HTHSCI 2F03 Lecture Notes - Lecture 16: Wrist, Anatomical Snuffbox, Capitulum Of The Humerus

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26 Dec 2020

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Distal Forearm Fractures

Colles’ Fracture

Clinical Features

 Fall onto an outstretched hand

 Most common in elderly females c

¯ osteoporosis

 Dinner fork deformity

Radiographic Features

 Extra-articular # of dist. radius (w/i 1.5” of joint)

 Dorsal displacement of distal fragment

 Dorsal angulation of distal fragment

 Normally 11 degrees volar tilt

 ↓ radial height (norm =11mm)

 ↓ radial inclination (norm=22O)

 ± avulsion of ulna styloid

 ± impaction

Specific Management

 Examine for neurovascular injuries as median nerve

and radial artery lie close.

 If much displacement → reduction

 Under haematoma block, IV regional anaesthesia

(Bier’s block) or GA.

 Disimpact and correct angulation.

 Position: ulnar deviation + some wrist flexion

 Apply dorsal backslab: provide 3-point pressure

 Re X-Ray – satisfactory position?

 No: ortho review and consider MUA ± K wires

 Yes: home c

¯ # clinic f/up w/i 48hrs for completion

of POP

 6 wks in POP + physio

 If comminuted, intra-articular or re-displaces:

 Surgical fixation c

¯ ex-fix, Kirschner-wires or

ORIF and plates.

Specific Complications

 Median N. injury

 Frozen shoulder / adhesive capsulitis

 Tendon rupture: esp. EPL

 Carpal tunnel syn.

 Mal- /non-union

 Sudek’s atrophy / CRPS

Other Distal Forearm Fractures

Smith’s / Reverse Colles’

 Fall onto back of flexed wrist

 Fracture of distal radius c

¯ volar displacement and

angulation of distal fragment.

 Reduce to restore anatomy and POP for 6wks

Barton’s Fracture

 Oblique intra-articular # involving the dorsal aspect of

distal radius and dislocation of radio-carpal joint

 Reverse Barton’s involves the volar aspect of the radius

Scaphoid Fractures

Clinical Features

 FOOSH

 Pain in anatomical snuffbox

 Pain on telescoping the thumb

Specific Management

 Request scaphoid x-ray view

 If clinical hx and exam suggest a scaphoid #, it should

initially be treated even if the x-ray is normal.

 # may become apparent after 10 days due to

localised decalcification.

 Place wrist in scaphoid plaster (beer glass position)

 If initial x-ray is negative, pt. returns to # clinic after 10

days for re-xray.

 # visible → plaster for 6 wks

 No visible # but clinically tender → plaster for 2

wks

 # not visible and not clinically tender → no plaster

Specific Complications

 Main risk is AVN of the scaphoid as blood supply runs

distal to proximal.

 → stiffness and pain at the wrist

Radial and Ulna Shaft Fractures

Classification

 Monteggia

 # of proximal 3rd of ulna shaft

 Anterior dislocation of radial head at capitellum

 May → palsy of deep branch of radial nerve →

weak finger extension but no sensory loss

 Galleazzi

 # of radial shaft between mid and distal 3rds

 Dislocation of distal radio-ulna joint

Specific Management

 Unstable fractures

 Adults: ORIF

 Children: MUA + above elbow plaster

 Fractures of forearm should be plastered in most stable

position:

 Proximal #: supination

 Distal #: pronation

 Mid-shaft #: neutral

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The Shoulder

Shoulder Dislocation

Classification

 Anterior

 95% of shoulder dislocations.

 Direct trauma or falling on hand

 Humeral head dislocates antero-inferiorly

 Posterior

 Caused by direct trauma or muscle contraction

(seen in epileptics).

Associated Lesions

Bankart Lesion

 Damage to anteroinferior glenoid labrum.

Hill-Sachs Lesion

 Cortical depression in the posterolateral part of the

humeral head following impaction against the glenoid

rim during anterior dislocation.

 Occurs in 35-40% of anterior dislocations.

Presentation

 Shoulder contour lost: appears square

 Bulge in infraclavicular fossa: humeral head

 Arm supported in opposite hand

 Severe pain

Specific Management

 Assess for neurovascular deficit: esp. axillary N.

 Sensation over “chevron” area before and after

reduction.

