Amy Adams

1/1/1965
URN 123456

PC
- FOOSH 3 hours ago
- Mechanical fall – tripped on carpet at home
- Developed increasing pain in L arm
Given Penthrox and arm placed in backslab when BIBA to TCH
- L hand dominant
- Pain currently 7/10
- NBM since accident happened
PMHx
- T2DM
Hypertension
Hypercholesterolemia
Depression
- Meds: Atorvastatin, Ramipril, Metformin, Fluoxetine
- Surgical Hx: appendectomy, tonsillectomy + adenoidectomy
- NKDA
Social hx
- Nil smoking, recreational drugs
- 5-6 std drinks/w
- Lives alone at home
- Well balanced diet
- No regular physical activity

O/E
- Vitals WNL
- Bruise visible over palmar aspect of wrist
- Obvious dinner-fork deformity of the wrist
- Maximal point of tenderness in distal radius
- NVI (neurovascularly intact)
Normal cap refill, warmth, temperature
- Unable to F/E L wrist, or perform medial + lateral deviation
 1.

Please describe the following Xrays (AP + lateral)

This is an AP and lateral wrist xray of the L arm of (3 identifiers)

There is an extra-articular complete transverse fracture of the distal radius, just proximal to
radioulnar joint. It is a closed fracture and is dorsally angulated. According to the AP image, it
appears to be minimal radial displacement. There is soft tissue swelling around the wrist.
All other findings of the Xray is normal

2. What is your diagnosis?

Colles fracture

3. What do you want to do now?

- Pain relief – paracetamol
- Pt education, NBM, immobilise joint
- Handover to orthopaedic registrar for management of fracture

4. Do a handover to the orthopaedic registrar using the ISBAR template

5. Explain the diagnosis to the patient and consent her for surgery

- Wound dehiscence, scar

Out of interest, you look through elbow fractures on radiopedia

Go through each of the following images and state why you think it is a supracondylar fracture (or
not)
Describing fracture
1. Anatomical site: proximal/distal, diaphysis/metaphysis/epiphysis
2. Open or closed
3. Fracture line: transverse/oblique/spiral/comminuted/greenstick
4. Displacement
a. Non displaced
b. Displaced e.g. Valgus vs varus
c. Angulated: anterior/posterior, medial/lateral
d. Rotated
5. Growth plate involvement (paediatric fracture)
6. Bone texture: bone looks normal or is it a pathological fracture?
7. Soft tissue
8. Neurovasculature: pulses, motor + sensory function, compartment syndrome

Complications of fractures
Immediate (h) Early (h-w) Late (m-y)

Local  Haemorrhage  Infection  Deformity - malunion,

 Damage to  Compartment syndrome non-union
arteries/nerves  Secondary OA
 Damage to surrounding  Avascular necrosis
structures  Osteomyelitis
 Complex regional pain
syndrome (CRPS)
 Myositis ossificans

Systemic  Hypovolaemic shock  Sepsis + septic shock

 DIC
 ARDS
 Fat embolism
 DVT/PE
 Crush syndrome
(traumatic
rhabdomyolysis) -> ARF

Scaphoid fracture
- FOOSH
Clinical features
- Wrist pain w circumduction
Pain w resisted pronation, weak grip strength
- Anatomical snuffbox tenderness dorsally
Scaphoid tubercle tenderness volarly
Scaphoid non-union advanced collapse (SNAC wrist), avascular necrosis
Xray – FU in 2w (immobilise beforehand)
First 2w – hyperaemia causes bony lysis -> fracture line wider/more visible after 2w. Later, callous
deposition + increased density along fracture line

Other ix
 - CT if negative -> bone scan or MRI
o MRI: most sn for detecting scaphoid fractures – see bone marrow oedema
o Bone scan: hyperaemia – technetium taken up by osteoblast and seen as hot spot

