Surgery: Upper Limb (Orthopedics) Flashcards
(72 cards)
1
Q
(4) general types of fracture
(re to underlying bone pathology)
A
- osteoporotic fracture → occurs with minimal trauma to the bone
- pathological fracture → occurs with no trauma
- stress fracture →when prolonged, unaccustomed activity with no specific trauma
- usually, fractures occur with a significant trauma, when the underlying bone quality is normal
2
Q
What’s that?
A
Stress fracture
3
Q
What’s that?
A
Pathological fracture
(underlying abnormal bone structure)
4
Q
Bone structure
A
5
Q
What muscles insert at the humerus?
A
- Pectoralis Major
- Deltoid
- Coracobrachialis
(insertion = attachment site that moves when the muscles contract; usually distal to the body)
6
Q
What muscles the humerus is the origin of? (3)
A
- Brachialis
- Biceps
- Brachioradialis
(origin = attachment site that doesn’t move when muscles contract; usually proximal to the body)
7
Q
What nerves run along/close to the humerus?
A
- Median and Ulnar→ run along the shaft (protected by muscles)
- Radial Nerve → in direct contact along spiral groove;14 cm proximal to lateral epicondyle
8
Q
Mode of injury and the resulting fracture
- Direct Trauma
- Indirect Trauma
A
- Direct Trauma → transverse fracture
- Indirect Trauma (arm wrestling) →spiral fracture
9
Q
Mode of injury and the resulting fracture
- Fall on outstretched hands or RTA
- Minimal or no trauma
A
- Fall on outstretched hands or RTA → high-velocity comminuted fractures
- Minimal or no trauma → pathological fractures (osteoporosis or metastatic deposits)
10
Q
Name tyes of fractures (picture)
A
11
Q
What clinical examination of a suspected fracture should involve?
A
- General Exam to assess for other associated injuries (ATLS protocol in polytrauma patients)
- Specific examination of affected limb in isolated injury: examine joint above and below, assess overlying skin for laceration / compromise
- Assess distal neurovascular compromise
12
Q
What imaging techniques should we use to investigate fractures?
A
- Plain X-rays usually satisfactory AP and lateral views
- Very rarely CT scan to identify anatomy in complex fractures
- MR scan and bone scan in pathological fractures
(In pathological fractures blood workup to assess serum calcium levels and try to identify primary malignancy)
13
Q
Initial fracture of upper limb management
A
- Pain relief
- Splintage in cuff and collar or broad arm sling
- X-ray examination
- Temporary splintage till definitive management can be planned by senior intervention
14
Q
Definitive management of humeral fractures
A
- Conservative
- Splintage in Sugar Tong Humeral Brace
- Regular monitoring with serial check x-rays
- Adjustment of splint which can get loose as swelling reduces with time
- Intervene surgically if satisfactory alignment is difficult to maintain
15
Q
What’s a functional brace used for?
A
Functional brace → conservative treatment for humeral shaft fractures
- Indications
- indicated in vast majority of humeral shaft fractures
once swelling has reduced. Suitable for most mid-shaft humeral fractures
16
Q
Criteria for functional humeral brace use
A
criteria for acceptable alignment include:
- < 20° anterior angulation
- < 30° varus / valgus angulation
- < 3 cm shortening
17
Q
What are definitive indications for surgery in a humeral fracture? (6)
A
Definite indications for surgical treatment:
- Open fractures
- Presence of neurovascular injury
- Segmental fractures
- Polytrauma
- Floating elbow (when there is fracture of humerus as well as forearm) or floating shoulder (fracture humerus and fracture clavicle or scapula)
- Adequate alignment is difficult to maintain (e.g. transverse fractures)
18
Q
Intramedullary Nailing
- types (2)
- indications (3)
- disadvantages (as compared to plating)
A
Intramedullary Nailing
- Can be done anterograde or retrograde
- Indicated in cases with pathological fractures, segmental fractures and very osteoporotic fractures
Is inferior to plating in terms of union rate and complication rates
19
Q
Compression plating
- advantages compared to nailing
A
Compression plating
- Method of choice for fixing humeral shaft fractures
- Better union rate and lower complication rate compared with nailing
20
Q
Complications of surgical treatment of the fractures (4)
A
- Infection
- Delayed union
- Non- union
- Nerve damage (radial nerve palsy)
21
Q
How long does it take for the humeral fracture to heal?
A
8 - 10 weeks
22
Q
What’s needed to be done in case of non-union?
A
Further surgery with internal fixation and bone grafting needed in cases with non-union
23
Q
How most humeral shaft fractures are treated?
A
Conservatively → collar and cuff for three weeks
24
Q
Which nerve involvement should be checked before and during treatment for humeral shaft fracture?
A
Radial nerve involvement
25
Management of the fracture of the clavicle
**Conservative treatment**
* broad arm sling for 3 weeks
* analgesia
\*surgical treatment with ORIF is only needed when there is an open fracture or neurovascular compromise
26
What does the abbreviation ***ORIF*** mean?
