nerves does this test in this order?
A
Rock = proximal radial
Paper = posterior interosseous
Scissors = ulnar
OK = anterior interosseous
Thumbs up = recurrent branch median
4
Q
Describe the radiocapitellar line
A
A line drawn through the center of the radial shaft that should bisect the radial head and capitellum
5
Q
What does an abnormal radiocapitellar line suggest?
A
Occult radius fracture or disloction
6
Q
Describe the anterior humeral line
A
A line drawn straight along the anterior border of the humerus that should transect between the anterior and middle third of the capitellum
7
Q
The anterior humeral line is passing through the anterior 1/3 of the capitellum, what does this suggest?
A
In adults: occult distal humerus #
In children: occult supracondylar #
8
Q
Which fat pad seen on an elbow xray, if small, can be normal?
A
Anterior
9
Q
Where is a biceps tendon rupture most likely to occur?
A
Proximally. Nearly alway proximal long head
Pain felt in anterior shoulder
10
Q
What is the biceps squeeze test?
A
With forearm flexed to 60 - 80 degree, sqeeze biceps belly. Should cause supination. If not, suggest distal biceps tendon repture
11
Q
You suspect a distal bicep tendon rupture, what is the hook test?
A
Flex pt eblow to 90 degree. On active supination examiner can hook index finger under the cord like tendon of biceps in elbow
12
Q
After examination, you a confident your pt has a triceps tendon rupture. Why is an xray still needed?
A
To exclude avulsion fracture
13
Q
While triceps tendon rupture is not common, when it does occur it is proximal or distal usually?
A
Almost always distal
If complete –> loss of eblow extension. Complete needs surgical repair.
14
Q
Approximatly what % of elbow dislocations are posterolateral?
A
90%
15
Q
What is the “terrible triad” regarding elbow injuries?
A
Elbow dislocation
Coronoid fracture
Radial head fracture
Needs emergency ortho consult
16
Q
What neurovascular structures are at risk with an elbow dislocation?
A
Brachial artery
Median nerve
Ulnar nerve
17
Q
What cause the fat pad sign on elbow xray in trauma
A
traumatic haemarthrosis displacing fat from olecranon fossa posteriorly and anterior fat
Can also be present in non-traumatic elbow joint effusion
18
Q
Do supracondylar fractures occur in adult?
A
less so, but can be seen in high velocity accidents
19
Q
What age do supracondylar fracture tend to occur?
A
5 - 10
20
Q
Should you get an emergent ortho consult for this fracture?
A
Yes
21
Q
What is an extension type supracondylar #
A
FOOSH with arm in extension
Distal segment displaced posteriorly
95% of supracondlar#’s
22
Q
What is a flexion type supracondlar #
A
Rare, 5%
Direct anterior force against flexed eblow
Anterior displacement of distal segment
Most likely to require ORIF –> refer emergently
Risk ulnar nerve injury
23
Q
What degree of displacement is acceptable for a supracondylar fracture?
A
None.
Displaced # must be reduced
> 20% often gets ORIF
24
Q
What nerve is MOST at risk with a supracondylar fracture?
A
Anterior interosseous
MOI usually traction or contusion. Complete laceration rare
25
A pt has a displaced supracondylar fracture and now they are refusing to open their hand, have pain with passive extension of their fingers and are in a lot of pain. What is causing this?
Forearm compartment syndrome. Signs of **Volkmann's ischaemia**
26
Are humeral intercondylar fractures more likely to occur in children or adults?
Adults
## Footnote
By default assume any distal humerus # in an adult is intercondylar. Refer anything displaced urgently
27
How is a minimally displaced lateral epicondyle avulsion fracture treated?
Long arm backslab 90 degree with arm in supination (reduces muscle pull)
## Footnote
Refer displaced urgently
28
What does this XR show? When is this complication most likely to occur?
This is a medial epicondyle trapped in the joint space. Most commonly occurs after an elbow reduction. Needs urgent ortho involvement
29
How is a minimally displaced medial epicondyle fracture treated?
Long arm backslab in pronation
## Footnote
Common in children and adolsecents "little league elbow" from throwing ball
30
What is myositis ossificans of the elbow?
