Upper Limb

Question 1

What is osteology of the clavicle?

Answer 1

S shaped bone- Flat laterally
Tubular centrally
Prism medially
Sup surface smooth
Inf surface rough

Question 2

What are the muscular and ligamentous attachements of the clavicle

Answer 2

SCM medially
Pec major- when fractured pulls clavicle medially
Deltoid
Subclavius
Sternohyoid
Traps

Ligaments
Medially- sternoclavicular joint- sternoclavicular/interclavicular/costoclavicular

Laterally- ACJ
Acromioclavicular ligament
Coracoclavicular ligament- medially Conoid, laterally trapezoid

Question 3

What type of joints are involved in the clavicle?

Answer 3

Sternoclavicular- synovial joint
ACJ- fibrocartillagenous joint

Question 4

Describe the Allman’s classification of clavicles?

Answer 4

Into 1/3s

Medial- 5%
Middle- 80%
Lateral- 15%

Question 5

Describe the Neer classification of clavicles

Answer 5

Lateral 1/3 clavicle fractures- all in relation to CC ligaments

Type 1- extra-articular, lateral to CC, non op
Type 2A- Medial to CC, operative due to high non union rate- 56%
Type 2B- Torn conoid +- Trapezoid lig, operative non union rate 30-45%
Type 3- intra-articular, lateral to CC, ACJ arthritis, non op
Type 4- physeal fracture- non op
Type 5- comminuted ##, intact CC ligs, operative

Question 6

Important points in examination of clavicle?

Answer 6

Open?
Skin tenting- is the skin freely mobile?
Brachial plexus injury?
Suprascapular nerve injury?- jobe’s test negative

SCJ dislocation/mediastinal injury in medial 1/3 clavicle #s- if posterior displacement need CT + Cardiothoracic referral- emergency

Listen to Chest!!

Question 7

Indication for operation on a clavicle?

Answer 7

Absolute:
Open/threatened
Polytrauma- floating shoulder
Subclavian A/V injury
Symptomatic non union

Relative:
Unstable # patterns- Neer 2a/b/5
Bilateral displaced #
Brachial plexus injury
Rib #s
Young sports injuries for quicker return to play

Question 8

Reasons for operation?
Reasons again operation

on clavicles that is

Answer 8

Faster time to uninon, fewer non/symptomatic malunions, increased satisfaction

RCT 2007 Canadian OTS

Infection, NVI (supraclavicular nerve- sensation only- important in breast feeding)
Removal of metalwork very likely- ~30%
Pneumothorax
Frozen shoulder

Question 9

What is the non operative management of clavicle fractures?

Answer 9

Sling- polysling
ROM exercises at 2 weeks
Strength exercises at 6 weeks
Sport at 4-6 months

Question 10

How to assess any trauma patient?

Answer 10

ATLS
A2E
AMPLE
Allergies
Medication
PMHx
Last ate
Events

Question 11

What is the most common nerve injury for shoulder discloation?

Answer 11

Axillary nerve injury- 5% of cases
Transient neuropraxia

Question 12

How to assess axillary nerve function?

Answer 12

Deltoid and teres minor strength
Regimental patch

Question 13

Axillary nerve course?

Answer 13

C5,C6 of posterior cord of brachial plexus
Through quadrangular space (with post circumflex humeral A)

Question 14

What are the theoretical spaces in the axilla and what runs through them and boarders?

Answer 14

Fingers together

Quadrangular space- Axillary N, post circumflex A +V
Triangular space- circumflex scapular
Triangular interval- radial N, profunda brachii A

Boarders- Teres minor/major, medial/long head triceps

Question 15

What are the associated bony/ligamentous injuries with a shoulder dislocation?

Answer 15

Bankart lesion-avulsion of the anterior labrum
Bony bankart- # of the ant.inf glenoid labrum
Hills sachs defect- chondral impact injury, present in 80-100% of dislocations
Rotator cuff injuries- 30% of those >40 years old, >80% of those greater than 60 years old
Superior labral tears from ant to post (SLAP lesions)

Question 16

How to examine a shoulder dislocation?