Supracondylar fractures
- Commonly due to fall onto extended elbow in children

Neurovascular complications
- Anterior interosseous n (median n) + brachial artery injury
o Lateral displacement of distal fragment
- Radial nerve – risk in medial displacement (+ midshaft fracture)
- Ulnar nerve – if involve medial epicondyle

Type 1: cast
Type 2: CRPP (closed reduction, percutaneous pinning)
Type 3: CRPP or ORIF

Things to comment on imaging (AP + lateral)

Anterior fat pad (sail sign) – if
small amount, normal

Posterior fat pad

Anterior humeral line

 Radiocapitellar line
- Undisplaced radial head

Salter Harris Fracture

- Physeal/growth plate injuries
Type 1 + 2 (rarely associated w growth disturbance)
- Undisplaced: backslab or removable splint for 4w
- Displaced: closed reduction + cast
Fracture clinic within 5d of immobilisation w FU xray
If delayed presentation >5d, do not attempt closed reduction due to risk of growth plate
injury
Type 3 + 4: ORIF
- Type 3: medium risk of growth disturbance
- Type IV: high risk of growth disturbance
Type 5: not seen in acute injury – diagnosis usually made in retrospect
- Due to growth arrest + progressive deformity
- High risk of growth disturbance

FOOSH
Colles fracture – commonly seen in OP, elderly women
- FOOSH w pronated forearm in dorsiflexion
- Fracture extra-articular (usually), proximal to radioulnar joint
Dorsal angulation of distal fracture -> if severe; dinner fork deformity
Smith fracture
- Volar angulation of distal fracture fragment
Xray
- degree of angulation
- displacement
- does it involve radioulnar joints; intra or extra-articular
- other fractures
Tx: closed reduction + cast; ORIF (if unstable, cannot be reduced)
From CFO:
Pronator teres
Flexor carpi radialis
Flexor digitorum superficialis
Palmaris longus (to block medial nerve, locate palmaris longus and inject dorsally)
Flexor carpi ulnaris (to block ulnar nerve, locate FCU and inject dorsally)?
Other flexors: (deep)
Pronator Quadratus
Flexor pollicis longus
Flexor digitorum profundus

Extensor Tendon Compartments:

1. Abductor pollicis longus
Extensor pollicis brevis
2. ECRB, ECRL
3. Extensor pollicis longus
4. Extensor indicis proprius
Extensor digitorum communis
5. Extensor digiti minimi
6. Extensor carpi ulnaris

Deep muscles - APL, EPB, EPL, Extensor indicis

Muscles of hand
Thenar muscles
Hypothenar muscles
Lumbricals
Interossei

There are 4 lumbricals

 2 ulnar lumbricals supplied by ulnar nerve
 2 median lumbricals supplied by median nerve (1st + 2nd)

Ulnar nerve supply all except thenar muscles and the 2 lumbricals

Musculocutaneous nerve: motor supply to flexors of arm (biceps, brachialis, coracobrachialis) and
sensory supply to lateral forearm
Axillary: supplies deltoid + teres minor
Often injured in anterior dislocation of humerus
Radial: supplies extensor compartment of forearm. Does not supply hand
Often injured in mid-shaft humerus fracture, use of crutches, supracondylar fracture
Test: ability to 'point a gun' or thumbs up [test posterior interosseus n], extend flexed MCPJ
Wrist drop
*posterior interosseous n supplies deep extensors of arm
Median: supplies flexor compartment of forearm, excl. FCU + medial 2 FDP
Supplies thenar + lateral 2 lumbricals of hand
Injured in supracondylar fracture
Test: o.k. Test [anterior interosseus n], thumb opposition (to check for thenar muscle)
o Anterior interosseus n supplies deep flexors of forearm, excl medial 2 FDP