Bone tissue forms within a muscle
Hard, palpable lump in the muscle
Restricts movement and strength
31
List the early complications of a supracondylar fracture
**Neuro:**
-radial nerve
-median nerve (anterior interosseous)
-ulnar nerve (iatarogenic)
**Vascular:**
-Brachial artery injury
-Forearm compartment syndrome
32
List the late complications of a supracondylar fracture
Nonunion
Malunion
Myositis ossificans
Loss of motion
33
humerus lateral condyle fractures occur in what age group?
< 7
mean of age 6
## Footnote
Common paediatric fracture 10 -20% of elbow fractures in kids. Refer all urgently to ortho as high complication rate
34
What are some unique features of isolated trochlear or capitellum fractures?
Rare
Hard to see on plane film
**Complications common:**
-eblow instability
-limited ROM
-avascular necrosis
-nonunion
-arthritis
35
What two mechanisms tend to cause coronoid fractures?
Eblow dislocation (most)
Elbow hyperextension
## Footnote
Hard to see on plane film. Need DW ortho. If displaced needs ORIF, associated with poor outcomes
36
Which olecranon fractures get conservative treatment?
Stable, non-displaced with intact eblow extensor function
Elderly
## Footnote
Represent 10% of upper extremity fractures
37
Why must you test triceps extension against resistance when assessing an olecranon fracture?
Extensor functoin may be impaired but gravity may draw forearm down and fool you
38
What is the MOST common fracture of the elbow in adults
radial head
39
What is the essex-lopresti lesion?
Radial head #
+ disruption of interosseous membranes
+ disruption triangular fibrocartialge complex of wrist
## Footnote
Don't miss. Radial head can migrate proximally. Urgent ortho review
40
Radial head fracture can be hard to see in children as the epiphysis has not fused. What features on plane film may suggest the fracture?
Fat pad sign
Displaced radiocapitellar line
41
The fibrous interosseous membrane of adult forearms transmits force above and below the injury. Why is this significant?
Isolated injury rare
**Look for the other**
-fracture
-ligementous injury
-dislocation
## Footnote
examine joint above and below injury
42
What degree of angulation is acceptable for a buckle or greenstick fracture?
< 10 years = 15 degree
> 10 years = 10 degree
## Footnote
the more growing time left, the more the bone will remodel. Reduce in ED or refer depending on local policy
43
How do you manage a displaced ulnar + radial shaft fracture in adults?
Refer ortho
| Risk of forearm compartment syndrome
## Footnote
If non-displaced could possibly refer as outpatient but this is rare as injury if high mechanism so bones often displaced. If paeds may be suitable for discharge if DW ortho and reduced ok
44
What features make an isolated unlar (nightstick) fracture unstable?
> 50% displacement
> 10 degree angulation
Involves proximal third of ulna
## Footnote
Refer unstable fractured to ortho
Always assess for the OTHER injury (# ,dislocation, ligamentous)
45
What is a monteggia fracture-dislocation?
Fracture proximal third of ulnar +
radial head dislocation
## Footnote
Apex of ulnar fracture points to radius dislocation. Don't miss
46
What are the complications of a missed monteggia fracture-dislocation
Chronic pain
Limited ROM
May need radial head excision
## Footnote
Radial head dislocation gets misssed as ulnar shaft fracture is obvious and overshadows the dislocation
47
Which proximal radius shaft fractures get referred to ortho urgently?
Rare fracture, but if seen refer anything
-displaced
-open
-neurovascular compromise
## Footnote
Compartment syndrome is rare
48
What is a galeazz's fracture-dislocation?
Fracture distal third of radius
+
dislocation distal radio-ulnar joint
49
What are the complicatios of a galeazzi fracture-dislocation?
Infection
non-union
malunion
chronic pain
50
Distal radioulnar joint disolcation is easily missed. What examination and xray features do yo look for?
-radioulnar distance of >6 mm between the most dorsal cortices on a true lateral radiograph
-prominant ulnar styloid
-narrow wrist
-volar fullness
## Footnote
rotation as little as >10° of rotation can cause false results option is to obtain bilateral clenched-fist radiograph
Swelling can make clinical assessment difficult
51
What age does the medial epiphaysis of the clavicle appear radiographically and what age does it close?
