1
Q
Aneurysm of the axillary artery:
- Which part of axillary artery is most likely to be affected?
- Complication of the aneurysm?
- Common aetiology?
A
- First part of axillary artery
- Can compress on the brachial plexus - causing pain + paraesthesia
- In baseball pitchers (due to rapid, forceful arm movements)
2
Q
Where can the 3rd part of the axillary artery be palpated or compressed to slow profuse bleeding?
A
Inferior part of lateral wall of axilla.
Can alternatively compress more proximal for proximal injuries.
3
Q
Which blood vessel is most commonly affected with axilla wounds? Why?
A
Axillary vein
- Due to its large size + exposed position (especially when arm is abducted - this is because it lies anterior to the axillary artery).
4
Q
Give a potentially fatal complication of a wound to the proximal part of the axillary vein
A
Profuse bleeding + potential to form air emboli in the blood stream.
5
Q
If we wanted to conduct a subclavian vein puncture, where would the needle be commonly inserted?
A
Insert into the proximal axillary vein and then immediately proceed into the subclavian vein.
6
Q
Give 3 reasons for swelling in the axilla
A
- Tumour
- Profuse bleeding
- Enlarged lymph nodes
7
Q
Which 2 nerves are most vulnerable during axillary node dissection (AKA Axillary clearance)?
Include nerve roots too?
A
Thoracodorsal nerve (C6,7,8) Long thoracic nerve (C5,6,7)
8
Q
Give the name of 2 common brachial plexus injuries (1 upper and 1 lower)
A
Upper = Erb's Palsy Lower = Klumpke's Palsy
9
Q
Erb’s Palsy:
- Give the section of brachial plexus most commonly affected (include nerve roots)
- Give a common aetiology
- Which main nerves are most commonly affected?
- Give the complication
A
- Upper brachial plexus (C5,6)
- Over extension between neck and shoulder (eg. motorbike crash or pulled head in giving birth)
- Musculocutaneous (C5,6,7), Suprascapular (C5,6), Axillary (C5,6)
- Loss of sensation to lateral arm (eg. regimental badge area) + forearm (eg. lateral cutaneous nerve of forearm). Waiter’s Tip deformity (you get medial rotation + pronation due to paralysis of deltoid, biceps, brachialis, supraspinatus + infraspinatus).
10
Q
Klumpke’s Palsy:
- Give the section of brachial plexus most commonly affected (include nerve roots)
- Give a common aetiology
- Which main nerves are most commonly affected?
- Give the complication
A
- Lower brachial plexus (C8,T1)
- Excessive abduction of the upper limb (eg. falling and catching hold of something -tree/rock climbing).
- Ulnar nerve (C8,T1), Medial pectoral nerve (C8,T1), Medial cutaneous nerve of arm (C8,T1), Medial cutaneous nerve of forearm (C8,T1)
- Loss of sensation to medial forearm + paralysis to most intrinsic hand muscles (innervated by ulnar nerve) + some flexor muscles + pec. minor (pec. major will be partially affected). Results in ulnar claw.
- Ulnar claw (AKA claw hand) is due to loss of innervation to medial 2 lumbricals and interossei - results in unopposed flexion of MCP joints and extension of IP joints of 4th & 5th digits.
11
Q
Brachial Plexus Block:
- How does it work?
- How do we maximise the local effect?
- Are there multiple ways this can be done, or not?
A
- Injection of anaesthetic solution into/immediately surrounding the axillary sheath. This interrupts conduction of impulses of peripheral nerves. Also, it produces anaesthesia of the structures supplied by the branches of the brachial plexus. Sensation is blocked to all deep structures of the upper limb, and the skin distal to the middle of the arm.
- We keep the anaesthetic solution localised by applying an occlusive tourniquet. This allows surgeons to operate on the upper limb without using a general anaesthetic.
- Yes there are multiple ways (eg. interscalene, supraclavicular, axillary approach or block).
12
Q
What is biceps tendinitis?
- Common aetiology?
