upper limb and hands trauma

Question 1

what causes proximal humerus fractures?

Answer 1

low energy injuries in osteoporotic bone due to a fall onto the outstretched hand or directly onto the shoulder

Question 2

what is the most common fracture pattern in a humeral neck fracture?

Answer 2

surgical neck rather than anatomic neck with medial displacement of the humeral shaft due to pull of the pectoralis major muscle

Question 3

what else might be avulsed with a humeral neck fracture?

Answer 3

greater and lesser tuberosities with the attachments of Supraspinatus, Infraspinatus and teres minor for the greater tuberosity and subscapularis for the lesser tuberosity.

Question 4

what is the treatment for minimally displaced proximal humerus fractures?

Answer 4

treated conservatively with a sling and gradual return to mobilization.

Question 5

what happens to displaced humeral neck fractures?

Answer 5

position improves once muscle spasm settles

Question 6

how do you treat persistently displaced fractures?

Answer 6

internal fixation (plate, screws, wires or intramedullary nail) but stiffness, chronic pain and failure of fixation can occur particularly in the older patient.

Question 7

how do you treat comminuted proximal humerus fractures?

Answer 7

Shoulder replacement (usually a hemiarthroplasty for trauma) has been used with the difficulty of reattaching the tuberosities and subsequent rotator cuff dysfunction. Range of motion is often limited.

Question 8

head splitting fractures management?

Answer 8

equire shoulder replacement unless the patient is younger with very good bone quality.

Question 9

what is commoner anterior or posterior shoulder dislocations?

Answer 9

anterior is much more common

Question 10

how does anterior shoulder dislocations occur?

Answer 10

excessive rotation force or a fall onto the back of the shoulder

can occur due to a seizure as well (bilateral dislocations)

Question 11

what does a ASD often result in?

Answer 11

detachment of the anterior glenoid labrum and capsule - banker lesion whilst the posterior humeral head can impact on the anterior glenoid producing an impaction fracture of the posterior head (Hill‐Sachs lesion).

Question 12

what passes through the quadrilateral space?

Answer 12

axillary nerve can be stretched, while other nerves of the brachial plexus as well as the axillary artery can be stretched or compressed

Question 13

clinical assessment of ASD?

Answer 13

loss of symmetry with loss of roundness of the shoulder and the arm held in adducted position supported by the patients other arm

Question 14

what is the principle sign of axillary nerve injury?

Answer 14

loss of sensation in the regimental badge area

full neuromuscular assessment should be carried out

Question 15

what happens in older patients with ASD?

Answer 15

tears of the rotator cuff - difficult to assess in acute setting

Question 16

what confirms ASD?

Answer 16

X-rays - 2 planes if in doubt. Fractures of the surgical neck and greater tuberosity can occur with shoulder dislocation.

Question 17

what is the management of ASD?

Answer 17

Closed reduction under sedation or anaesthetic is the mainstay of treatment with neurovascular assessment before and after reduction. Radiographs are repeated to confirm reduction. The patient is placed in a sling for 2‐3 weeks to allow the detached capsule to heal then rehabilitation with physiotherapy is commenced.

Question 18

what is the management of delayed presentation dislocations?

Answer 18

may require open reduction due to difficulty to reduce using closed means

Question 19

if there is an associated fracture of the greater tuberosity?

Answer 19

usually reduces to an acceptable position of the shoulder however ORIF is usually required if it remains displaced

Question 20

what is the management of fracture-dislocations?

Answer 20

surgery

Question 21

what is the risk of dislocation in patients less than 20?

Answer 21

have an 80% chance of re‐dislocation and many surgeons advocate stabilization surgery after first time dislocation in this age group.

Question 22

what is the risk of dislocation in patients over 30?

Answer 22

Patients over 30 have only a 20% risk of further dislocation and the re‐dislocation rate reduced further with increasing age. Recurrent dislocations can be stabilized by a Bankart repair with reattachment of the torn labrum and capsule by arthroscopic or open means.

Question 23

how else does some shoulder dislocations occur?

Answer 23

in patients with marked ligamentous laxity - idiopathic generalized laxity/hypermobility or due to CTD (Ehlers-Danlos syndrome, Marfan’s syndrome)

Question 24

what type of dislocations do people with ligamentous laxity get?

Answer 24

atraumatic multidirectional dislocations which can be painful

Question 25

what is the management of ligamentous laxity dislocations?

Answer 25

The results of surgery are less predictable due to the underlying biological component. An open tightening of the shoulder capsule (known as a capsular shift) can improve stability but the tightened capsule may stretch out again. Physiotherapy to strengthen the rotator cuff muscles (which are secondary restraints to dislocation) is the mainstay of treatment.

Question 26

how do posterior shoulder dislocations occur?

Answer 26

posterior force on the adducted and internally rotated arm | the humeral head may be palpated posteriorly

Question 27

what is seen on the X-ray of a posterior shoulder dislocation?

Answer 27

light bulb sign - special lateral x-ray views assist in the diagnosis

Question 28

what is the management of posterior shoulder dislocations?

Answer 28

closed reduction and a period of immobilization followed by physiotherapy

Question 29

how do ACJ injuries occur?

Answer 29

fall onto the point of the shoulder - fairly common sporting injury

Question 30

what are the 3 types of injuries that can occur?

