Fall on an outstretched hand most commonly results in what two fractures?

1. Scaphoid

2. Colles’ fracture (distal radius fracture)

(Colles’ fracture also known as the “dinner fork deformity” – seen mainly in adults)

Which type of fracture most commonly injures the radial nerve?

Humeral fracture –

midshaft

What important motor job does the radial nerve do for us?

Radial

Raises

the wRist

What sensory function does the radial nerve do?

1. Back of the forearm

2. Back of the hand

3. Back of first 3 digits

fingers)

Ulnar nerve damage produces what type of problem?

Claw hand

(can’t abduct fingers)

What is the ulnar nerve’s main motor job?

Finger abduction

(also wrist & MCP flexion)

In terms of bone trauma, when is the ulnar nerve most likely to be injured?

Posterior elbow dislocation

(it sits in the “ulnar groove” – the funny bone spot!)

Which artery is most likely to be damaged in an elbow dislocation?

The brachial artery

With any significant dislocation (elbow, knee, ankle) what is the most important step in management?

Reduce the dislocation ASAP

(if this cannot be accomplished immediately – splint it!)

What is the common name for lateral epicondylitis?

Tennis elbow

What is a nursemaid’s elbow?

Radial head subluxation

How is a nursemaid’s elbow usually reduced?

Supination + flexion at the elbow

(gentle pressure on the radial head also helps)

OR

Hyperpronation

Should a nursemaid’s elbow be X-rayed?

No – not needed before or after reduction

What percentage of children with a nursemaid’s elbow will have a reoccurrence?

About 25 %

Should a nursemaid’s elbow be splinted after reduction?

No

What post-reduction management is required for a nursemaid’s elbow?

None, except for education on how to prevent them

What is a “nightstick” fracture?

An ulnar fracture

(as if you were protecting yourself from someone with a nightstick)

Are nightstick fractures displaced, or nondisplaced?

Either

How are nightstick fractures managed?

Displaced – surgically plated into anatomic position to maintain forearm ROM

Nondisplaced – cast

What is Tinel’s sign, and what does it indicate?

Tapping on the volar wrist (over the median nerve) produces paresthesia

(indicates carpal tunnel syndrome – usual treatment rest/NSAIDs/splint)

What is Phalen’s sign?

Sustained pressure on the volar wrist causes paresthesia – “drooping” the hands at the wrists has the same effect

(indicates carpal tunnel syndrome)

In addition to repetitive actions, what are four other risk factors for carpal tunnel syndrome?

Pregnancy Hypothyroidism Diabetes

Rheumatoid arthritis

Which X-ray finding almost invariably indicates an elbow fracture?

Posterior fat pad

What nerve is likely to be damaged by a proximal humerus fracture?

Axillary nerve

How is axillary nerve function tested?

Test deltoid muscle strength

&

Sensation of the overlying skin

Which two shoulder injuries mean that you definitely need to check axillary nerve function?

Proximal humerus fracture

&

Shoulder dislocation

Can radial nerve entrapment occur at the wrist?

No – it’s not enclosed there

What is the “Tea Drinker” mnemonic for the functions of the median nerve?

The functions needed for drinking a cup of tea:

Pincer grasp

(thumb & index finger in the “okay” position)

Biceps

Pronators

Wrist flexors

What is Guyon’s canal?

The space for the ulnar nerve at the wrist

Can the ulnar nerve be entrapped at Guyon’s canal?

Yes –

Usually due to external compression

(for example, from bicycle handlebars or a desk surface with computer mouse use)

Which fracture most often produces a Volkmann’s contracture?

A supracondylar fracture of the elbow

(the humerus at the elbow, specifically)

What causes Volkmann’s contracture?

Inadequate circulation – producing fibrosis and death of forearm soft tissues

(brachial artery obstruction)

What causes “swan neck” deformity of a finger?

A tear or avulsion of the extensor tendon for the distal phalanx that goes untreated

(may result from trauma, rheumatoid arthritis, or other degenerative & inflammatory conditions)

What is another name for a “swan neck” deformity?

Mallet finger

(because the end hangs down like a mallet)

If you diagnose a mallet finger, what should you do about it?

Splint it from the top (dorsal splint) in extension –

Ortho follow-up for wiring

(the tendon and bone need to be together for it to heal properly)

What is a boxer’s fracture?

Fracture at the neck of the 5th metacarpal

(just proximal to the knuckle)

How does a boxer’s fracture happen?

Axial load landing on a closed fist

(e.g., punching a wall)

How is a boxer’s fracture usually treated?

Closed reduction and casting

What is a Bennett’s fracture?

A non-comminuted fracture at the base of the thumb (the proximal phalanx is fractured, including the articular surface)

How does a Bennett’s fracture happen?

Axial loading on a closed fist

(e.g., punching a wall, with too much force going to the thumb)

Which two named fractures refer to fractures at the base of the thumb?

Bennett’s and Rolando’s fractures

(Rolando’s is comminuted & less common)

How are Bennett’s and Rolando’s fractures managed?

Surgically

(both involve the articular surface of the thumb)

If a fracture includes the articular surface of a joint, what management is usually required?

Operative

(not necessarily immediate, though)

Which flexor tendon only goes to the middle phalanx?

The flexor digitorum superficialis

Which flexor tendon goes to the end of the finger?