- Presentation?
A
Biceps tendinitis is the inflammation of the long head of biceps (as it passes through a synovial sheath which moves in the intertubercular groove).
- Commonly from micro-trauma (eg. throwing sports) or with a narrow and/or a rough intertubercular groove).
- Presents with tenderness and crepitus.
13
Q
What is dislocation of tendon of long head of biceps brachii?
- Common aetiology?
A
Tendon of long head of biceps partially, or completely, dislocates form the intertubercular groove.
- Can be very painful and is often found in young children (following traumatic separation of proximal epiphysis of humerus) or older people with a history of biceps tendinitis.
14
Q
What is rupture of tendon of long head of biceps brachii?
- What deformity does it produce?
- Common aetiology? (acute vs. chronic)
A
This is when the tendon of the long head of biceps brachii is torn from the supraglenoid tubercle of the scapula.
- Usually occurs with a “snap” quite dramatically and produces the “popeye deformity”.
- Acutely = Forceful flexion (eg. heavy weight lifting)
- Chronic = Prolonged tendinitis which weakens the tendon. With “wear and tear” from repetitive overhead motions (eg. swimming), the tendon then ruptures.
15
Q
Mid-humeral fracture:
- Which nerve is most commonly affected? Why?
- Will triceps be affected?
A
- Radial nerve (C5,6,7,8,T1) due to the nerve running in the radial groove (along with deep brachial artery).
- Triceps tend not the be affected due to superior innervation of 2 out of 3 of the tricep heads.
- Moore’s does not specify which head is NOT innervated, but it is likely to be medial head due to it originating inferior to the radial groove*
16
Q
Supracondylar/Supraepicondylar fracture of humerus:
- Where does this fracture occur?
- What happens to the fragments?
- Complications?
A
- Occurs distal humerus, proximal to the epicondyles
- Brachialis + triceps tend to pull distal fragment over the proximal one, giving shortening of the upper limb (can occur anteriorly or posteriorly).
- Can cause damage to brachial artery + ulnar (most commonly), radial, & median nerve injury.
- Can get Volkmann’s Contracture with brachial artery damage (as flexor muscles necrose, become shorter and contract the forearm).
17
Q
Injury to musculocutaneous nerve:
- Effects on muscles?
- Effects on sensation?
A
- Can cause paralysis of muscles in anterior arm compartment (causes weaker flexion + supination).
- Can have loss of sensation to lateral forearm (lack of lateral cutaneous nerve of the forearm).
18
Q
Injury to radial nerve in the arm:
- Complications if:
- Superior to branches of triceps
- In the radial groove
- Lack of innervation to forearm
A
Complications depend on the location of the injury
If the injury is…
- Superior to branches of triceps… We can get triceps paralysis
- In the radial groove… We are unlikely to have affected triceps as 2 out of 3 heads are still innervated (only medial head affected).
- Causing lack of innervation to forearm… We can get “wrist drop” due to unopposed flexion (loss of extensors). Can lose sensation to lateral part of the hand + posterior arm/forearm/hand.
19
Q
Elbow tendinitis/Lateral epicondylitis:
- Common Name?
- What is it?
- Presentation
- Common aetiology
A
- Tennis Elbow
- Inflammation of the periosteum of the lateral epicondyle.
- Presents pain over the lateral epicondyle which radiates down the posterior forearm
- From repetitive extension of forearm, which strains the lateral epicondyle.
20
Q
Medial epicondylitis:
- Common name?
A
Golfer’s Elbow
21
Q
Mallet or Baseball finger:
- What is it?
- Common aetiology
- Presentation
A
- Avulsion of a long extensor tendon from the base of the distal phalanx of a finger
- From forceful flexion of distal interphalangeal joint (eg. using a mallet)
- Presents as person is unable to extend distal interphalangeal joint of a finger.
22
Q
Fracture of olecranon:
- Common aetiology
- What occurs to the fragments?
A
- Commonly caused by a fall on elbow combined with forceful contraction of triceps brachii.