Appear = 18 years
Closes = 22 - 25 years
## Footnote
Is epiphysis to appear and last to close. Injury here is usually a sprain but if fracture does occur < 25 tends to be Salter Harris 1 or 2
52
What are symptoms and signs of a posterior clavicle dislocation?
**Symptoms:**
- severe pain, worse with arm movement and being supine
**Sign:**
- medial end less visible, may not be palpable
- stridor, dysphagia, SOB if mediastinal compression
53
How is a sprain to the sternoclavicular joint treated
Ice
Sling
Analgesia
## Footnote
Very strong ligaments. Sprain common. Dislocation rare. Injury can be from direct impact or impact to shoulder
54
A pt has non-traumatic sternoclavicular pain. What should you be worried about?
Septic arthritis
## Footnote
Esp in IVDU. USS can asssist in detection and aspiration
55
How do you treat an anterior sternoclavicular dislocation?
Ice
sling
Analgesia
closed reduction can be befored within 10 days - not urgent
## Footnote
To attempt reduction: towel roll between scapular, pt lying down arm abducted 90 degree. Longitudinal traction, extend up (move to ground) slightly, pressure over medical dislocated end. Unstable and dislocated again 50% of time
56
You suspect a posterior sternoclavicular dislocation. What imaging do you get?
Can start with CXR - pneumothorax, pneumomediastinum
**CT chest + angiogram**
| Orthopaedic emergency
## Footnote
Angiogram to assess for vessel injury/compression
57
How do you reduce a posterior sternoclavicular dislocation
Towel between shoulder blades
Pt lying down arm abducted 90 degree
Extened arm 15 degree
Assistant pulls medial end of claviclar forward
| Orthopaedic emergency
58
What complications as associated with a posterior sternoclavicular dislocation?
pneumothorax
compression/laceration of great vessels, trachea or eosophagus
59
What imaging modality made be needed to see proximal or distal claviclar fractures?
CT
## Footnote
Overyling structures medially and distally can make seeing some of these fractures difficult on plane film
60
What are middle clavicle non-union risk factors?
Shortening > 2cm
Comminuted
Displaced > 100%
Significant trauma
Female
Elderly
## Footnote
Also take into consideration if an athlete, profressional impact, cosmetic concerns
61
What clavicle fractures need emergent ortho review?
Open
neurovascular injury
Skin tenting
62
What MOI is associated with medical clavicular fractures?
High mechanism
## Footnote
Associated with thoracic trauma. Consider need for CTA to assess for mediastinal injury
63
What injuries as associated with a scapula fracture?
Ipsilateral lung injury
rib fractures
Shoulder girdle
Spine #'s
Pelvic #'s
## Footnote
High MOI. Consider at least CT chest + scapular views
64
How are most scapular fractures treated?
Non-surgically
- sling
- ice
- analgesia
- early ROM
## Footnote
surgery only if significantly displaced articular #s, angular glenoid neck, acromial with rotator cuff tears, some coracoid
65
What injuries are associated with scapulothoracic dissociation?
Injury subclavian or axillary vessels
Brachial plexus injury
Injury shoulder muscles
AC seperation
Sternoclavicular dislocation
66
A trauma pt arrived intubated, what features on xray make you suspect scapulothoracic dissociation?
Lateral displacement of scapular
Clavicle fracture
AC separtion
Sternoclavicular dislocation
## Footnote
Orthopaedic emergency. Get a CTA
67
How is an AC joint injury diagnosed?
Clinical assessment +
AC xray can assist to grade severity and exclude fractures
## Footnote
Ask specifically for AC xray w/ axillary view. Is 1/3 of radiation dose AND shoulder xray may overpenetrate the AC and small fractures can be missed
68
Why is an axillary view useful when assessing for AC injury
Needed to see type IV injury. Without axillary view can look like type I/II on xray
## Footnote
clavicle dislocated posteriorly
69
Which AC injuries need emergent orthopaedic review?
- open
- neurovascularinjury
- skin tending
70
What arm movement is particuar painful and assist in diagnosing an AC sprain?
Arm abduction
71
How do you treat type 1 or 2 AC sprains?
