Upper limb fractures

Question 1

What is a Boxer fracture?

Answer 1

A Boxer fracture describes a minimally displaced fracture of the fifth metacarpal.

This typically results following the patient punching a hard surface, for example a wall.

Question 2

What is a Colles’ fracture?

Answer 2

A distal radius fracture with dorsal displacement of fragments.

It classically follows a fall onto an outstretched hand (FOOSH) and is described as a dinner fork type deformity.

Question 3

What are the three classical features of a Colles’ fracture?

Answer 3

1. Transverse fracture of the radius
2. 1 inch proximal to the radio-carpal joint
3. Dorsal displacement and angulation.

Question 4

What is the deformity associated with a Colles’ fracture?

Answer 4

Dinner fork deformity.

Question 5

What are the early complications of a Colles’ fracture?

Answer 5

1. Median nerve injury: acute carpal tunnel syndrome presenting with weakness or loss of thumb or index finger flexion
2. Compartment syndrome
3. Vascular compromise
4. Malunion
5. Rupture of the extensor pollicis longus tendon.

Question 6

What are the late complications of a Colles’ fracture?

Answer 6

1. Osteoarthritis
2. Complex regional pain syndrome.

Question 7

What is a Colles’ fracture?

Answer 7

A transverse fracture of the radius occurring 1 inch proximal to the radio-carpal joint with dorsal displacement and angulation.

Also known as the dinner fork deformity, typically caused by a fall onto an extended outstretched hand.

Question 8

What characterizes a Smith’s fracture?

Answer 8

A reverse Colles’ fracture with volar angulation of the distal radius fragment.

Also known as the garden spade deformity, caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed.

Question 9

What is a Bennett’s fracture?

Answer 9

An intra-articular fracture of the first carpometacarpal joint caused by impact on a flexed metacarpal.

Often seen in fist fights; X-ray shows a triangular fragment at the ulnar base of the metacarpal.

Question 10

What is a Monteggia’s fracture?

Answer 10

A fracture involving dislocation of the proximal radioulnar joint in association with an ulna fracture.

Typically results from a fall on an outstretched hand with forced pronation and requires prompt diagnosis to avoid disability.

Question 11

What is a Pott’s fracture?

Answer 11

A bimalleolar ankle fracture caused by forced foot eversion.

Question 12

What is a Barton’s fracture?

Answer 12

A distal radius fracture (Colles’ or Smith’s) with associated radiocarpal dislocation.

Usually results from a fall onto an extended and pronated wrist.

Question 13

What are the types of humeral fractures?

Answer 13

Humeral fractures may be divided into proximal humeral fractures, humeral shaft fractures, and distal humeral fractures.

Proximal fractures are typically seen in the elderly, while distal fractures are typically seen in children and include supracondylar fractures.

Question 14

What are supracondylar fractures?

Answer 14

Supracondylar fractures are fractures of the distal humerus just above the elbow joint, typically seen in children.

They are the most common type of elbow fracture in this demographic.

Question 15

What are the common features of supracondylar fractures?

Answer 15

Common features include pain, swelling over the elbow immediately, and the elbow typically being in a semi-flexed position.

They typically result from a fall onto an outstretched hand.

Question 16

What complications can arise from supracondylar fractures?

Answer 16

Complications due to neurovascular involvement can include injury to the median nerve, radial nerve, brachial artery, and ulnar nerve.

Question 17

How are non-displaced supracondylar fractures managed?

Answer 17

Non-displaced fractures are managed with a collar and cuff.

Question 18

How are displaced supracondylar fractures managed?

Answer 18

Displaced fractures are managed with manipulation under anaesthesia with fixation.

Question 19

What is a complete fracture?

Answer 19

Both sides of the cortex are breached.

Question 20

What is a toddler’s fracture?

Answer 20

Oblique tibial fracture in infants.

Question 21

What is plastic deformity?

Answer 21

Stress on bone resulting in deformity without cortical disruption.

Question 22

What is a greenstick fracture?

Answer 22

Unilateral cortical breach only.

Question 23

What is a buckle (‘torus’) fracture?

Answer 23

Incomplete cortical disruption resulting in periosteal haematoma only.

Question 24

What are growth plate fractures classified by?

Answer 24

The Salter-Harris system.

Question 25

What characterizes a Type I Salter-Harris fracture?

Answer 25

Fracture through the physis only (x-ray often normal).

Question 26

What characterizes a Type II Salter-Harris fracture?

Answer 26

Fracture through the physis and metaphysis.

Question 27

What characterizes a Type III Salter-Harris fracture?

Answer 27

Fracture through the physis and epiphysis to include the joint.

Question 28

What characterizes a Type IV Salter-Harris fracture?

Answer 28

Fracture involving the physis, metaphysis and epiphysis.

Question 29

What characterizes a Type V Salter-Harris fracture?

Answer 29

Crush injury involving the physis (x-ray may resemble type I, and appear normal).

Question 30

What is an indicator of an underlying fracture in growth plate tenderness?

Answer 30

It is safer to assume that growth plate tenderness indicates an underlying fracture even if the x-ray appears normal.

Question 31

Which Salter-Harris injury types usually require surgery?

Answer 31

Types III, IV and V.

Question 32

What are signs of non-accidental injury?

Answer 32

Delayed presentation, delay in attaining milestones, lack of concordance between proposed and actual mechanism of injury, multiple injuries, injuries at sites not commonly exposed to trauma, children on the at risk register.