Answer 16

A2E AMPLE
Nerves/vascular injury
Isolated injury?
Age
Hypermobility?

Imaging- Scapula Y, AP, modified trauma axial

Question 17

How to manage a shoulder dislocation

Answer 17

Relocate in ED with sedation
My technique- traction counter traction with bed sheet in axilla
Avoid any rotation- can lead to a associated neck fracture
May need abduction in the axilla to unstick from hills sachs lesion

Other techniques:
Kocher’s,
Milch’s (supine + ER + ABDuction)
Stimpson’s (Prone + hanging on bed, traction + ER)
Dowson et al. for modified approach

Sedation in ED
Penthrox
Propofol

If un reducible, attempt reduction under GA
Assess for instability post reduction

Open reduction as back up

Once reduced- immobilise for 1 week and ensure has PT follow up for rehab
May need MRI if significant Rotator cuff injury- large tear in supraspinatus
Or if repeated dislocator

In my unit

<25 years old + symptoms for MRAtrhrogram to assess for labral injuries

> 40 years old for MRI to assess for rotator cuff injuries

Question 18

Causes of posterior dislocation of shoulder?

Answer 18

Seizures/electric shock

Question 19

Describe the anatomy of the proximal humerus?

Answer 19

GT and LT- LT is anterior, GT laterally facing

Head
Surgical neck- common site of fractures- more distal
Anatomical neck- site of old epiphyseal plate

Question 20

What is the main blood supply for the head of the humerus?

Answer 20

Medially from the circumflex humeral Artery

Question 21

How do you classify proximal humerus fractures?

Answer 21

Neer’s classification

Into parts- head, LT, GT and shaft

2o parts- fracture dislocation and head splits

Question 22

When would you CT scan a proximal humerus fracture?

Answer 22

For pre op planning
if ?head split #
Or if GT/head position was uncertain
Intra-articular comminution

Question 23

When would you MRI a proximal humerus fracture?

Answer 23

To assess for rotator cuff injury
Will guide your decision regarding a reverse vs total shoulder replacement

Question 24

When would you operate on a fracture proximal humerus?

Answer 24

Patient and injury factors!!!

Absolute:
Open,NVI
GT fracture + >5mm displacement
Fracture dislocations
Head splits
Open
Vascular injury

Relative indications- Hurtle criteria
Young patients with 3/4 part #s

Failed non op management- non union/painful/traumatic osteoarthritis

RTSR better has less complications after failed non op management than failed operative management- Santana et al.

Question 25

What did the Propher trial demonstrate?

Answer 25

Pragmatic trial Surgical vs non surgical treatment of displaced proximal humerus #s Mean age 66 No significant difference in outcomes between outcomes at 2 or 5 years Cost analysis significantly worse for surgery

Question 26

What is a pragmatic trial?

Answer 26

Evaluates the performance of treatment options in a real world clinical setting with a focus on patient centred outcomes. It aims to situations where there are clinical equipoise.

Question 27

Describe the deltopectoral approach?

Answer 27

Internervous and intermuscular approach between axillary nerve (deltoid) and medial/lateral pectoral nerve (pec major) Patient is position in beach chair + bolsters + head support Landmarks are coracoid process/acromion/clavicle/humerus Incision is along the deltopectoral groove Skin, fat Identify the cephalic vein overlying fascia- take laterally and divide medial perforators Incise deltopectoral fascia Deep dissection between deltoid and pec major Identify conjoint tendon Incised subscapularis tendon and reflect medially to access the joint capsule Dangers are: Cephalic vein musculocutaneous nerve 5-8cm distal to the coracoid process Axially NVI all lie medial to the coracoid along with the brachial plexus

Question 28

What are the cardinal signs of a flexor sheath infection?

Answer 28

Knavel's signs Sausage digit Fixed flexion position Pain on passive extension Tenderness on palpation of the flexor sheath

Question 29

Describe the function and the anatomy of the flexor sheaths?

Answer 29

Protect and nourishes tendons Lots of variation but traditionally: In index, middle and ring finger run from DIPJ to A1 pulley Thumb runs from IPJ to radial bursa LF runs from DIPJ to ulna bursa

Question 30

what is the aetiology of a flexor sheath infection?

