HTHSCI 2F03 Lecture Notes - Lecture 12: Anterior Interosseous Nerve, Varus Deformity, Pronator Quadratus Muscle
26 Dec 2020
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Department
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Professor
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.
© Alasdair Scott, 2012
117
Femoral and Tibial Fractures
Specific Management
Resus and Mx life-threatening injuries first.
X-Match
Tibial #: 2 units
Femoral #: 4 units
Assess neurovascular status: esp. distal pulses
If open
Abx and ATT
Take to theatre urgently for debridement,
washout and stabilisation
Fixation methods
Intramedullary nail
Ex-fix
Plates and screws
MUA c
¯ fixed traction for 3-4mo
Specific Complications
Hypovolaemic shock
Neurovascular
SFA: swelling and check pulses
Sciatic nerve
Compartment syndrome
Respiratory complications
Fat embolism
ARDS
Pneumonia
Ankle Injuries
Ligament Strains
Typically twisting inversion injury
Strains anterior talofibular part of lateral collateral
ligament
Medial deltoid ligament strains are rare.
May be assoc. c
¯ malleolar avulsion #s
Ankle Fracture
Ottowa Ankle Rules
X-ray ankle if pain in malleolar zone + in any of:
Tenderness along distal 6cm of posterior tib / fib
including posterior tip of the malleoli.
Inability to bear weight both immediately and in
ED
Weber Classification
Relation of fibula # to joint line
A: below joint line
B: at joint line
C: above joint line
Weber’s B and C represent possible injury to the
syndesmotic ligaments between tib and fib → instability
Mx
Weber A
Boot or below-knee POP
Non-displaced Weber B/C
Below-knee POP
Displaced Weber B/C
Closed reduction and POP if anatomical
reduction achieved
ORIF if closed reduction fails
© Alasdair Scott, 2012
118
Knee Injuries
History
Mechanism
Swelling
Immediate = haemarthrosis = # or torn cruciates
Overnight = effusion = meniscus or other lgt
Pain / tenderness
Joint line = meniscal
Med/lateral margins = collateral lgts.
Locking: meniscal tear → mechanical obstruction
Giving way: instability following lgt. injury
Knee Haemarthrosis
1O: spontaneous bleeding
Coagulopathy: warfarin, haemophilia
2O: trauma
ACL injury: 80%
Patella dislocation: 10%
Meniscal injury: 10%
Outer third where its vascularised
Osteophyte #
Unhappy Triad of O’Donoghue
ACL
MCL
Medial Meniscus
Mx of acutely injured knee
Full examination of acutely swollen knee after injury is
difficult.
Take x-ray to ensure no #s
Fluid level indicates a lipohaemarthrosis and
indicates either a # or torn cruciate.
If no # → RICE + later re-examination for pathology
If meniscal or cruciate injury suspected → MRI
Arthroscopy
Direct vision of inside of knee joint by arthroscope
Can examine knee under anaesthesia (↓ muscle tone)
Meniscal tears can be trimmed or repaired.
Mx of Ruptured ACL
Conservative
Rest
Physio to strengthen quads and hamstrings
Not enough stability for many sports
Surgical
Gold-standard is autograft repair
Usually semitendinosus ± gracilis (can use patella
tendon)
Tendon threaded through heads of tibia and femur and
held using screws.
© Alasdair Scott, 2012
119
Document Summary
Supplies deep forearm flexors (fpl, lateral half of fdp and pronator quadratus) 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. 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. Sharp edge of proximal humerus may injure brachial artery which lies anterior to it. Type 2: angulated c intact posterior cortex. Type 3: displaced c no cortical contact. If radial pulse absent or damage to brachial artery suspected, take urgently to theatre for reduction on-table angiogram. 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.