Answer 30

subluxed(partially dislocated) or dislocated or sprained

Question 31

what is the management of ACJ injuries?

Answer 31

injuries are treated with conservative management wearing a sling for a few weeks followed by physiotherapy Surgery (reconstruction of the coracoclavicular ligaments) is reserved for those with chronic pain (although some surgeons advocate early reconstruction for younger athletes with dislocation – controversial).

Question 32

what causes humeral shaft fractures?

Answer 32

direct trauma (such as during an RTA) resulting in transverse or comminuted fractures, or by fall with or without twisting injury resulting in oblique or spiral fractures.

Question 33

what is the union rate of humeral shaft fractures?

Answer 33

Union rates are high (90%) and due to the mobility of the ball and socket shoulder joint proximally and the elbow joint distally, up to 30° of angulation can be accepted.

Question 34

what is susceptible to injury in a humeral shaft injury?

Answer 34

The radial nerve in the spiral groove is susceptible to injury which present with a wrist drop and loss of sensation in the first dorsal web space.

Question 35

what is the management of humeral shaft injuries?

Answer 35

Most cases are treated non-operatively with a functional humeral brace which compresses the fragments into acceptable alignment and provides some stability.

Question 36

what is the management of polytraumatic humeral shaft injuries?

Answer 36

Internal fixation with an intramedullary nail or plate and screws may afford a quicker recovery and intramedullary nailing may be used in polytrauma.

Question 37

non-union humeral shaft fractures require?

Answer 37

plating and bone grafting

Question 38

how do olecranon fractures occur?

Answer 38

fall onto the point of the elbow with contraction of the triceps muscle

Question 39

management of olecranon fractures?

Answer 39

ORIF to restore triceps function and restore the articular surface

Question 40

how can a simple transverse avulsion olecranon fractures be fixed?

Answer 40

with tension band wiring which compresses the tension side of the fractures

Question 41

comminuted olecranon fracture management?

Answer 41

don't have a fulcrum for the tension band and require ORIF with a plate and screws

Question 42

what should be a high index suspicion if there is an isolated displaced fracture?

Answer 42

of a fracture or dislocation involving the other bone

Question 43

what should be screened for in nightstick fractures?

Answer 43

Monteggia injury

Question 44

what is the treatment of nightstick fractures?

Answer 44

many dealt with conservatively however ORIF many afford earlier return to function and may reduce e risk of non-union

Question 45

what is the management for fractures of both bones of the forearm in adults?

Answer 45

ORIF with plates and screws as the injury is highly unstable and anatomic reduction is required to maximize function and prevent deformity

Question 46

what is the management for fractures of both bones of the forearm in children?

Answer 46

minimally angulated fractures can be treated with plaster only as a small degree of angulation will remodel as the child grows

Question 47

how are substantially angulated fractures of the forearm managed in children?

Answer 47

substantially angulated fractures or displaced fractures turns with an intact t periosteum (identified after reduction) are only unstable in one direction and can be treated with MUA (if necessary) and plaster

Question 48

how are very unstable forearm fractures managed in children?

Answer 48

flexible intramedullary nails can be used

Question 49

what x-ray is advised in those with a monteggia fracture dislocation?

Answer 49

elbow x-rays along with forearm

Question 50

what is the management of monteggia fracture dislocations?

Answer 50

ORIF of the ulna fracture (even in children) which should result in reduction of the radiocapitellar joint manipulation alone risks re-dislocation due to the unstable nature of the injury

Question 51

what is mandatory in a galeazzi fracture dislocation?

Answer 51

lateral x-ray of the wrist is mandatory

Question 52

what is the management of Galeazzi fracture dislocations?

Answer 52

ORIF of the radius is required which should allow DRUF to reduce

Question 53

hw do you get a colle's fracture?

Answer 53

FOOSH with the wrist extended

Question 54

what is the treatment of a colle's fracture?

Answer 54

minimally displaced or angulated fractures may be treated with splint age alone but any angulation past neutral (the distal radius articular surface is normally 10 degrees volubly angulated) is usually corrected y manipulation the fracture may be held with a plaster cast alone or if the fracture has dorsal communition or is felt to be particularly unstable after reduction, percutaneous wires may be used to pin the distal fragment in place or ORIF with plate and screws may be preferred

Question 55

what accompanies a colles fracture?

Answer 55

median nerve compression from stretch of the nerve or a bleed into the carpal tunnel

Question 56

treatment of median nerve compression?

Answer 56

reduction may relive the pressure on the nerve and the fracture is usually stabilized with fixation the carpal tunnel may need to be surgicaly decompressed

Question 57

what is a specific late local complication of collet fractures?

Answer 57

rupture of the extensor policies

Question 58

how do you get a smith's fracture?

Answer 58

falling onto the back of a flexed wrist

Question 59

what is the management of smith's fractures?

Answer 59

all should go under ORIF using a plate and screws as they are highly unstable injuries

Question 60

what is reduced in smith's fractures?

Answer 60

grip strength and wrist extension if there is a malunion with excessive solar angulation

Question 61

how are Barton's fractures treated?

Answer 61

using ORIF

Question 62

how are comminuted intra-articular distal radius fractures managed?

Answer 62

to restore the shortening and hold the wrist in reasonable alignment and therefore limit functionality deficit, an external fixator can be sited across the wrist joint supplementary wires can be used to pin larger fragments in place