- Rest
- Ice
- Sling
- Anaglesia
- eary ROM 7 - 14 days
**Type 2** AC ligaments ruptured only
| Type 1: sprains AC ligaments only
## Footnote
Excellent prognosis. Very small % of pts needing late symptoms/pain needing distal clavicle excision
72
A pt falls on an adduction arm. They have pain with mild step-off deformity of AC joint.
AC xray shows slight widening of AC joint, clavicle is elevated 25 - 50% above acromion. Slight widening of coracoclavicular space.
What grade of AC injury is this and do they need conservative or surgical management?
**Grade II**
Conservative management
## Footnote
Excellent prognosis
73
A pt falls on an adduction arm. They have pain with a prominent distal clavicle. The shoulder is drooping.
AC xray shows the clavicle 100% above the acromion. The coracoclavicular space is widened 25 - 100%.
What grade of AC injury is this and does it need conservative or operative management?
**Grade III**
Depents, but most orthopods offer trial of conservative treatment. Treatment depends on age, occupation, activity level
| Rupture of all supporting ligaments, deltoid + trapezius still attached
74
What grade of AC injuries always get surgical management?
Type IV, V, VI
| rupture of all supporting ligaments + significant clavicle displacement
## Footnote
Severe injuries
75
What combination of arm movement tends to cause an anterior glenohumeral dislocation?
- abduction +
- extension +
- external rotation
76
Why do you need a Y view shoulder xray when assessing shoulder dislocations?
To see if dislocated anterior or posteriorly
77
How much and where do you injected 1% lignocaine to assist with reducing an anterior a shoulder dislocation?
10 -20ml
At hollow created by displaced humeral head just inferior to acromion.
USS guidance can help
## Footnote
https://rebelem.com/intra-articular-lidocaine-vs-procedural-sedation-and-analgesia-for-closed-reduction-of-acute-anterior-shoulder-dislocation/
78
What complications are associated with anterior shoulder disloctions?
- recurrence
- rotator cuff tears
- humeral head defects (Hill-sach deformity)
- glenoid labral defects (Bankart lesion)
- neurovacular injury (rare)
79
Why are first time shoulder dislocations refer to ortho clinic?
For consideration of early surgical repair. Young adults may have recurrence rates of 90% otherwise
80
What is the ED management of a Hill-sach deformity, soft or bony bankart injury, fracture greater tuberosity of humerus after shoulder dislocation?
Refer to ortho as outpatient
81
An elderly pt present with an anterior shoulder dislocation. What examination findings suggest and axillary artery injury?
- absent radial pulse
- axillary haematoma
- bruising of lateral chest wall
- axillary bruit
## Footnote
Rare injury. At risk age group = elderly
82
What % of anterior shoulder dislocations are associated with an axillary nerve injury?
10 - 25%
## Footnote
From neuropraxia. Loss sensation upper arm, deltoid weakness (weak abduction) teres minor weakness ( weak external rotation). Temporary. Resolves spontaneously.
83
What method of shoulder reduction is this?
Kocher
## Footnote
Peform slowly to avoid spasm
84
Describe the scapular manipulation technique for shoulder reduction
Pt prone with 5 kg weight in hand or assitant proving traction towards gound
Physician uses their hands to push the inferior tip of the scapula medially while moving the superior aspect laterally.
| 96% success rate
85
What shoulder reduction method is this?
Traction-counter traction (modifed Hippocratic)
## Footnote
Gentle internal and external rotation or outward pressure on the proximal humerus may aid reduction
86
What method of shoulder reduction is this? How long till shoulder relocates?
Stimson technique
20 - 30 min
5 kg weight
| Intra-articular lignocaine can help
87
What method of shoudler reduction is this?
Milch
88
What method of shoulder reduction is this?
Cunningham
## Footnote
If no 2nd assistant, ask pt to shrug and retract shoulder - try get shouder blades to touch
89
What method of shoulder reduction is this?
FARES
## Footnote
Once arm abducted to 90 degree externally rotate. Relocation occurs at 120 degree. 90% success WITHOUT sedation or analgesia!
90
Which direction is the shoulder dislocaton for
1) pt cant internally rotate to touch opposite shoulder
2) pt can't externally rotate or abduct arm
1) anterior
2) posterior
| Clinical appearance of posterior dislocation
91
What type of shoulder dislocation is the doctor trying to fix with the following method?
