Upper Extremity

Question 1

Most sensitive examination finding for wrist fractures

Answer 1

Pain with wrist extension (95.7% sensitivity)

Question 2

A common fracture in children after FOOSH injury is _____ fracture of the distal radius (+/- ulna), a type of incomplete compression fracture characterized by bulging of one side

Answer 2

Buckle or Torus fracture

Question 3

Treatment of buckle fracture of distal radius +/- ulna

Answer 3

3 weeks of immobilization (commonly volar wrist splint vs soft cast) followed by gradual return to activity. May not even need a clinic visit to assess healing given low rate of complications, but reasonable to have them come back for evaluation to determine further need for X-ray

Question 4

How does a greenstick fracture differ from a buckle fracture?

Answer 4

Greenstick fracture: cortical disruption on tension side + cortical bulging on compression side

Buckle fracture: incomplete fracture just showing cortical bulging, no disruption

Question 5

Management of greenstick fractures (<10 years old)

Answer 5

If angulation <20-30 degrees in sagittal alignment and <50% displacement, management similar to buckle fractures

Question 6

Management of NON-DISPLACED (or minimally displaced) distal radius fracture (adults)

Answer 6

[if applicable] closed reduction followed by X-ray to confirm alignment

Sugar-tong splint x3 days –> X-ray to determine continued non-displacement –> short arm cast x4-6 weeks (until fracture site is nontender and X-ray shows healing)

Question 7

Displaced distal radial fractures: ortho referral indicated if:

• radial step-off is >____ mm
• involvement of articular surface of distal radial-ulnar joint
• > ____ degrees of _____ (dorsal/volar) angulation
• > ____ mm radial shortening after reduction

Answer 7

• radial step-off is >2 mm
• involvement of articular surface of distal radial-ulnar joint
• > 10 degrees of dorsal angulation
• > 2 mm radial shortening after reduction

Question 8

A ______ fracture is a distal radius fracture with dorsal displacement of the distal radius fragment

Answer 8

Colles

Question 9

A Colles fracture is a distal ______ fracture with _____ displacement of the distal fragment

Answer 9

Radius, Dorsal

Question 10

A Smith fracture is a distal ______ fracture with _____ displacement of the distal fragment

Answer 10

Radius, Volar

Question 11

A _____ fracture is a distal radius fracture with volar displacement of the distal fragment

Answer 11

Smith

Question 12

Management of isolated NON-DISPLACED distal ulnar fracture (“Nightstick fracture”)

Answer 12

Ulnar gutter (posterior) splint x10 days –> plaster sleeve or functional brace x4-6 weeks

Question 13

If an isolated ulna fracture is identified via X-ray, it is important to rule out dislocation of _____

Answer 13

radial head (ulna fracture + dislocation of radial head = Monteggia fracture)

Question 14

Isolated ulnar fractures are stable if <_____ degrees angulation and >_____% apposition

Answer 14

<10 degrees, >50% apposition

Question 15

Combined fractures of the radius and ulna requires orthopedic evaluation. Immobilize with sugar-tong splint and then refer to ortho, to be seen within 48 hours

Answer 15

Combined fractures of the radius and ulna requires orthopedic evaluation. Immobilize with sugar-tong splint and then refer to ortho, to be seen within 48 hours

Question 16

Radial head fractures are associated with limitations of range of motion, notably elbow ____ and ____

Answer 16

extension, supination

Question 17

Injury with limited elbow extension and supination should make you suspicious for _______

Answer 17

Radial head fracture

Question 18

Radial head fracture presents with limitation of ROM of elbow __________ and __________

Answer 18

Elbow extension and supination

Question 19

Management of nondisplaced radial head fracture

Answer 19

Posterior arm splint (holds elbow in 90 degrees flexion) x3 days –> sling x2 weeks

Longer immobilization results in stiffness without improvements in healing, but extend restrictions of use to 4 weeks generally

Question 20

Ulnar fracture + dislocation of radial head = ________ fracture

Answer 20

Monteggia

Place in sugar-tong splint and URGENT ortho referral - needs operative management

Question 21

Radial fracture + distal radioulnar joint dislocation = ________ fracture

Answer 21

Galleazzi

Requires operative management

Question 22

Distal radius fractures: The _____ nerve is commonly affected, with injury to the nerve present in up to ________ of patients

Answer 22

Median, 25%

Question 23

What finding on physical exam would make a radial head fracture need to go to ortho?