- Fracture olecranon is pulled away by the active + tonic contraction of triceps (can be considered as an avulsion fracture).
23
Q
Synovial cyst of wrist:
- What is it?
- Common sites?
- Clinical name?
A
- Non-tender cyst containing clear, mucinous fluid.
- Dorsum of wrist, Attachment of extensor carpi radialis brevis on base of 3rd metacarpal, Common flexor sheath (can cause carpal tunnel syndrome)
- Ganglion
24
Q
Median Nerve Injury:
- Motions affected?
A
- Loss of proximal interphalangeal joint flexion in 1st-3rd digits
- Weakened proximal interphalangeal joint flexion for 4th-5th digits
- Loss of distal interphalangeal joint flexion in 2nd-3rd digits
- Loss of 2nd-3rd digit MCP joint flexion (as normally supplied by lateral 2 lumbricals.
25
Anterior Interosseous Syndrome:
- Which gesture cannot be made?
- Which nerve is affected?
- Which muscles are affected? Movements?
- "Ok" hand gesture
- Anterior Interosseous nerve (branch of median nerve)
- Lateral 1/2 of flexor digitorum profundus + flexor pollicis longus are partially paralysed (thenar eminence is NORMAL). There is an absence of flexion of interphalangeal joint of thumb + flexion of distal interphalangeal joint of index finger.
26
Pronator Syndrome:
- What is it?
- Common aetiology?
- Presentation?
- When the median nerve is trapped between the heads of pronator teres (following trauma, muscle hypertrophy, fibrous bands).
- Following repetitive pronation
- Proximal anterior forearm pain + hypoaesthesia to lateral 3.5 digits on the palmar surface of the hand + adjacent palm.
27
Ulnar nerve injury:
- 4 most common places to injure?
- Sensation changes?
- Muscle changes?
- 1. Posterior to medial epicondyle of humerus, 2. In cubital tunnel (formed by tendinous arch connecting humeral & ulnar heads of FCU), 3. At the wrist, 4. In the hand
- Can alter sensation to medial 1.5 fingers (and adjacent palm/dorsum of hand).
- Intrinsic hand muscles are mostly innervated by ulnar nerve. You can get ulnar claw (as lumbricals lost + interosseous muscles). Also, with wrist flexion, hand can abduct due to unopposed actions of flexor carpi radialis.
28
Radial nerve injury:
- Muscle loss?
- Sensation loss?
- Depending on location, can get different effects. Can lose extension (and hence get wrist drop) if extensor muscles are paralysed.
- If the deep radial nerve is severed, this does not affect sensation as the superficial radial nerve is responsible for this. If we do injure the superficial radial nerve, sensation loss is surprisingly little due to overlap from cutaneous brancehs of median and ulnar nerves. Area to test is a coin shaped region, distal to base of metacarpal 1 & 2.
29
Dupuytren Contracture of Palmar Fascia:
- What is it?
- Complications?
- Common aetiology?
- Treatment?
- Progressive shortening + thickening + fibrosis of the palmar fascia and aponeurosis.
- Pulls 4th & 5th digits into partial flexion at MCP and proximal IP joints. Normally bilateral.
- Tends to be in males >50 years old. Unknown cause, but thought to have hereditary predisposition.
- Treatment = Surgical excision of all fibrotic parts of the palmar fascia.
30
Hand infections:
- Is the palmar or dorsal surfaces most commonly affected?
- How is spread limited?
- What consequences can be seen with an untreated infection in the midpalmar space?
- Dorsal surface, as the palmar fascia is very thick, so swellings are less obvious.
- Spread is often well managed by antibiotics.
- Infection can travel from the midpalmar space, to the forearm (via carpal tunnel).
31
Tenosynovitis:
- What is it?
- Which digits tend to have little spread of infection?
- Which digits are more likely to spread infection?
- Infection of digital synovial sheaths. This leads to inflammation of tendon + synovial sheath. This causes the digit to swell and movement is painful.
