Upper Extremity Trauma

Front 1

What XR view can be done to diagnose a sternoclavicular joint dislocation?

Back 1

Serendipity View (or CT scan)
Serendipity view: Patient supine, beam is angled 40 deg. cephalad off verticle centered on the sternum

Front 2

What is the most common SC joint dislocation direction and how is it treated?

Back 2

Anterior dislocation—more common, treated by closed reduction. The majority will remain unstable regardless of initial treatment modality, but these are typically asymptomatic

Front 3

What is the most serious direction of dislocation of the SC joint and how is it treated?

Back 3

Posterior dislocation—more serious—30% associated with significant compression of posterior structures. May cause dysphagia or difficulty breathing and sensation of fullness in the throat. Treated by closed reduction with a towel clip in the operating room. A thoracic surgeon should be on standby

Front 4

How is chronic dislocation of the SC joint treated?

Back 4

Chronic dislocation—treated by resection of the medial clavicle, with preservation and reconstruction of costoclavicular ligaments

Front 5

What is a pseudodislocation of the SC joint (bold)?

Back 5

Pseudodislocation—The medial clavicular epiphysis is the last to close at a mean age of 25 years. In patients younger than this, sternoclavicular dislocation is often a Salter-Harris type I or II fracture

Front 6

What is the most common location for a clavicle fracture?

Back 6

▪ Middle—80%
▪ Distal—15%
▪ Medial—5%
When the distal end of the clavicle is fractured, the ligaments may either remain intact and maintain apposition of the fracture fragments (type I) or rupture, allowing wide displacement of the fragments (type II)

Front 7

What 2 non-orthopedic injuries are open clavicle fractures associated with? (bold)

Back 7

Open clavicle fractures are associated with high rates of pulmonary and closed-head injuries

Front 8

Most mid-third clavicle fractures are treated nonoperatively in a sling.
Is there a difference with figure 8 sling vs regular?
What populations and fractures characteristics have a higher risk of nonunion?

(All Bold)

Back 8

No difference in outcome regular sling vs figure of 8

Females and elderly are at higher risk of nonunion. Comminuted fractures and fractures shortened > 2cm have a higher risk of nonunion

Lateral fractures have a higher risk of nonunion than midshaft

Front 9

What are options for fixation off clavicle fractures?

Back 9

Dynamic compression plate: Can be place superiorly (better strength, more prominent so more commonly requires removal) or anteroinferiorly

IM rod and screw can be placed percutaneously but have higher rates of hardware irritation and complication

Front 10

What is the classification system for proximal humerus fractures?

Back 10

Neer. Described as parts where a part is > 1cm or 45-degree displacement. Parts are the articular surface, greater tuberosity, lesser tuberosity, and shaft

One-part (most common): Impaction of the humeral neck. Tx with sling for comfort and early motion

Two-part: Displacement of greater tuberosity > 1cm. Repair ranges from close to ORIF

Three-part: Displacement of greater or lesser tuberosities and articular surface

Four-part: Displacement of shaft, articular surface, and both tuberosities. "Head splitting" is a variant, with split through the articular surface

Front 11

What percentage of bone stock loss in a hill sachs lesion leads to instability?

Back 11

< 20% is stable
20-50 is unstable and can tx with xfrer of lesser tuber.
> 45 is unstable and tx w/ prosthesis vs rotational osteotomy

Front 12

What is a term for a Fracture of the glenoid neck and clavicle

Back 12

Floating shoulder

Front 13

What would nonunion of a greater tuberosity following arthroplasty for proximal humerus fractures cause?

Back 13

Loss of active shoulder elevation (pseudoparalysis)

Front 14

What are the VI classes of AC separation?

Back 14

In a type I injury, a mild force applied to the point of the shoulder does not disrupt either the AC or coracoclavicular (CC) ligament. In a type II injury, a moderate to heavy force applied to the point of the shoulder disrupts the AC ligaments but the CC ligaments remain intact. In a type III injury, when a severe force is applied to the point of the shoulder, both the AC and the CC ligaments are disrupted. In a type IV injury, not only are the ligaments disrupted but the distal end of the clavicle is also displaced posteriorly into or through the trapezius muscle. In a type V injury, a violent force applied to the point of the shoulder not only ruptures the AC and CC ligaments but also disrupts the muscle attachments and creates a major separation between the clavicle and the acromion. A type VI injury is an inferior dislocation of the distal clavicle in which the clavicle is inferior to the coracoid process and posterior to the biceps and coracobrachialis tendons. The AC and CC ligaments have also been disrupted

Front 15

When can a humeral shaft fracture be treated nonoperatively? When is operative fixation required?