Pt is supine
Traction applied to adducted arm in long axis of humerus
Assistant pushes humeral head anterior
Posterior
92
What types of injuries are associated with a posterior shoulder dislocation?
Bony bankart (fracture glenoid rim)
Reverse hill-sach (fracture humeral head)
Humeral shaft #
Lesser tuberosity #
## Footnote
neurovascular and rotator cuff tears less common than anterior dislocation
93
A pt has had a hyperabduction force to their arm. They present with their arm above their head and their hand is resting on their head. What injury to they likely have?
Inferior shoulder dislocation
## Footnote
Associatd with significant soft tissue injury or fractures. To reduce, upwards tracting and outward direction in line with humerus with assistant provided countertraction. Some will be irreducible and need OT
94
What nerve injuries are associated with a proximal humerus fracture?
Axillary nerve (most common)
Suprascapular nerve
## Footnote
Suprascapular nerve innervates supraspinatus (abduction) and infraspinatus (external rotation
95
Why does the axillary artery become more likely to be injured with a proximal humerus fracture as the pt becomes more elderly?
Atherosclerosis
## Footnote
In elderly may be injured even in non-displaced fracture. May be as high as 50% in displaced #'s
96
Descibe what are 'parts' using the neer classification of proximal humerus fractures
## Footnote
If parts of displaced < 1 cm or angulated < 45 then even with multiple fragments the fracture is considered '1 part'
97
What is the treatment of a 1 part proximal humerus fracture?
- sling
- ice
- analgesia
- refer ortho outpatient
## Footnote
early mobilisation to avoid adhesive capsulitis
98
Which if the following proximal humerus fractures using Neer classification needs inpt ortho consult:
1) 1 part
2) 2 part
3) 3 part
4) 4 part
2, 3 and 4 part
## Footnote
More frequently associated with complications and difficult to manage. A part only counts if > 1 cm or angulated > 45
99
A fracture of the articular surface of the proximal humerus may be complicated by what?
Ischaemic necrosis of articular surface
## Footnote
Refer to ortho for operative management regardless of Neer classification
100
A significantly angulated surgical neck fracture of the proximal humerus is at risk of what complication?
- axillary nerve injury
- axillary vessel injury
- brachial plexus injury
101
Significant displacement of the greater tuberosity of the proximal humerus implies what other injury is present?
Rotator cuff injury
102
A fracture of the lesser tuberosity is also associated with what injury until proven otherwise
Posterior dislocation
103
Using the Neer classification, describe this image
3 part fracture dislocation
103
Using the Neer classification, describe this image
2 part fracture involving lesser tubersoity + articular surface humeral head (could argue 3 par if all displaced)
## Footnote
Refer other as it is 2 part AND involves anatomical neck = risk avascular necrosis
104
What part is fractured. What is the Neer classification?
One part fracture (of could be 2 part if displaced, hard to tell) involving greater tuberosity
105
Fractures of which third of the humerus risk radial nerve entrapment?
Distal 1/3
## Footnote
Can occur due to fracture or closed reduction
106
Which artery and vein are most at risk of injury with a humeral shaft fracture?
Brachial artery and vein
106
What degree of displacement indicates possible operative management of a humeral shaft fracture?
> 20 degree angulation in sagital plane
> 30 degree varus or valgus angulation
> 2-3cm shortening
107
What is the treatment of an uncomplicated humerus shaft fracture?
Immobilsations
Ice
Anaglesia
Refer out pt ortho
## Footnote
Most get conservative treatment. Sling may be all that is needed. Can also use sugar tong cast, u-slab, hanging cast. Gravity pulls fracture straight. Sling supports wrist not elbow.
108
What are the some complications of shoulder athroplasty?
Infection
Periprosthetic loosening
Glenohumeral instability
Periprosthetic fracture
Soft tissue dysfunction
109
How does treatment of a minimally displaced fracture at the humerus anatomical neck (Neer 1) differ from the standard treatment of a neer 1 fracture
Rare fracture. Risks of avascular necrosis of humeral head.
In young = ORIF
In old = hemiathroplasty
Usually Neer 1 is treated conservatively