- 2nd,3rd,4th digits tend to have separated sheaths so infection spread is limited. If untreated though, proximal ends of sheaths could rupture and infection can spread to midpalmar space.
- Little finger is continous with common flexor sheath so infection may spread to palm, carpal tunnel, and anterior forearm. Likewise, tenosynovitis of thumb could spread via continuous synovial sheath of flexor pollicis longus.
32
Quervain tenovaginitis stenosans:
- What is it?
- Common aetiology?
- Pain in the wrists, which radiates to forearm and thumb.
- Caused by excessive friction between abductor pollicis longus and extensor pollicis brevis (which share a synovial sheath). Results in the thickening of the sheath + stenosis of osseofibrous tunnel. (eg. friction from gripping + wringing repeatedly).
33
Digital Tenovaginitis Stenosans:
- What is it?
- What happens if FDS or FDP thicken proximal to osseofibrous tunnel?
- Common name?
- Thickening of fibrous digital sheath on palmar aspect of digit (leads to stenosis of osseofibrous tunnel).
- If FDS or FDP thicken proximal to osseofibrous tunnel, this means that the patient cannot extend their fingers. If passive extension, this can cause a snapping sound as the tendon is moved.
- AKA Trigger finger.
34
Laceration of palmar arches:
- Can ligation be used?
- How can blood supply be stopped for surgery?
- To stop profuse bleeding, ligation can be used on the forearm artery. However, we must remember that there may be multiple communications of blood vessels so multiple ligations may be needed to stop the bleeding.
- For surgery, a tourniquet may be needed to compress the brachial artery proximal to the elbow.
35
Raynaud Syndrome/Disease:
- What is it?
- Aetiology?
- Stimulus?
- Treatment?
- Intermittent, bilateral attacks of ischaemia of the digits, marked by cyanosis + paraesthesia + pain.
- Idiopathic condition, but there is a similar condition due to anatomical abnormalities + underlying disease.
- Cold + emotional stimuli.
- Can perform cervico-dorsal presynaptic sympathectomy (remove part of sympathetic nerve so that digital arteries dilate).
36
Simian Hand: (Occurs with Median nerve trauma)
| - What is it?
Deformity in which the thumb is limited in opposition + abduction - this results in limited flexion + extension of the thumb in the plane of the palm.
*If we lose thenar muscle innervation, the thumb loses most of its usefulness.*
37
Ulnar Canal Syndrome:
- What is it?
- Common name?
- Presentation?
- How does it differ to proximal ulnar nerve injury?
- Compression of the ulnar nerve may occur at the wrist (between pisiform and hook of hamate).
- Guyon Canal Syndrome
- Ulnar claw + hypoaesthesia in medial 1.5 fingers.
- Different to proximal ulnar nerve injury at flexor carpi ulnaris is unaffected here (so flexion + hand adduction is ok).
38
Handlebar Neuropathy:
- What is it?
- Common aetiology?
- Presentation
- Compression of ulnar nerve
- Long distance cycling with hands in extended position (puts strain on hook of hamate)
- Causes sensory loss to medial hand + weakness to intrinsic hand muscles.
39
Where is a common location for venipuncture? Why is it a good site to use?
- Median cubital vein
- Easily accessible, prominent, has bicipital aponeurosis deep to it, acting as a protector to deep brachial artery + median nerve.
* Also a site for cardiac catheters + cardiac angiography.
40
Carpal Tunnel Syndrome:
- What is it?
- Presentation?
- Why is the central palm sensation not affected?
- Long term complication
- Treatment?
- Tests?
- Median nerve compression due to narrowing of carpal tunnel, or increase in size of tendons.
- Presents with paraesthesia, hypoaesthesia, anaesthesia to lateral 3.5 digits.
- Central palm is not affected as the palmar cutaenous branch of median nerve arises before the carpal tunnel and travels superficially (not in tunnel).
- Long term compression can cause thenar wasting as recurrent branch of median nerve is being affected. Also, sensory changes can radiate to forearm + axilla.