 Occurs in 5%

 X-ray: AP and transcapular view

 Reduction under sedation (e.g. propafol)

 Hippocratic: Longitudinal traction c

¯ arm in 30O

abduction and counter traction @ the axilla

 Kocher’s: external rotation of adducted arm,

anterior movement, internal rotation

 Rest arm in a sling for 3-4wks

 Physio

Complications

 Recurrent dislocation

 90% of pts. <20yrs with traumatic dislocation

 Axillary N. injury

Recurrent Shoulder Instability

TUBS: Traumatic Unilateral dislocations with a Bankart lesion

often require Surgery

 Mostly young patients: 15-30yrs

 Surgery involves a Bankart repair

AMBRI: Atraumatic Multidirectional Bilateral shoulder

dislocation is treated with Rehabilitation, but may require

Inferior capsular shift

Impingement Syndrome / Painful Arc

Pathology

 Entrapment of supraspinatus tendon and subacromial

bursa between acromion and grater tuberosity of

humerus.

 → subacromial bursitis and/or supraspinatous

tendonitis

Presentation

 Painful arc: 60-120O

 Weakness and ↓ ROM

 +ve Hawkin’s test

 Plain radiographs: may see bony spurs

 US

 MRI arthrogram

 Conservative

 Rest

 Physiotherapy

 Medical

 NSAIDs

 Subacromial bursa steroid ± LA injection

 Surgical

 Arthroscopic acromioplasty

Differential of Painful Arc

 Impingement

 Supraspinatous tear or partial tear

 AC joint OA

Frozen Shoulder: Adhesive Capsulitis

Presentation

 Progressive ↓ active and passive ROM

 ↓ ext. rotation <30O

 ↓ abduction <90O

 Shoulder pain, esp. @ night (can’t lie on affected side)

Cause

 Unknown, may follow trauma in elderly

 Commonly assoc. c

¯ DM

 Conservative: rest, physio

 Medical

 NSAIDs

 Subacromial bursa steroid ± LA injection

Rotator Cuff Tear

 2

O to degeneration or a sudden jolt or fall

 Partial tears → painful arc

 Complete tear

 Shoulder tip pain

 Full range of passive movement

 Inability to abduct the arm

 Active abduction possible following passive

abduction to 90O

 Lowering the arm beneath this → sudden drop

 “drop arm” sign

Rx: open or arthroscopic repair

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Supracondylar Fractures of the Humerus

Presentation

 Common in children after FOOSH

 Elbow very swollen and held semi-flexed.

 Sharp edge of proximal humerus may injure brachial

artery which lies anterior to it.

Classification

Extension

 Commonest type

 Distal fragment displaces posteriorly

 Gartland further classified extension type:

 Type 1: non-displaced

 Type 2: angulated c

¯ intact posterior cortex

 Type 3: displaced c

¯ no cortical contact

Flexion

 Less common

 Distal fragment displaces anteriorly

Specific Management

 Ensure there is no neurovascular damage

 If radial pulse absent or damage to brachial

artery suspected, take urgently to theatre for

reduction ± on-table angiogram.

 Median nerve is also vulnerable

 Restore the anatomy

 No displacement → flex the arm as fully as

possible and apply a collar and cuff for 3wks –

triceps acts as sling to stabilise fragments.

 Displacement → MUA + fixation with K-wires +

collar and cuff with arm flexed for 3wks.

Specific Complications

Neurovascular Injury

 Brachial artery

 Radial nerve

 Median nerve: esp. anterior interosseous branch

 Supplies deep forearm flexors (FPL, lateral half

of FDP and pronator quadratus)

Compartment syndrome

 Monitor closely during the first 24h

 Pain on passive extension of the fingers (stretches

flexor compartment) is early sign.

 Mx: try extension of the elbow, surgical Rx may be

needed.

 Volkmann’s ischaemic contracture can result → fibrosis

of flexors → claw hand.

Gunstock Deformity

 Valgus, varus and rotational deformities in the coronal

plane do not remodel and → cubitus varus.

 Cubitus varus deformity is referred to as a “gunstock”

deformity.

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Document Summary

If clinical hx and exam suggest a scaphoid #, it should initially be treated even if the x-ray is normal. # may become apparent after 10 days due to localised decalcification. Place wrist in scaphoid plaster (beer glass position) If initial x-ray is negative, pt. returns to # clinic after 10 days for re-xray. # visible plaster for 6 wks. No visible # but clinically tender plaster for 2 wks. # not visible and not clinically tender no plaster. Main risk is avn of the scaphoid as blood supply runs distal to proximal. Stiffness and pain at the wrist. # of proximal 3rd of ulna shaft. Anterior dislocation of radial head at capitellum. May palsy of deep branch of radial nerve weak finger extension but no sensory loss. # of radial shaft between mid and distal 3rds. Fractures of forearm should be plastered in most stable position: Most common in elderly females c osteoporosis.

HTHSCI 2F03 Lecture Notes - Lecture 16: Wrist, Anatomical Snuffbox, Capitulum Of The Humerus

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