Back 15

Functional bracing if there is less than 20 degrees of anterior angulation, less than 30 degrees of varus/valgus angulation, or less than 3cm of shortening

Operative fixation: Open fracture, floating elbow, polytrauma, pathologic fracture, associated brachial plexus injury

Front 16

With humeral shaft fracture fixation, what are the risks of using a nail vs plate fixation?
What is the concern with placement of distal locking screws?

Back 16

A nail may have a higher complication rate associated with higher reoperation rates. Nails have higher incidence of shoulder pain

Distal locking screws: radial nerve at risk with lateral to medial screws.
Musculocutaneous nerve with anteroposterior screws

Front 17

What is a common complication of humeral shaft fractures?

Back 17

Radial nerve palsy (5-10%). Up to 92% reesolve with observation for 3-4 months. Brachioradialis and ECRL are the first to return. EPL and EIP are the last (last innervated nerves)

Explore the radial nerve with the following: open fractures, consider after secondary palsy (new palsy after reduction), spiral or oblique fractures of distal third (Holstein-Lewis fractures)

Front 18

What are the classifications of a capitellum fracture?

Back 18

Type I: Hahn-Steinthal; complete fracture

Type II: Kocher-Lorenz; shear fracture of articular cartilage

Type III: Comminuted

McKee Modification
Type IV - Coronal shear fracture including capitellum and troachlea

Front 19

What is this depicting?

Back 19

A Type IV capitellum fracture in which there is a coronal shear fracture including the capitellum and trochlea

Front 20

What is the classification system for olecranon fractures?

Back 20

Colton Classification:
Type I: Avulsion
Type II (A-D): Oblique fractures with increasing complexity
Type III: Fracture-dislocations
Type IV: Atypical high-energy multifragmented fractures

Front 21

What is the classification system for coronoid fractures?

Back 21

Regan and Morrey classified into 3 types:
Type I: Fracture of the tip of the coronoid process
Type II: Fracture of 50% or less of the coronoid
Type III: Fracture of more than 50%

Front 22

What is the classification system & treatment for radial head fractures?

Back 22

Type I - Nondisplaced (splint for no more than 7 days then allow motion)

Type II - Partial articulation with displacement (Nonsurgical, pain mgmt & active ROM if elbow is stable & no block to motion with good reduction; otherwise ORIF)

Type III - Comminuted fractures involving the entire head (Radial head replacement. ORIF if fewer than 3 pieces. Excise only in elderly low-demand patients)

Type IV - Fractures associated with ligamentous injury or other fractures (requires surgical repair with ORIF or radial head replacement; do not excise)

Front 23

What is the safe zone for ORIF of radial head/neck fractures?

How do you avoid PIN injury when performing ORIF for the radial head?

Back 23

110-degree arc (i.e., 25%) along lateral side, defined by radial styloid and Lister tubercle

Pronate the arm to avoid PIN injury

Front 24

What are the types of simple (no assoc. fracture) elbow dislocations and which type is the most common? How are simple dislocations treated?

Back 24

Posterior, Anterior, Lateral, Medial, and Divergent

80% of dislocations are posterolateral.

Treatment is with reduction, brief (1 week) immobilization, then allow motion. Long-term results are good

Front 25

What is the terrible triad of the elbow?

Back 25

Elbow dislocation with lateral collateral ligament injury, radial head fracture, and coronoid fracture. The LCL injury is typically a ligamentous avulsion from the origin on the distal humerus

Front 26

How are terrible triad of the elbow injuries treated?

Back 26

These are always unstable and always require treatment:
Coronoid ORIF
Radial head ORIF or replacement
LCL repair (typically to distal humerus)
Possible MCL repair depending on stability