- Treatments include: splints, steroid injections, anti-inflammatories, carpal tunnel release surgery
- Tinel's sign = tap over carpal tunnel to elicit pain (if CTS is present).
Phalen's Manoeuvre = Hold wrists at 90 degree flexion against each other, for 60 seconds. Pain induced if CTS is present.
41
Scaphoid Fracture:
- Aetiology
- Complication?
- Blow to the wrist (from falling on an outstretched hand). Typical in teenagers.
- Avascular necrosis. Due to distal-->proximal blood supply of the scaphoid. Can lead to future arthritis here for the patient.
42
How does ulnar paradox differ to ulnar claw?
In ulnar paradox, injury to ulnar nerve occurs proximally so more muscles are affected (eg. flexor carpi ulnaris + medial 1/2 of FDP). This means that we see less flexion in medial 2 fingers. The claw is less evident despite injury being infact worse.
43
Degenerative Joint Disease:
- What happens to articular cartilage?
- Presentation?
- Aetiology?
- Articular cartilage is eroded so it is less effective at lubrication + shock absorbance.
- Presents with pain + discomfort + stiffness on movement. Common in older people, especially at main weight bearing joints.
- Wear and tear.
44
Dislocation of Sternoclavicular Joint:
- Common or Rare?
- Which age range does it affect?
- Rare condition as this joint is very strong and forces tend to be distributed to other areas of the clavicle instead.
- Occurs in
45
Clavicle Fracture:
- Common or Rare?
- Most common location?
- What happens to the fragments?
- What type of fracture can it occur as in children?
- Fairly common as it is a superficial bone which transfers forces from upper limb to trunk of body.
- Most commonly occurs between medial and lateral 1/3s of the clavicle.
- Medial fragment is pulled superiorly by sternocleidomastoid muscle whilst lateral fragment is moved inferiorly by weight of upper limb (as trapezius can no longer hold weight). Lateral fragment may be pulled medially by adductor muscles such as pec. major.
- Can occur as greenstick fractures in children.
46
Dislocation of acromioclavicular joint:
- Easy or hard to dislocate?
- Aetiology?
- What happens in coracoclavicular ligament tears?
- What if coracoclavicular ligament ruptures?
- Which direction can clavicle move?
- Easy to dislocate, despite strong coracoclavicular ligament.
- Can occur with direct blows, or with severe blow to superolateral part of the back.
- If CC ligament tears, shoulder + clavicle separate and shoulder drops due to upper limb weight.
- If CC ligament ruptures, fibrous layer of joint capsule tears so acromion passes inferiorly to clavicle.
- Clavicle can move more superiorly in this injury type.
47
Ankylosis of sternoclavicular joint:
- What is it?
- Possible treatment?
- This is stiffening/fixation of SC joint.
- This movement at the SC joint is essential, so if ankylosis occurs, it needs to be resolved. To solve, can remove a section of the centre of the clavicle - this creates a pseudo-joint, to allow movement.
48
Calcific Supraspinatus Tendinitis:
- What is it?
- Presentation?
- What is the name of the resulting condition?
- Inflammation + calcification of subacromial bursa, caused by supraspinatus tendon becoming calcified and increasing local pressure on the overlying subacromial bursa.
- Pain on abduction between 50-130 degrees
- Painful Arc Syndrome - as the supraspinatus tendon is in intimate contact with the inferior surface of the acromion (subacromion bursa normally separates them).
49
Rotator Cuff Muscles:
- Name of rotator cuff muscles?
- Aetiology?
- Is the joint capsule affected?
- How is supraspinatus affected by a complete tear of rotator cuff muscles?
- Supraspinatus, Infraspinatus, Teres Minor, Subscapularis
- Repetitive use of upper limb above horizontal, Recurrent rotator cuff inflammation (in particular the avascular area of supraspinatus tendon), Sudden strain of muscles + fall on rotator cuff muscles can cause previously degenerated musclotendinous rotator cuffs to rupture/tear.
