Upper limb injuries Flashcards by Chris Mason

Features of SCJ dislocation:

FOOSH/direct blow to shoulder
Anterior > Posterior
Sprain more common

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Complications of posterior SCJ dislocation:

Pneumothorax
Great vessel injury - subclavian veins, R brachiocephalic artery, L common carotid artery, L subclavian veins
Dyspnoea, stridor and dysphagia
CT mandatory

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AC joint injuries: Rockwood classification:

1 = Radiographically normal
2 = Distance between clavicle and acromion <1cm
3 = Distance between clavicle and acromion >1cm
4-6 are defined by displacement
(1-2 = sling + rest, 3 = sling + referral, 4-6 = sling +surgery)

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Difference in treatment between anterior and posterior SCJ dislocations?

Anterior requires broad arm sling and fracture clinic

Posterior requires orthopaedics referral

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When do you refer a fracture?

Open fractures
Neurovascular compromise
Tenting of the skin

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Clavicular fracture associations?

Middle - intra-thoracic injury
Distal - rupture of C-C ligament (floating fragment)
Medial - intra-thoracic injury to subclavian vessels

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Most common type of shoulder dislocation?

Anterior: Subcoracoid, subglenoid, subclavicular, intrathoracic

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Signs of shoulder dislocation:

Arm abducted and externally rotated with flexed elbow
“Squaring” loss of contours
Palpable head in the infra-clavicular fossa

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Humeral head may appear falsely dislocated with…

Proximal humerus fracture due to bleeding into joint and displacement

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What should you always check before manipulation of the dislocated shoulder?

Sensation of the deltoid and radial pulse

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Complications of shoulder dislocation:

Axillary nerve/artery injury - badge sign
Bruising of lateral chest wall
Axillary haematoma/bruit
Fractures of humeral head, ant. glenoid lip, greater tuberosity
Rotator cuff injuries - pain and weakness after 2 weeks
Radial/medial/ulnar/musculocut/brachial plexus injury

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Neer classification of fracture surgical neck of the humerus:

1 = one-part fracture - no displacement
2 = two-part fracture - displacement of one fragment
3 = three-part fracture - displacement of two fragments
4 = four-part fracture - displacement of all segments
5 = dislocation (ant. or post.) regardless of displaced segment

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Management of fracture surgical neck of the humerus:

Broad arm sling, analgesia and refer
Early mobilisation to prevent capsulitis
Ortho referral for very comminuted fractures

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Associations with fracture shaft of humerus:

Elderly/FOOSH
Middle 1/3
Elderly
Metastatic (e.g. pathologic fracture from breast cancer)
Osteoporosis
Radial nerve injury and wrist drop in 10-20%
Brachial artery injury

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Management of fracture shaft of humerus:

Conservatively
Humeral brace - reduced risk of compartment syndrome
U-slab for minimally displaced +/- referral for displaced
Always X-ray elbow and shoulder

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What is the positioning of a dislocated elbow?

Elbow flexed at 45 degrees and prominent olecranon posteriorly

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Complications of elbow dislocation:

Injury to brachial artery, median, ulnar and radial nerves (10%)

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Which fractures occur with elbow dislocation?

Fracture medial epicondyle in children

Fracture coronoid, radial head, capitellum and olecranon in adults

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Signs of fracture of radial head:

Tender radial head
Tender on pronation and supination
FOOSH

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Associated injuries with fracture of the radial head:

Fracture of capitellum, olecranon, coronoid, medial epicondyle

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Treatment for simple clavicular fracture?

Either broad arm sling (BAS) or collar and cuff (C+C)

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Management of shoulder dislocation:

7 weeks immobilisation to allow the surrounding structures to recover
Younger people need longer immobilisation
Need to move shoulder within 2 days of immobilisation

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Normal shoulder vs posterior GH dislocation?

Normally the humeral head appears asymmetric on X-ray whereas with posterior GH dislocation it is symmetrical and looks like a lightbulb

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What is chocolate therapy?

Midazelam and morphine - give for big muscley men

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Management of elbow dislocation:

Manipulation under anaesthesia | Back slab for a week for swelling then full cast

Management of fracture of the radial head:

Broad arm sling for minimally displace | Ortho referral for grossly displaced

Which two lines should intersect within the capitellum?

