Upper limb fracture/dislocations

Question 1

Describe the Stimson technique for shoulder relocation

Answer 1

Patient lies prone on bed with affected shoulder over the edge. Weight 2-3kg suspended from wrist. Gentle continuous traction overcomes muscle spasm. Most reduce within 20-25 minutes.

Question 2

Describe Scapula manipulation technique for shoulder manipulation

Answer 2

Set up patient in the Stimson manoeuvre. Rotate inferior border of the scapula medially while stabilising superior aspect of scapula with other hand. Add some external rotation of the humerus if needed.

Question 3

Describe the FARES method for shoulder reduction

Answer 3

Patient supine. Traction on the arm. Small Anterior and posterior oscillating movements whilst slowly abducting arm. When abducted to 90 degrees add external rotation.

Question 4

Describe the Milch manoeuvre for shoulder reduction

Answer 4

Patient supine. Downward traction at the elbow with gentle abduction and external rotation

Question 5

Describe the Spaso technique for shoulder reduction

Answer 5

Patient supine. Vertical traction with the shoulder flexed to 90 degrees. Add small external rotation. (Pulling arm up and away). Add pressure on humeral head from axilla if required.

Question 6

Describe the Cunningham method for shoulder reduction

Answer 6

Patient sitting with back straight. Shouder adducted with elbow flexed. Kneel down and gently put patients hand on your shoulder. Loop your forearm through and place your forearm on the forearm/cubital fossa of patient. Apply gentle constant traction with the weight of your forearm. Massage traps, deltoid and biceps. Repeat massage. Will reduce in 10 minutes. Pick you patient- calm and cooperative.

Question 7

Contraindications to shoulder reduction in ED

Answer 7

-associated humeral neck fracture
-nerve injury/deficit
-suspected vessel injury
-Delayed presentation > 48 hours

Question 8

Injuries associated with anterior shoulder dislocation

Answer 8

-greater tuberosity fracture
-hill Sachs lesion- compression lesion of the posterolateral aspect of the humeral head
-bankart lesion-fracture of anterior lip of glenoid fro impaction of humeral head during dislocation

Question 9

What is a Hill Sachs deformity?

Answer 9

Wedge shaped defect on the posterolateral aspect of the humeral head from impaction on the anterior glenoid rim during dislocation.

Question 10

What is a Bankart lesion?

Answer 10

-occur with anterior shoulder dislocation where humeral head is compressed against labrum. Can be a soft tissue lesion i.e. Labral tear. Can be a boney Bankart lessor which is an avulsion fracture anterior inferior aspect of the glenoid rim. Usually coexists with hill ash defect.

Question 11

Which nerve is commonly injured with shoulder dislocation?

Answer 11

Axillary nerve- patch test

Question 12

What is happening in this XR?

Answer 12

Intraarticular fracture of the humeral head with associated lipohaemarthrosis

Question 13

What is happening in this XR?

Answer 13

Anterior shoulder dislocation
-humeral head sitting below the coracoid process on first view
-humeral head sitting anteriorly (towards the ribs) on the scapula Y view (not in middle of Mercedes benz)
-Hill Sachs defect on the Y view

Question 14

What does the light bulb sign in this picture suggest?

Answer 14

Posterior shoulder dislocation.
Should be a walking stick shape.
Check the y view to confirm

Question 15

What is this XR suggestive of?

Answer 15

Posterior shoulder dislocation

Question 16

What mechanisms are most commonly associated with posterior shoulder dislocation?

Answer 16

-electrocution
-seizures
-high impact trauma- outstretched hand with internal rotation of shoulder

Question 17

What are the complications of posterior shoulder dislocation?

Answer 17

-avascular necrosis of the humeral head
-acute recurrent dislocation
-posterior instability and recurrent dislocations
-functional incapacity
-post traumatic osteoarthritis

Associated with reverse Hill Sachs deformity- anteromedial surface of humeral head
often accompanied by fracture neck of humerus or tuberosity fracture

Question 18

What is the method for relocation of a posterior shoulder dislocation?

Answer 18

Traction counter traction

Question 19

Discharge advice for shoulder dislocations?

Answer 19

Anterior
-sling for 1-2 weeks
-avoid external rotation movements for 4-6 weeks
-follow up with physio
-may need stabilisation procedure if recurrent

Posterior
-sling in neutral or external rotation for 4 weeks
-avoid internal rotation
-follow up with physio +/- ortho
-may need stabilisation procedure for recurrent

Question 20

What is the classification system for AC joint injury?