- Joint capsule of glenohumeral joint tends to be compromised when rotator cuff is injured.
- If there is a complete tear, supraspinatus cannot abduct first 15 degrees so passive initial abduction is needed so deltoid can take over.
50
Impingement of coracoacromial arch between humeral head + rotator cuff:
- Aetiology
- What can it lead to?
- Test for degeneration tendinitis of rotator cuff?
- Repetitive rotator cuff use.
- Can lead to degenerative tendonitis of the rotator cuff alongside weakness of the supraspinatus tendon
- Can test for degeneration tendinitis of rotator cuff by asking patient to slowly lower their arm from a fully abducted position. Will see a drop around 90 degrees - particularly supraspinatus part if rotator cuff is diseased and/or torn.
51
Dislocation of glenohumeral joint:
- Common or Rare?
- Why is superior dislocation very rare?
- How can anterior dislocations be caused? What happens to the head of the humerus?
- How can inferior dislocations occur?
- How can posterior dislocations occur?
- Which nerve is vulnerable in these dislocations?
- Fairly common as glenohumeral joint sacrifices stability for range of movement.
- Superior dislocation is prevented by coracoacromial arch + support of rotator cuff muscles.
- Anterior dislocations are common in young adults by excessive extension and lateral rotation of the humerus (in this, humeral head is driven inferoanteriorly and the fibrous layer of the joint capsule + glenoid labrum can be stripped out from the anterior aspect of the cavity). Anterior dislocations can also occur from a hard blow to a fully abducted arm. Humeral head moves inferiorly through weak part of the joint. Adductor muscles then pull the head anterosuperiorly into a subcoracoid position.
- Inferior dislocations often occur with avulsion fracture of greater tubercle (upward, medial pull produced by these muscles is lost).
- Posterior dislocations occur with landing on medially rotated limb.
- AXILLARY NERVE = loss of deltoid + teres minor as well as sensation to regimental badge area.
52
Glenoid Labrum Tear:
- What is it?
- Aetiology?
- Which part of the labrum is most commonly affected?
- Presentation
- Tearing of the fibrocartilaginous glenoid labrum.
- Often seen in those who throw a lot, or have shoulder instability/subluxation of glenohumeral joint. Tear can occur from sudden contraction of biceps or forceful subluxation of humeral head over glenoid labrum.
- Tears usually occur in anterosuperior labrum.
- Throbbing/popping/snapping. Presents also with abduction + lateral rotation of arm.
53
Adhesive capsulitis of glenohumeral joint:
- Common name
- What is it?
- Aetiology?
- Presentation
- Complication
- Frozen Shoulder
- Adhesive fibrosis and scarring between inflammed joint capsule of: the glenohumeral joint, rotator cuff, subacromial bursa, and deltoid.
- Seen in 40-60 year olds. Acute capsulitis may be due to calcific supraspinatus tendinitis, partial tearing of the rotator cuff, and bicipital tendinitis.
- Presents as struggle to abduct arm (may achieve 45 degrees of abduction through elevation and rotation of scapula)
- Lack of movement at shoulder leads to increased stress on the AC joint - can cause pain during other movements.
54
Fracture of scapula:
- Aetiology
- Treatment?
- Requires severe trauma. Normally occurs alongside fractured ribs + protruding acromion.
- Little treatment required as muscles hold fragments in place for healing.
55
Surgical Neck Humeral Fractures:
- Most common sufferers
- Stable or unstable fracture?
- Particularly common in those who are elderly and have osteoporosis.
- Humeral fractures often result in 1 fragment being driven into the spongy bone of the other fragment (impacted fracture). Means that the site can be stable and the person may be able to move their arm passively with little pain.
56
Avulsion fracture of the greater tubercle:
- Aetiology + most affected age
- Which way is the limb pulled?
- Most common in:
- Middle-aged + elderly with a fall on the acromion
- Children due to a fall on the hand when the arm is abducted.