Open Reduction Internal Fixation
27
What is a possible neurovascular compromise with fractures of the clavicle?
neurovascular compromise of a distal limb → **rare** but may damage: **brachial plexus** and **subclavian artery**
28
Presentation of a patient with a fracture of the humerus
* pain
* tenderness
* swelling
* deformity
* inability to move the shoulder
29
Is neurovascular compromise common in the fractures of **surgical neck** of the humerus?
No, because these fractures are **extracapsular** → blood supply is not disturbed (avascular necrosis is rare)
30
Is neurovascular compromise common in the fractures of **anatomical neck** of the humerus?
High risk of avascular necrosis
31
What to assess with the fracture of the **proximal humerus**?
Deltoid sensation → to assess for axillary nerve injury
32
What are (3) most common wrist&hand fractures?
* Colles Fracture
* Scaphoid Fracture
* Boxer’s Fracture
33
Wrist anatomy (bones)
34
Anatomy of the hand (bones)
35
***Colle's fracture***
- anatomical location and deformity
the distal end of the radius + dorsal angulation
36
***Colle's fracture***
- mechanism of injury
- common in what group of patients
**Mechanism:** following a FOOSH
**Common group:** women over 50 y old (osteoporosis)
37
What's that?
Colle's fracture
38
Management of Colle's fractures
* **Reduction of the fracture** under regional anaesthesia (Bier's block) or LA (haematoma block) → to reverse deformities
\*radiographs to confirm satisfactory reduction
* **Plaster backslap** (from the elbow to metacarpophalangeal) for 6 weeks
39
Possible complications of Colle's fracture
- carpal tunnel syndrome
- mal-union → persistent dinner fork deformity
- stiffness
- rupture of extensor pollicis longus
40
Indications for surgical management of Colle's fracture
- intra-articular involvement
- failed reduction
- mal-union
41
**Smith's fracture**
* How does it look like?
* Management
* reverse Colle's → anterior angulation and tilt
\*it is uncommon
**Management:**
manipulation under anaesthesia and a plaster cast above the elbow for 6 weeks
42
What is fractured in a Chauffeur's fracture?
Fracture of radial styloid
43
What's most frequently fractured carpal bone?
Scaphoid
44
Possible clinical findings in a scaphoid fracture (3)
Tender anatomical snuffbox may be the only sign
45
What's the danger with a scaphoid fracture?
Scaphoid has a retrograde blood supply ( enters via distal end) → a complete fracture may disturb a blood supply to proximal end → avascular necrosis
46
What investigations to do for a suspected scaphoid fracture?
* Four x-ray views ('scaphoid series')
* it may not be visible at early stage
\*variation in the choice of when and how to re-image for suspected scaphoid fracture. Repeat plain x-ray, isotope bone scans, CT and MRI are all used
(MRI as imaging as second line)
47
When to suspect and how to manage a **scaphoid fracture**?
* even with series of x-ray imaging, a scaphoid fracture may not be seen
* therefore, suspect if there is **tenderness over the anatomical snuffbox**
Management:
* apply s**caphoid plaster** (from the elbow to knuckles)
* **repeat x-ray at 2 weeks** (bone may be needed) → if this show fracture → plaster cast remain for further **8 weeks**
* if the fracture has not united after **12 weeks** → **internal fixation** is needed
48
Complications of scaphoid fracture
* Non-union
* Malunion
* Osteoarthritis
* Scapho-lunate disassociation
* Avascular necrosis due to interruption of blood supply by fracture
49
What's the most common metacarpal fracture?
Boxer's fracture
50
What's ***Boxer's fracture?***
* Fracture of the 5th metacarpal neck with palmar displacement of the metacarpal head
* Transverse fracture after striking a hard object with a clenched fist, i.e. a punch
51
Clinical features of Boxer's fracture
52
Management of a boxer's fracture
* if sustained in a fight consider other injuries
* antibiotics for open wounds
* x-ray should be examined for foreign bodies such as glass or teeth
* most fractures will heal well with minimal immobilisation or splintage
* Angulation of \> 45 degrees or rotation of \> 20 degrees may require operative fixation with percutaneous wires
* T&O / Hand Clinic follow-up
53
54
Case 1
## Footnote
**What is the initial management?**
**The initial management should be based on ATLS principles:**
* Acute control of airway (A), breathing (B), and circulation (C)
* Prevention of hypoxia
* Prevention of hypotension
* A brief initial neurologic evaluation, including the Glasgow Coma Scale (GCS) (D), assessment of the pupils, and an evaluation for any focal deficit
* Assessment of the cranium and face for external injuries
* Evaluation of the spine for deformities and / or open abnormalities
* Concomitant head-to-toe evaluation for other life- or limb-threatening injuries (E)
55
How should you initially assess that arm clinically?
* **initial inspection →** look for any open wounds, penetrating injuries or marked deformities
* a quick but thorough **neurovascular examination** should be done and recorded
* Any open wounds should be addressed (e.g. dressed, antibiotics, anti-tetanus cover etc.)