Answer 30

Penetrating trauma to the sheath Direct spread from a felon/septic joint/ deep space infection

Question 31

What are the common bugs causing a flexor sheath infection and the high risk groups?

Answer 31

Staph A/MRSA Staph Epi Beta haemolytic strep Pseudomonas Polymicrobials High risk groups- immunocomprimised/Animal/human bits/DM/PVD/renal failure

Question 32

What is the treatment of a flexor sheath infection?

Answer 32

Urgent washout + IV Abx + re washout Incision is made over A1 and A5 pulleys + incision over flexor sheath Insert cannula into sheath + gentle washout Aspirate pus + send for samples If there is purulent pus + ischaemic digit there is a 59% amputation rate as per Pang et al. 8% if just purulent and no ischaemia

Question 33

Describe the anatomy of the flexor compartment of the forearm?

Answer 33

Superficial- FCU, Palmaris longus, FCR and pronator teres Intermediate- FDS Deep- FPL, FDS, Pronator quadratus

Question 34

What is the nerve supply of FDP?

Answer 34

Radial 1/2 is medial Ulna 2 fingers is ulna

Question 35

Describe the pulley anatomy in the fingers?

Answer 35

Annular ligaments- prevent bowstringing A1-A5 A1- MCPJ- trigger finger commonest A3 PIPJ A5 over DIPJ A2- proximal phalanx A4 middle phalanx Cruiciate ligaments- prevent sheath collapse during flexion C1 between A2 and A3 C2 between A3 and A4 C3 between A4 and A5

Question 36

What is the blood supply of the scaphoid bone?

Answer 36

Retrograde- 80% from dorsal carpal branch of radial A

Question 37

What are the boarders and contents of the anatomical snuffbox?

Answer 37

Ulnar (medial) border: Tendon of the extensor pollicis longus. Radial (lateral) border: Tendons of the extensor pollicis brevis and abductor pollicis longus. Proximal border: Styloid process of the radius. Floor: Carpal bones; scaphoid and trapezium. Roof: Skin. Radial A Superfiscial radial N Cephalic vein- hosueman's

Question 38

When would you get a MRI for ?scaphoid fracture

Answer 38

If clinical concerns of scaphoid fracture but no sign on xray

Question 39

What are the risk factors for AVN in scaphoid fractures?

Answer 39

Displaced Multifragmentary Proximal 1/3- 33% Proximal 1/5- 100% Patient factors- DM, smoking, PVD

Question 40

What is the management of scaphoid injuries?

Answer 40

As per SWIFT study Undisplaced waist #s <2mm displacement- cast for immobilisation for 6 weeks- if non union for immediate fixation >2mm displacement at waist needs fixation If proximal fracture/associate #s/scapolunate dissocation for fixation Screw fixation - either percutaneous or ORIF

Question 41

What is carpal tunnel syndrome?

Answer 41

Compressive neuropathy of the median nerve at the level of the wrist

Question 42

What are the risk factors for carpal tunnel syndrome?

Answer 42

Pregnancy Women Obesity Hypothyroidism RA Reptitive motion activities

Question 43

What are the contents and the boundary of the carpal tunnel?

Answer 43

Contents- FDS, FDP, FPL and median nerve Boundaries- Formed laterally by the scaphoid and trapezium tubercles Formed medially by the hook of the hamate and the pisiform Flexorretinaculum sueprfiscially

Question 44

What are the symptoms of carpal tunnel syndrome?

Answer 44

Numbness/tingling in radial 3.5 digits Pain/parasthesia at night Clumsiness

Question 45

What are the signs of carpal tunnel syndrome?

Answer 45

Thenar atrophy Hand diagram of symptoms- most specific test Durkan's test- compression for 30s Phalen's- reverse prayer for 30-60s Tinnel's tapping for 30s

Question 46

Why may some patients get sparing of sensation over the thenar eminence?

Answer 46

Palmar cutaneous branch given off pre tunnel- so not affected compression

Question 47

How do you investigate/diagnose carpal tunnel syndrome?