- Muscles which remain attached (eg. subscapularis) pull the limb medially.
57
Transverse fracture of the shaft of the humerus:
- Aetiology
- What does deltoid do?
- Direct blow to the arm
| - Deltoid pulls the proximal fragment laterally.
58
Spiral fractures of the humerus shaft:
- Aetiology
- Do the oblique ends overlap?
- Indirect injury (eg. fall on outstretched hand)
- Oblique ends could overlap (causing limb shortening) but this is unlikely as the humerus is surrounded by muscles and a well developed periosteum.
59
Intercondylar fracture of the humerus:
| - Aetiology
- Falling on a flexed elbow can cause olecranon of ulna to be driven between epicondyles - can separate them from the humeral shaft.
60
```
Different nerves can be injured with different sites of fractures....
Surgical neck?
Radial Groove?
Distal end of humerus?
Medial epicondyle?
```
Surgical neck = Axillary nerve
Radial groove = Radial nerve
Distal end of humerus = Median nerve
Medial epicondyle = Ulnar nerve
61
Subcutaneous Bursitis of the elbow:
- Where is the affected bursa?
- Aetiology?
- Is there a risk of infection?
- Common name?
- Found in subcutaneous tissue over olecranon
- From falls on the elbow + excessive/repeated pressure on the elbow
- Infection risk, especially with abrasions of the elbow
- Student's Elbow
62
Subtendinous olecranon bursitis:
- Where is the affected bursa?
- Aetiology?
- Between olecranon + triceps tendon (proximal to where tendon inserts into olecranon)
- Repeated flexion-extension of forearm as this causes friction between the triceps tendon and olecranon. Most painful in flexion as bursa is pressed against tendon.
63
Bicipitoradial bursitis:
- Where is the affected bursa?
- Presentation?
- Separates biceps tendon from anterior radial tuberosity
| - Pain on pronation as bicipitoradial bursa is pressed against the tuberosity of the radius.
64
Avulsion fracture of medial epicondyle:
- Aetiology?
- Complication?
- Occurs in children (under 14 in females, and 16 in males) due to severe abduction of an extended elbow. This causes the ulnar collateral ligament to pull the medial epicondyle distally. This can only occur due to lack of fusion between medial epicondyle and distal humerus (epiphyseal growth plates).
- Common complication is traction of the ulnar nerve = stretching of ulnar nerve.
65
How can the ulnar collateral ligament be reconstructed?
Following tearing, rupturing, or stretching we can replace the ligament using a 10-15cm piece of a long tendon (eg. palmaris longus or plantaris). The tendon is attached through holes drilled in the medial epicondyle and the lateral aspect of the coronoid process of the ulna.
66
Dislocation of elbow joint:
- Aetiology
- Complications
- Posterior dislocation can occur when a child lands on their hands with flexed elbows. Can also arise from hyperextension of blows which drive the ulna posteriorly/posterolaterally.
- Often, ulnar collateral ligament is torn (with associated fracture of head of radius, coronoid process, or olecreanon process). Ulnar nerve can also be damaged.
67
Transverse fracture of ulna and radius:
| - Aetiology
Direct blow (usually affects them at the middle 1/3 level).
68
Colles Fracture:
- What is it?
- Which deformity is seen?
- Aetiology
- Is bone reunion good?
- What complication can happen with distal epiphyseal plate fractures in children?
- Most common fracture of forearm. Transverse fracture of distal 2cm of radius.
- Dinner fork deformity (distal fragment is moved dorsally).
- Forced dorsiflexion (eg. FOOSH).
- Bone reunion tends to be good due to good blood supply
- Malalignment of the epiphyseal growth plate and disturbance to radial growth.
69
Smith's Fracture:
- What is it?
- Aetiology
- Fracture of distal radius
- Direct blow to dorsal forearm or falling on a palmar-flexed wrist. Distal fragment is displaced anteriorly as apposed to colles. May or may not involve articular surface of wrist joint.