Answer 23

Instability of MCL or LCL of elbow

Question 24

Management of mallet fracture

Answer 24

Strict immobilization x8 weeks in extension (to slightly hyperextension)

Splints: Aluminum splint with dorsal padding, Volar splint, or Thermoplastic stack splint

Question 25

Mallet finger is avulsion of the ________ tendon at the DIP

Answer 25

Extensor tendon

Question 26

Indications to refer a mallet finger to ortho (2)

Answer 26

- Fracture involving >1/3 of the joint surface - Inability to passively extend DIP

Question 27

Indications for ortho referral for distal phalanx fractures (3)

Answer 27

- Inability to flex/extend DIP - Loss of distal sensation - Complex fractures

Question 28

Management of distal phalanx fractures (if no indications for ortho referral)

Answer 28

Splint DIP in full extension x4-6 weeks

Question 29

Jersey finger is an avulsion fracture of the ____________ muscle

Answer 29

Flexor digitorum profundus (avulses at the site where the FDP tendon attaches to the volar base of the distal phalanx)

Question 30

Jersey finger most commonly occurs in the ___th finger

Answer 30

4th

Question 31

Examination findings of Jersey finger

Answer 31

Volar-sided pain, inability to actively flex DIP joint

Question 32

Management of Jersey finger

Answer 32

ORTHO (in the meantime, splint DIP and PIP in slight flexion)

Question 33

Classic physical examination finding of middle or proximal phalanx fractures

Answer 33

Malrotation (when flexed, all fingers should point to the scaphoid)

Question 34

Indications for ortho referral for middle/proximal phalanx fractures (a lot of indications)

Answer 34

- Malrotation on exam - X-ray showing oblique, spiral, displaced, or rotational fractures - Intra-articular fractures - >10 degrees angulation

Question 35

Management of NON-DISPLACED, EXTRA-ARTCIULAR proximal/middle phalanx fractures

Answer 35

Buddy taping x3-4 weeks (apply the tape/wrap in the proximal phalanx and the middle phalanx)

Question 36

I did not create cards about finger dislocations

Question 37

Clavicle fractures: _____% in the middle _____% distal _____% proximal

Answer 37

80% in the middle 15% distal 5% proximal

Question 38

When is ortho needed for midshaft clavicle fracture?

Answer 38

Neurovascular compromise Open fracture Skin tenting Otherwise generally not needed, even if fairly significantly displaced. Though if "completely displaced" (e.g. more than 1 bone width or shortening >14-18mm)

Question 39

Most common mechanism for clavicle fractures

Answer 39

Direct blow to the shoulder

Question 40

Management of midshaft clavicle fractures (assuming ortho referral is not needed)

Answer 40

Figure-of-eight OR arm sling for 4-8 weeks (until crepitus resolves and tenderness is minimal or absent) Sling is preferred if non-displaced or minimally displaced, as it is more comfortable and healing is comparable

Question 41

3 types of distal clavicle fractures and their management

Answer 41

Type 1: Nondisplaced and ligaments are not affected --> sling x3-6 weeks Type 2: Displaced and coracoacromial ligaments are ruptured --> Sling/Swath and ortho referral (needs surgery) Type 3: Intra-articular fracture (into AC joint) --> sling x3-6 weeks (has high rate of AC joint pain in the future)

Question 42

Proximal clavicle fracture management

Answer 42

Sling x3-6 weeks followed by X-ray (unless significantly displaced, SC joint dislocation, or NV injury)