Answer 47

Clinical diagnosis Nerve conduction studies are useful. Corticosteroid injection

Question 48

What is the management of carpal tunnel syndrome?

Answer 48

Conservative- non op, activity modifications Medical- NSAIDs Corticosteroid injection- 80% have transient improvement. 20% of these symptom free at 1 year. Can be diagnostic in equivocal cases Operative- carpal tunnel decompression

Question 49

How do you perform a carpal tunnel decompression?

Answer 49

M + C WHO Checklist Supine Arm board LA + Tourniquet + Abx at induction Standard Ortho set Pre and drape Incision is from intersection of Kaplan's line with radial boarder of index finger to distal wrist crease- if needing to cross wrist crease zig zag Skin fat Identify the flexor retinaculum Macdonalds beneath to protect medial nerve Cut as ulnarly as you can to avoid possible recurrent motor branch injury Check flexors freely moving post release Caution- palmar cutaneous branch- comes off between PL and FRC Recurrent motor branch off median nerve- 50% extraligamentous (post CT), 30% subligamentous (given off within CT), 20% transligamentous (pierces CT)

Question 50

What is the difference between a perilunate and a lunate dislocation?

Answer 50

Mayfield stage 3 vs stage 4 Perilunate- lunate stays in the correct position and the carpal bones dislocate Lunate dislocation- lunate dislocates

Question 51

How do you classify lunate dislocations and correlate this with the pathoantomy?

Answer 51

Mayfield stages Stage 1- scapholunate dissociation Scapholunate ligament disrupted Stage 2- perilunate dislocation Disruption of capitolunate articulation Stage 3- Midcarpal dislocation Disruption of Luniotriquetral articulation Stage 4- lunate dislocation Failure of dorsal radiuocarpal ligament https://www.google.com/url?sa=i&url=https%3A%2F%2Fajronline.org%2Fdoi%2Ffull%2F10.2214%2FAJR.13.11680&psig=AOvVaw1IBZBDmWvjsFZuzux160q8&ust=1704565381440000&source=images&cd=vfe&opi=89978449&ved=0CBMQjRxqFwoTCLDf1IbvxoMDFQAAAAAdAAAAABAD

Question 52

Associated injuries in lunate/perilunate dislocation?

Answer 52

Scaphoid- v common Other carpal bones Radius/ulna #s

Question 53

What common neurovascular injury is associated with a lunate dislocation?

Answer 53

Median nerve symptoms in ~25%

Question 54

How do you manage the perilunate/lunate dislocation?

Answer 54

Emergent closed vs open reduction Fingertraps- 15mins +2-4kg hanging weight Pull carpus up and over- extension traction + flexion. With applied dorsal pressure Good sedation needed Open reduction- ligamentous repair, fixation +/- carpal tunnel release

Question 55

Describe the anatomy of the median nerve?

Answer 55

From lateral and medial cord of brachial plexus- C5-T1 C5-C7 lateral contributors provide sensation to hand and motor to PL and PT C8-T1 medial contributors supply long flexors + intrinsics Runs lateral to brachial artery in the arm crossing to medial at the mid humerus Crosses into antecubital fossa- R TAN- from lateral to medial: Radial nerve, biceps tendon, brachial artery, median nerve Exits fossa by passing through 2 heads of pronator teres Gives AIN which supplies PQ , FPL and radial half of fdp Runs between FDP and FDS Gives off palmar cutaneous branch 5cm proximal to wrist crease Runs under the carpal tunnel Recurrent motor branch given off- may be extra, trans or sub ligamentous Terminates in digital cutaneous branch

Question 56

Describe the anatomy of the musculocutenaous nerve?

Answer 56

Comes from lateral cords C5-C7 Pierces coracobrachialis Runs between biceps and brachialis Lateral to biceps tendon at the elbow terminating in lateral cutaneous nerve of the forearm Supplies Biceps brachii, coracobrachialis and brachialis

Question 57

Describe the anatomy of the ulnar nerve?