o
o Seen in distal median nerve injury – due to loss of FPL + FDP (supplies deep flexors)
Ulnar: supplies FCU + medial 2 FDP, all muscles of hand, excl thenar + lateral 2 lumbricals
Goes through Guyon's canal: often injured due to riding motorcycle, elbow dislocation,
fracture of medial epicondyle
Test: able to do a 'starfish' (finger abduction)
Ulnar nerve injury
o If distal nerve injury (e.g. Close to wrist) -> claw hand is pronounced as it innervates
intrinsic muscles which is involved in MCPJ flexion and IPJ extension [cannot extend 4th
+ 5th finger]
o If proximal nerve injury (e.g. Supracondylar fracture) above flexor digitorum profundus,
claw hand less pronounced (paradoxical), as affects FDP.
Carpal Tunnel Syndrome
Peripheral neuropathy due to compression of median nerve by transverse carpal ligament
 Contents: 4 FDS, 4 FDP, median nerve, flexor pollicis longus
 Carpal tunnel decompression: cut flexor retinaculum (increase space, and will be replaced with
scar tissue)
 Risk factors
o Female, obesity, pregnancy, hypothyroidism, RA
o Smoking, alcohol
 Pathophysiology
o Repetitive motions
o Certain athletic activities: cycling, tennis, throwing
o Compression due to space occupying lesions (e.g. Gout)
 Clinical features
o Paraesthesia (Numbness + tingling) in radial 3 + 1/2 digits
o Pain + paraesthesia that awaken patient at night
o Thenar wasting but sensation intact as supplied by palmar cutaneous n that runs
superficial to flexor retinaculum
o Phalen + Tinel's test

 Ix - EMG + NCS
 Tx:
o Wrist splints, physio, modification of normal activities
o NSAIDs, CS injections
o Carpal tunnel decompression
Femoral neck fractures
- Subcapital
- Transcervical

Xray
- Shenton’s line disruption (from medial edge of femoral neck + inferior edge of superior pubic
ramus)
- Femur often positioned in flexion + ER
o LT more prominent due to ER of femur
Shortened + ER – hip fracture
Shortened + IR (+ adducted) – posterior hip dislocation
Lengthened + ER (+ abducted) – anterior hip dislocation

Tx
- Non operative
- Internal fixation
- Replacement – hemiarthroplasty, THA
o Hemiarthroplasty: replace femoral head w prosthesis
o THA: replace femoral head + acetabulum w prosthesis
Garden stage I + 2 – stable fractures – internal fixation
Stage III + IV – unstable - arthroplasty
Complications
- Avascular necrosis, non-union
Subcapital femoral neck fracture

Pelvic ring fractures

 3 types
A: rotationally stable, vertically stable
B: rotationally unstable, vertically stable (partial fracture)
C: rotationally unstable, vertically stable

Comment on:
- Pelvic ring + obturator foramina
- Sacroiliac joint, pubic symphysis
- Shenton line

Ottawa ankle rules

Rickets (osteomalacia)
- Vit D deficiency causing soft, weak bones
- Only occurs in growing bones

Risk factors of low Vit D

- Dark skin, minimal sun exposure
- Decreased intake of Vit D containing foods
Breastfed
- CF, coeliac disease, renal failure
- Prematurity
Clinical features
- Bone pain, poor growth
Late crawling, walking
Bone fractures easily
 - Bow legs (normal to have bowing <2y)
- Craniotabes (soft skull) and frontal bossing
Late closure of fontanelle
- Rachitic rosary
o Expansion of rib ends at costochondral junctions
Marfan sign
o Expansion of bone-cartilage junction in joints (seen in lateral malleolus)
Harrisons groove
- Swelling at wrists, knees, ankles (ends of bones larger than normal)
- Late tooth eruption
- Features of hypocalcemia

Ix
- PTH, CMP, Vit D, LFT
o PTH high, Ca + P + Vit D low (hypocalcemic rickets)
o ALP elevated (high bone turnover)
- UEC (if renal disease)
- Xray of long bone
o Wide epiphyseal plane
o Growth plate less defined – cupping, splaying, fraying of metaphysis
o Looser’s zones (pseudofracture)
Mgx
- Vit D supplementation