* **Analgesia** or sedation should be given
* The fracture should be reduced and stabilised with a **back-slab** immobilising the joint below (elbow) and above (shoulder)
* A repeat neurovascular and radiological assessment should be made and recorded in the notes
56
**Case 1**
How would the fracture be assessed (after initial/clinical examination)?
After clinical examination → t**he fracture should be assessed radiologically**
* Clear AP and lateral radiographs of the humerus pre and post-reduction would be taken
* The Joint above and elbow would also be assessed both clinically and radiologically
57
Case 1
Describe that fracture
This fracture is:
* comminuted (more than one fragment)
* transverse (fracture pattern)
* 100% displaced (no end to end contact)
* in the mid diaphyseal region of the left humerus
58
Case 1
What would be definitive management?
Open reduction internal fixation (ORIF) with plate fixation (absolute stability-primary bone healing)
59
Case 1
Is that the x - ray of ORIF with a plate fixation?
No
X-ray 2 shows an intramedullary nail fixation and this is NOT the optimal fixation method for the fracture from case 1
60
Possible complications of nail fixation management
* restriction of shoulder movements
* risk of delayed union
* rotator cuff violation /naruszenie/
* adhesive capsulitis
Impairment of shoulder function with the antegrade interlocking nails could be because of impingement due to proximal migration of nail
61
Case 2
* What is the most likely metabolic or endocrine abnormality contributing to this patient’s presentation?
* What other conditions should you consider?
* osteoporosis
* cancer → either metastatic or primary bone cancer
62
How to investigate for osteoporosis and what value defines it?
* To assess the actual bone mineral density → dual-energy X-ray absorptiometry (**DEXA) scan** is used
* The DEXA scan looks at the hip and lumbar spine
* If either have a T score of \< -2.5 then treatment is recommended
T score
\> -1.0 = normal
-1.0 to -2.5 = osteopaenia
\< -2.5 = osteoporosis
63
What is T score and what is Z score in DEXA scan?
* **T score:** based on bone mass of young reference population
* T score of -1.0 means bone mass of one standard deviation below that of young reference population
* **Z score** is adjusted for age, gender and ethnic factors
**T score**
* \> -1.0 = normal
* -1.0 to -2.5 = osteopaenia
* \< -2.5 = osteoporosis
64
What other investigations would you perform?
* Bloods: FBC, U+E, Calcium and 25 hydroxyvitamin D level
\*Low 25 hydroxy vit D in patients sustaining low energy fractures needs further investigation
* Dexa Scan (Dual Energy X-ray Absorptiometry)
* CT scan to assess boney union
65
Case 2
Can we consider conservative management only for this patient?
Conservative managemen
* the patient is 80 years old and patient-specific risk factors need to be taken into consideration → possibly a number of co-morbidities that would make surgery extremely high risk
* The activity level of the patient should also be considered → If the patient is a low demand patient, i.e. nursing home resident, then conservative management with regular analgesia and physiotherapy is an option
66
Case 2
May this patient be considered for surgery?
* patient has to fulfil certain criteria in order to be considered for surgical intervention
* CT scan / radiographs and clinical examination must show signs of a painful non-union which is affecting the patient’s daily life
* patient and patient’s family would need to be counselled on the risks of surgery and whether it is suitable
* If the patient has minimal co-morbidities and is independent of all activities of daily living, **surgical management by open reduction internal fixation using a locking plate construct may be offered**
67
Case 2
What impact such an injury could have on this patient. What assessments would you do and which agencies might you wish to consider involving?
* This injury has a large impact on the patient’s life: there will be a long period (6-12 months) of rehabilitation. This may impact her independence and subsequent living situation
* She will firstly need to be assessed by **physiotherapy and occupational therapy (OT)** to quantify her social needs
(Living adaptations and care packages will need to be introduced or re-evaluated)
* **Social workers** liaise with physiotherapy, O.T and the family to create the best social and care package for the patient and her needs
68
Case 3
Describe what you can see
* fracture at the waist of the right scaphoid
* showing signs of proximal pole sclerosis indicating ***avascular necrosis***
69
Why does **avascular necrosis** may occur with **scaphoid fractures**?
* The blood supply to the scaphoid is retrograde → it comes from distal to proximal
* Dorsal carpal branch of the radial artery provides 70% and superficial palmar branch of the radial artery provides 30%
* If this blood supply is disrupted, the more proximal fracture has the highest non-union / AVN rate
70
What can happen if a scaphoid fracture goes undiagnosed?
* Undiagnosed and untreated scaphoid fractures can go into non- / malunion → increased risk of complications such as arthritis in the wrist and Scaphoid Non-Union Advanced Collapse (SNAC wrist) as the biomechanics of the wrist do not function properly
* This will need more complex orthopaedic surgery and sometimes salvage procedures which carry a poor functional outcome
* if it is patient's dominant hand, it will cause issues with his grip strength and overall function
71
Difference beteween Galeazzi and Monteggia fractures
* ***Monteggia*** fracture → ulnar fracture with dislocation of radial head
* ***Galeazzi*** → radial fracture with dislocation of distal radioulnar joint
72
Management of:
* Monteggia and Galeazzi fractures
Both → ORIF with plates or intramedullary nail