Answer 57

Comes from medial cord C8-T1 Runs along posteromedial aspectof brachial artery and humuer us Pierces intermuscular septum at atcade of struthers 8cm proximal to medial epicondyle Runs in cubital tunnel- post to medial epicondyle Exits through 2x heads of FCU Travels under FCU between FDP with ulnar a Enters the hand through guyon's canal

Question 58

What is the ulnar paradox?

Answer 58

The more distal the lesion the more severe the clawing the of the hand Due to the fact that a high ulnar lesion will cause paralysis of the ulnar half of FDP as well as intrinsic muscles Whereas in low lesions FDP is not paralysed so there is unopposed action of it leading to clawing

Question 59

Describe the course of the radial nerve?

Answer 59

From posterior cord- C5-T1 Exitrs through the triangular interval with profunda brachii giving off motor supply to triceps Runs in the spiral groove along the posterior aspect of the humerus between medial and lateral heads of triceps Pierces lateral intermuscular septum 8cm proximal to lateral epicondyle Runs anterior to lateral epicondyle along lateral boarder of antecubital fossa Divides into Superfiscial radial nerve- runs betweemn brachioradialis and FPL Posterior interosseous nerve- runs through supinator Arcades of frohse run over the nerve at this point (supinator arch)

Question 60

What is Hertle's criteria for prox humeral #s?

Answer 60

Predicts humeral head ischaemia Increased # complexity Displacement >10mm Angulation of >45o >8mm of calcar length attached to articular segment Medial hinge disrupted

Question 61

When to consider operative vs non operative treatment of olecranon #s?

Answer 61

Non op- non op if undisplaced in low demand + good ROM R/V at 1 week + early ROM exercises Operative if displaced (Tension band wiring) ORIF if comminuted/monteggia's/fracture dislocation/coranoid inolvement

Question 62

What is the terrible triad of elbow injuries?

Answer 62

Elbow dislocation (posterolateral) Coranoid process # Radial head #

Question 63

Ix of choice for a medial 1/3 clavicle fracture and scenarios where it is essential?

Answer 63

CT scan Assess posterior displacement Esp if Hoarse voice SOB Hypotension SCJ dislocation

Question 64

Describe the flexor zone of injury?

Answer 64

1- FDP to FDS insertion 2- FDS to A1 pulley 3- A1 pulley to carpal tunnel 4-Carpal tunnel 5- carpal tunnel to forearm

Question 65

What are the extensor compartments at the wrist?

Answer 65

Radial to ulna 1- APL + EPB 2- ECRB + ECRL 3- EPL 4- EI + EDC 5- EDM 6- ECU

Question 66

When to consider operative fixation for distal radius fractures?

Answer 66

Unstable fractures- volar Irreducible intra-articular fractures If under 65 years old and non reducible

Question 67

What xray parametres may you consider when thinking about operative fixation in distal radius fracutres?

Answer 67

Dorsal tilt (normal is 11o of volar tilt, acceptable is 5o of dorsal angulation) Ulna variance (radial height in reality- but official neutral is when the ulna is level with the lunate fossa) Intra-articular step >2mm

Question 68

When to operate on distal radius fractures?

Answer 68

As per BOAST Within 72 hours for intra-articular fractures Within 1 week for all extra-articular

Question 69

How to decide between K wires and ORIF for distal radius fractures?

Answer 69

ORIF if unstable fracture pattern K wires if able to reduce the fracture closed

Question 70

What evidence is there for distal radius fracture management?

Answer 70

Draft 1 and 2 Draft 1 Extra-articular dorsally displaced DRs K wires vs ORIF Pragmatic, multi centred No difference in primary outcome K wires quicker and cheaper Kwire had increased rates of loss of position Draft 2 Dorsally displaced DRs Non reducible, close intra-articular #s excluded No difference in outcomes between k wires and cast Significant number of patients lost position in cast so needed reoperation

Question 71

Describe the FCR approach the wrist?