Answer 20

Question 21

What is the discharge advice/management for the different grades of AC joint injury?>

Answer 21

-Grade 1- broad arm sling for 2 weeks
-Grade 2 board arm sling for 2 weeks and avoid heavy lifting and contact sports for 6 weeks
-Grade 3- conservative or surgical
-Grade 4 and 5 and 6- surgical

Question 22

What is the Neer classification for humeral head fractures?

Answer 22

-Fracture classification of proximal humeral fractures
-Works on displacement and how many parts to the fracture

Question 23

What structures are most likely to be damaged with proximal humeral fractures?

Answer 23

-axillary artery
-axillary nerve
-brachial plexus

Question 24

What is the treatment of proximal humerus fractures?

Answer 24

One or two part fractures
-discharged
-early Ortho follow up- may need fixation
-collar and cuff
-early mobilisation and physion

3 and 4 part need immediate Ortho review

Question 25

What structures damaged with mid shaft humeral fractures?

Answer 25

-brachial artery and vein -ulnar median and radial nerve

Question 26

Which structure is most likely damaged in a mid shaft humeral fracture and how do you test it?

Answer 26

-radial nerve -wrist drop -altered sensation first dorsal web space

Question 27

How are midhsaft humerus fractures manages?

Answer 27

-U shaped plaster -functional humeral brace -surgery

Question 28

CRITOE- what ages doe the ossification centres match up to?

Answer 28

C-1 R-3 I- 5 T-7 O-9 E-11

Question 29

How old is this child?

Answer 29

2

Question 30

How old is this child?

Answer 30

4

Question 31

How old is this child?

Answer 31

5-6

Question 32

How old is this child?

Answer 32

9-10

Question 33

How old is this child?

Answer 33

11 +

Question 34

What is happening with this 12 year olds elbow?

Answer 34

-Internal epicondyle avulsion -Most common ossification centre avulsed -I before T- internal epicondyle ALWAY ossifies before the Trochlear. So if you can see the trochlear but the Internal epicondyle is missing, it has moved somewhere.

Question 35

Describe the Gartland Classification of Supracondylar fractures

Answer 35

Gartland 1- undisplaced fracture. no separation of the cortex Gartland 2- separation of the anterior cortex, and angulation of distal segment. posterior cortex remains intact Gartland 3- disruption of the anterior and posterior cortex- no cortical contact

Question 36

What is the Gartland Classification of Supracondylar fractures

Answer 36

Question 37

What is the treatment of Gartland fractures based on classification?

Answer 37

Question 38

What are the reasons for immediate orthopaedic referral with supracondylar fractures?

Answer 38

-arterial compromise -nerve compromise -open fracture -associated forearm injury on same arm -Gartland 2 or 3 -unable to reduce and maintain position in ED -flexion type (rare) where the distal fragment is displace anteriorly

Question 39

What are the long term complications of Supracondylar fracture

Answer 39

-volkmanns ischaemic contracture of the forearm- can be avoided with treatment- missed compartment or brachial artery injury -malunion- gun stock deformity -nerve injury

Question 40

Which structures are most commonly compromised with Supracondylar fractures?

Answer 40

-Median nerve- 50% (posterolateral displacement) unable to complete OK sign, sensation loss molar surface of index finger -Radial nerve- 30% posteromedial displacement weakness risk extension and sensory loss dorsal them web space -Brachial artery reduced radial pulse

Question 41

Early complications of Supracondylar fractures

Answer 41

-median nerve injury -radial nerve injury -Brachial artery injury -compartment syndrome

Question 42

Which nerve is most commonly injured with fractures to distal radius?

Answer 42

median

Question 43

How do radial head fractures present?

Answer 43

-pain -restricted movement of the elbow

Question 44

Injuries to what other structures are associated with radial head fractures?

Answer 44

-distal radial ulnar joint subluxation -elbow dislocation

Question 45

What classification system is used for radial head fractures?

Answer 45

Mason Hotckiss -1-< 2 mm displacement with no mechanical block -2-may have mechanical block -3- comminuted -4- associated with elbow dislocation

Question 46

What is the ED treatment of radial head fractures?

Answer 46

Sling referral to orthopaedics- mechanical block difficult to assess in acute phase