Anterior humeral line and radiocapitellar line

Features of supracondylar fractures:

Direct blow to posterior aspect of the flexed elbow | Open fractures

Management of supracondylar fractures:

Splint for non-displaced | If displaced then ortho referral and admission for displacement and soft tissue swelling

Complications of supracondylar fractures:

``` Radial nerve (posterior-medial displacement) Median nerve (posterior-lateral displacement) High incidence of anterior interosseous nerve injuries so test 'OK' sign for the motor component Vascular entrapment of the brachial artery Non-union/mal-union and loss of mobility ```

Associations of fracture olecranon:

Other fracture in 30% (radial head) Ulnar nerve injury Triceps rupture

Management of fractured olecranon:

Undisplaced (<2mm in flexion) = conservative management | Majority require operative fixation

What should you rule out in fracture of forearm bones?

Compartment syndrome

What is the Galeazzi fracture?

Fracture to the distal radius which distal radio-ulnar dislocation Caused by FOOSH/direct blow to back of wrist

Complication of Galeazzi fracture?

Ulnar nerve injury

Treatment of Galeazzi fracture?

Open reduction and internal fixation (ORIF)

What is the Monteggia fracture?

Fracture to the proximal 1/3 of ulnar with dislocation of the radial head Caused by FOOSH/direct blow to the posterior aspect of the ulnar

Complication of Monteggia fracture?

Radial nerve injury

Treatment of Monteggia fracture?

ORIF and closed reduction/splinting

What is the Colles' fracture?

Transverse fracture of distal radius with dorsal displacement of distal fragment Impaction, radial deviation, ulnar angulation and rotation

Signs of Colles' fracture:

FOOSH Age >50 Dinner fork deformity

Associated injuries of Colles' fracture:

Ulnar styloid fracture | Median nerve injury

What makes an unstable Colles' fracture?

>20 degrees of angulation Intra-articular involvement Comminuted >1cm of shortening

Treatment of Colles' fracture:

``` Non-displaced = Sugar tong splint and refer to trauma clinic Displaced = Reduction: finger traps and manipulation under sedation or with haematoma block then sugar tong splint and ortho referral ```

Differential in the history between Colles' and Smith's fractures?

Colles' fracture is due to falling onto wrists in extension | Smith's fracture is due to falling onto wrists in flexion

What is Smith's fracture?

Fracture of the distal radius with solar (palmar) displacement and angulation

What is Barton's fracture?

Fracture of the distal radius which extends through the dorsal aspect of the articular surface with associated dislocation of radoiocarpal joint

What differentiates Barton's fracture?

No disruption of radoiocarpal ligaments and the fractured articular surface of the distal radius remains in contact with the carpal row

What is Hutchinson's fracture?

Intra-articular fractures of the radial styloid process Radial styloid is within the fracture fragment Fragments can vary markedly in size

Complications of Hutchinson's fracture:

``` Median nerve injury Carpal tunnel syndrome Mal-union Reflex sympathetic dystrophy Rupture of extensor policis tendon Osteoarthritis of the wrist ```

When should you reduce although the fracture is not grossly displaced?

>20 degrees angulation >1cm shortening Intra-articular involvement Marked comminution

What is Bier's block?

Prolocaine or lignocaine

What is Haematoma block?

Adrenaline and bupivacaine

What is Conscious sedation?

Midazolam, morphine an cyclizine

Management of distal radius fractures:

Smith and Barton fracture = refer to ortho Distal radius fracture in young = refer to ortho Otherwise back-slab and follow up in fracture clinic

Above elbow injuries...

Usually managed in a sling

Always assess what?

The joint immediately proximal and distal (might tell you the wrong joint e.g. if dementia)

Which fractures do you always refer?

Smith's Barton's Hutchinson's

Protocol for palmarly displaced fracture e.g. Smith's?

Urgent ortho referral

Management for articular step-off >2mm?

Urgent ortho referral

Risk with large ulnar styloid fractures with displaced fragments at the styloid base?

Increased risk of distal radioulnar joint instability | Urgent ortho referral

Management of fracture dislocations?

Urgent ortho referral

What are distal radial fractures associated with?

Scaphoid fractures or scapholunate ligament injuries | Require urgent ortho referral

Problem with near-anatomic reduction of comminuted/displaced fractures?

Need urgent ortho referral as they are unstable even if reduction is near-anatomic and are likely to lose position