Answer 71

Appropriately marked and consented patient GA Supine + arm board Tourniquet vs LA + adrenaline Upper limb pre and drape Internervous incision- AIN (FPL) and Median nerve (FCR) Mark on FCR, 10cm incision, if crossing wrist crease then z across Superfiscial Skin, fat Find FCR tendon + expose, retract ulnarly Incise through muscle belly of FPL + take ulnarly Watch out for radial artery- v close Expose PQ L shaped incision to take off- dont go into joint Watch out for median nerve Ulna Periosteal elevator to expose fracture site Stryker Variax plate Can release BR to help reduction Watch out for Radial A- radial to FCR Median N- between FDS and FDP Palmar cutaneous branch- Ulna to FCR, 5cm proximal to wrist crease Volar wrist capsule

Question 72

Volar approach to the forearm explain?

Answer 72

Marked + consented Supine + arm board GA + tourniquet to 250mmHg Internervous approach between radial and median nerve (BR + FCR)- take radial artery ulnarly, SPN laterally Incision Lateral to biceps tendon and elbow crease to radial styloid Superfiscial Incise fascia between BR and PT/FCR Deep prox 1/3- supinated position, remove supinator from radius middle 1/3- pronate bring PT insertion into view on lateral radius- release distal 1/3- retract FCR and incise PQ Watch out for PIN- between superfiscial and deep supinator heads- take supinator off subperisoteally Radial A SRN- runs under BR/lateral to radial A

Question 73

How to perform forearm fasciotomies

Answer 73

M+C WHO sign/time out Supine arm board Tourniquet Standard ortho set VAC 10 + 15 blade Incisions Volar S shaped incision from medial epicondyle to radial to FCU, can extend into Carpal tunnel decompression. Retract FCU ulnarly to expose deep compartment. Dorsal 2cm distal to lateral epicondyle + to mid wrist 1 compartment + mobile wad EDC + ECRB interval

Question 74

What are you looking for when assessing compartments during faciotomies?

Answer 74

Do the compartments ping open? Assess for Colour Consistency Contractility CRT Debride VAC relook in 48 hours Delayed 1o closure

Question 75

How to do hand fasciotomoies

Answer 75

Carpal tunnel release Dorsal incision over 2nd and 4th MCP Radial side of 1st MCP Ulna side of 5th MCP

Question 76

What are the deforming forces in a midshaft clavicle fractures

Answer 76

Main ones SCM pulling medial aspect superior Weight of arm pulling lateral part inferior Pec major also pulling inferior part medially to shorten

Question 77

Classification system for olecranon fractures?

Answer 77

Mayo classification A vs B (simple vs comminuted) 1- Non displaced 2- Displaced 3- Unstable (fracture dislocation)

Question 78

Indications for non operative management of olecranon #s?

Answer 78

Non displaced with intact extensor mechanism Low demand elderly frail 1 week of cast then rehab

Question 79

What are the stabilisers of the elbow?

Answer 79

Primary static: Ulnohumeral joint- coronoid MCL Lateral collateral lig complex Secondary static: Joint capsule Common flexor and extensor origins Radiocapitellar joint Dynamic stabilisers: Muscles crossing the elbow joint Brachialis, Aconeus, triceps and biceps

Question 80

How to manage a humeral shaft fracture with a radial nerve palsy?

Answer 80

Seen in 8-12% of closed fractures. Increased in distal 1/3 fractures. BOAST guidelines for PNI Neuropraxia is commonest in closed #s Neurotmesis is commonest in open #s Management options: Conservative- 90% recover at 3 months. Perform EMG at 2 months for prognosis Surgical- Open fracture with palsy, closed fracture failing to improve, fibrillations on EMG

Question 81

Complications of scaphoid #s?

Answer 81

Avascular necrosis Non union Mal union SNAC- scaphoid non union advanced collapse (chronic scaphoid non union- arthritis- options include stylectomy + stabilisation, proximal row carpectomy)

Question 82

Commonest organisms in animal and human bites?

Answer 82

Ekinella for humans Pasturella for animals

Question 83

Associated injuries with clavicle fractures?

Answer 83

Pneumothorax Rib #s Mediastinal injury if medial 1/3 # ACJ injury Coracoclavicular injury Scapula #- scapulothoracic dissociation NVI