Question 33

What can cause pathological fractures?

Answer 33

Genetic conditions, such as osteogenesis imperfecta.

Question 34

What is osteogenesis imperfecta?

Answer 34

Defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine.

Question 35

What are the characteristics of osteogenesis imperfecta?

Answer 35

Failure of maturation of collagen in all the connective tissues.

Question 36

What does radiology show in osteogenesis imperfecta?

Answer 36

Translucent bones, multiple fractures, particularly of the long bones, wormian bones, and a trefoil pelvis.

Question 37

What are the subtypes of osteogenesis imperfecta?

Answer 37

Type I - Normal quality but insufficient quantity; Type II - Poor collagen quantity and quality; Type III - Poorly formed collagen, normal quantity; Type IV - Sufficient quantity but poor quality.

Question 38

What is osteopetrosis?

Answer 38

Bones become harder and more dense.

Question 39

What is the inheritance pattern of osteopetrosis?

Answer 39

Autosomal recessive condition.

Question 40

In which age group is osteopetrosis most common?

Answer 40

It is commonest in young adults.

Question 41

What does radiology reveal in osteopetrosis?

Answer 41

A lack of differentiation between the cortex and the medulla described as marble bone.

Question 42

What is a scaphoid fracture?

Answer 42

A scaphoid fracture is a type of wrist fracture, typically arising from a fall onto an outstretched hand (FOOSH).

Question 43

What causes a scaphoid fracture?

Answer 43

Causes include falling onto an outstretched hand (FOOSH) and contact sports, particularly during the autumn season.

Question 44

What are typical patient presentations for a scaphoid fracture?

Answer 44

Patients typically present with pain along the radial aspect of the wrist and loss of grip/pinch strength.

Question 45

What is the point of maximal tenderness in scaphoid fractures?

Answer 45

Point of maximal tenderness is over the anatomical snuffbox, which is a highly sensitive but poorly specific test.

Question 46

What are some signs of a scaphoid fracture?

Answer 46

Signs include wrist joint effusion, pain on telescoping of the thumb, tenderness of the scaphoid tubercle, and pain on ulnar deviation.

Question 47

What is the sensitivity and specificity of clinical examination for scaphoid fractures?

Answer 47

Clinical examination has a sensitivity of 100% and specificity of 74% when certain signs are positive.

Question 48

What investigations should be conducted for suspected scaphoid fractures?

Answer 48

Plain film radiographs in anterior-posterior and lateral views, as well as specific 'scaphoid views' should be requested.

Question 49

What is the sensitivity of radiographs in the first week of injury?

Answer 49

The sensitivity in the first week of injury is only 80%.

Question 50

What is considered the definitive investigation for scaphoid fractures?

Answer 50

MRI is considered the definitive investigation to confirm or exclude a diagnosis.

Question 51

What is the initial management for suspected scaphoid fractures?

Answer 51

Initial management includes immobilisation with a Futuro splint or standard below-elbow backslab and referral to orthopaedics.

Question 52

How are undisplaced scaphoid waist fractures managed?

Answer 52

Undisplaced fractures are typically managed with a cast for 6-8 weeks, achieving union in over 95% of cases.

Question 53

What are the complications of scaphoid fractures?

Answer 53

Complications include non-union, leading to pain and early osteoarthritis, and avascular necrosis.

Question 54

What is a Colles' fracture?

Answer 54

A fracture caused by a fall onto extended outstretched hands, described as a dinner fork type deformity. ## Footnote Classical Colles' fractures have three features: transverse fracture of the radius, 1 inch proximal to the radio-carpal joint, and dorsal displacement and angulation.

Question 55

What characterizes a Smith's fracture?

Answer 55

A reverse Colles' fracture with volar angulation of the distal radius fragment, resembling a garden spade deformity. ## Footnote Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed.

Question 56

What is a Bennett's fracture?

Answer 56

An intra-articular fracture at the base of the thumb metacarpal, typically caused by impact on a flexed metacarpal, often from fist fights. ## Footnote X-ray shows a triangular fragment at the base of the metacarpal.

Question 57

What defines a Monteggia's fracture?

Answer 57

A fracture involving dislocation of the proximal radioulnar joint in association with an ulna fracture, often due to a fall on an outstretched hand with forced pronation. ## Footnote Needs prompt diagnosis to avoid disability.

Question 58

What is a Galeazzi fracture?

Answer 58

A radial shaft fracture with associated dislocation of the distal radioulnar joint, occurring after a fall on the hand with a rotational force. ## Footnote Examination reveals bruising, swelling, and tenderness over the lower end of the forearm; X-rays show a displaced fracture of the radius and a prominent ulnar head.

Question 59

What is a Barton's fracture?

Answer 59

A distal radius fracture (Colles'/Smith's) with associated radiocarpal dislocation, typically resulting from a fall onto an extended and pronated wrist.

Question 60

What are scaphoid fractures?

Answer 60

The most common carpal fractures, associated with falls onto an outstretched hand. ## Footnote Main signs include swelling and tenderness in the anatomical snuffbox, pain on wrist movements, and pain on longitudinal compression of the thumb.

Question 61

What is a radial head fracture?

Answer 61

A common fracture in young adults, usually caused by a fall on the outstretched hand, characterized by marked local tenderness over the head of the radius and impaired elbow movements. ## Footnote Sharp pain occurs at the lateral side of the elbow at the extremes of rotation (pronation and supination).