70
Fracture of radial head:
| - Aetiology
FOOSH - push radial head against capitulum and it fractures the radial head.
71
Subluxation and dislocation of radial head:
- Common name
- Aetiology + what happens?
- What causes the pain?
- Treatment
- Pulled elbow
- Preschool children are vulnerable to transient subluxation of the head of the radius. Caused by sudden jerking of the upper limb whilst it is pronated. There is tearing of distal attachment of annular ligament (where it loosely attaches to radial head). Radial head then moves distally out of annular ligament socket.
- Pain is caused by pinching of annular ligament between head of radius and capitulum.
- Supinate forearm whilst the elbow is flexed. Sling for 2 weeks.
72
Anterior Dislocation of the Lunate:
- Aetiology
- What happens?
- Complications?
- Fall on dorsiflexed wrist
- Lunate is pushed out of its place (in the floor of the carpal tunnel) towards the palmar surface.
- Lunate can now compress medina nerve (carpal tunnel syndrome). Or due to its poor circulation, avascular necrosis of lunate may occur.
73
Which surgical process may be performed for degenerative joint disease of the wrist?
Surgical fusion of the carpals may be needed (arthrodesis)
74
With scaphoid fractures, is the injury seen on X-rays immediately?
No, initially shows no fracture but after 10-14 days, x-ray shows fracture as bone resorption has occurred.
75
Fracture of hamate:
- Complication?
- Which nerve and artery can be damaged?
- May result in non-union of bone fragments due to traction produced by attached parts.
- Ulnar nerve and ulnar artery may be damaged as they lie closely (can get decreased grip strength).
76
Bull Rider's Thumb:
- What is it?
- Aetiology
- Sprain of radial collateral ligament and an avulsion fracture of the lateral part of the proximal phalanx of the thumb.
- Can occur with those who ride mechanical bulls.
77
Skiers' Thumb:
- What is it?
- Aetiology
- Rupture or chronic laxity of the collateral ligament of the 1st MCP joint. In severe cases, can have avulsion fracture of on head of metacarpal.
- Hyperabduction of the thumb (eg. from thumb on ski pole whilst rest of hand hits the ground when skiing).
78
Fracture of metacarpals:
- Why are isolated fractures of 2-5th metacarpals stable?
- When aren't 2-5th metacarpal fractures stable?
- Do they heal well?
- Aetiology?
- They are closely bound so act as splints
- With crush injuries when multiple metacarpals are fractured
- Yes - good blood supply
- Commonly from crush injuries or direct injury
79
Boxer's Fracture:
- What is it?
- Aetiology
- What deformity is present?
- Fracture of 5th metacarpal
- When closed, abducted fist is hit.
- Flexion deformity - as head of bone rotates over distal shaft.
80
Fracture of phalanges:
- Painful or not? Why?
- What type of fractures do distal phalanges tend to be? and common cause?
- How do proximal + middle phalanges get fractured?
- Why must bones be carefully realigned in the fingers?
- Very painful due to highly developed sensation in fingers
- Comminuted fractures with painful haematomas. Commonly by crush injuries.
- From crush or hyperflexion injuries
- Due to close lying flexor tendons.
81
Herpes Zoster (Shingles):
- Bacterial/Viral/Other?
- Reactivation of what?
- How does it travel?
- Viral
- Varicella Zoster Virus
- Virus travels through cutaneous nerve and lies dormant in dorsal root ganglion after chickenpox. When host is immunosuppressed, virus reactivates and travels through peripheral nerve to skin of a single dermatome.
82
Fracture-Dislocation of Promixal Humeral Epiphysis:
- Aetiology?
- In severe injury, how may the shaft of the humerus move relative to the head of the humerus?
- Why is the joint capsule not damaged?
- From direct or indirect trauma to the shoulder of a child or adolescent.
- In severe cases, head of humerus may stay in place in the glenoid cavity and the shaft could be displaced.
- Joint capsule is strong so isn't damaged.
MSK Clinical Conditions
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