The flexor digitorum profundus

(it’s profound – it goes the whole way)

How is a subungual hematoma treated?

Trephination and drainage

(meaning, put a hole through the nail)

What two tests should be positive with an anterior cruciate ligament tear?

The Lachman and anterior drawer tests

If you have a choice, which test is better for diagnosing anterior cruciate ligament tears – Lachman or anterior drawer?

Lachman

How is the Lachman test performed?

1. Knee is flexed at just 20–30°

(vs. 90°

for anterior

drawer)

2. Thigh is stabilized

3. Tibia is pulled forward ANY ANTERIOR MOVEMENT IS ABNORMAL

The anterior drawer test is especially unreliable in what setting?

Acute injury

What type of injury often produces false positives on either the Lachman or the anterior drawer test?

Posterior cruciate ligament injury

What is the most common cause of hip pain in children?

Transient synovitis

How do you make a diagnosis of transient synovitis, as a cause for hip pain in a child?

By excluding all of the bad reasons (like fracture, infection, avascular necrosis, or SCFE)

What does SCFE stand for?

Slipped

Capital

Femoral

Epiphysis

Who most commonly develops SCFE?

Obese adolescent boys

Why are pelvic fractures so dangerous?

(2)

1. The force required to break the pelvis often means that other injuries are present

2. Bleeding is not compressible (so it’s hard to control)

Is a double break in the pelvic ring stable or unstable?

Unstable

(there is a strong risk of bleeding and visceral injuries because the separate pieces can move and injure other structures)

Why are “unstable” joint fractures important to recognize?

They require:

1. Surgical management

2. Total non-weight bearing

Does patellar tendon damage affect the knee joint?

No

(the patella is a sesamoid bone, so it forms on its own, outside the knee joint)

What function is lost when the quadriceps tendon is ruptured?

Can’t extend the knee

(surgical repair is required)

How is a patellar dislocation reduced?

Extend the leg and put gentle medial pressure on the patella

(it usually dislocates laterally, so medial pressure puts it back)

What is a Baker’s cyst?

Inflammation of a bursa behind the knee joint

(several different bursa are present & can cause it)

How does a Baker’s cyst present?

Painful, swollen popliteal fossa or calf

(if it ruptures, the whole calf can swell)

What does SCIWORA stand for?

S pinal

C ord

I njury

W ith O ut

R adiographic

A bnormality

Which patients are at risk for SCIWORA?

Pediatric patients

(most often seen in children < 10 years old)

What really happens in SCIWORA?

Children’s hyperflexible vertebrae can move a long way without being damaged, but the spinal cord cannot

(so the X-rays look fine, but the cord is still damaged)

What is the prognosis for recovery of function with SCIWORA in a child over 10 years old?

Good

What is the prognosis for recovery of function with SCIWORA in a child under 10 years old?

Poor

What is the most important step in the initial management of SCIWORA?

IV steroid administration

Why is SCIWORA usually seen in pediatric patients?

In adults, the force required to damage the spinal cord will usually damage the vertebrae, as well

If a patient suffers a spinal cord injury, but has “sacral sparing,” what does that mean for prognosis?

It is good – it indicates that at least part of the cord is intact –

30–50 % recovery

What is “sacral sparing?”

Motor & sensory in the anal/perianal area is intact

(although there are deficits higher up)

Is a single break in the pelvic ring dangerous?

Not usually

(Not likely to cause significant bleeding or additional injury)

When is a clavicle fracture worrisome?

If it is near the sternum (middle 1/3)

• Otherwise no treatment needed

Why are certain clavicle fractures worrisome?

Bleeding –

Big vessels are close by, and may also be injured

What does the median nerve supply?

The palm & adjacent fingers (except for the ulnar part)

&

Distal half of digits 2, 3, & half of 4, on the back of the hand

(wraps around the tips of the fingers, ending its innervation at the PIP joint)

So for which fingers, specifically, does the median nerve provide sensation?

Digits 2, 3, and ½ of 4 (thumb also, of course)

The ulnar nerve provides sensation to which fingers?

Fifth finger and medial half of the fourth

(the half of the fourth digit that is closest to the fifth digit)

Which dermatome does the pinky? Which one does the thumb?

Pinky = C8

Thumb = C6

(C7 does the area in between)

What is a paronychia, and how is it treated?

• An infection of the nail bed (usually near the nail crease)

• I & D and warm soaks

Should a patient receive antibiotics after I & D of a paronychia?

No – not ordinarily

Osgood-Schlatter disease – What is it? Who gets it?

• Pain over the anterior tibial tuberosity

• Active adolescent males (mainly)

What is osteochondritis dissecans?

What does it cause?

• A loose body (from the joint) in the knee joint space

• Pain & locking of the knee joint

What problem can result from prolonged shoulder immobilization?

(Prolonged being more than 3 days)

Adhesive capsulitis (frozen shoulder)

What’s a greenstick fracture?

A pediatric long bone fracture in which only one side of the cortex is disrupted

(like when you bend a “green stick,” and the bark pops open on just one side)

How is radial nerve motor function tested?

R adial R aises the w R ist

(and extends the fingers – makes sense – it runs along the back of the forearm)

How do you test ulnar nerve motor function?

Finger abduction/

adduction

(technically, you’re testing the strength of the “lumbricals” in the hand)

What is the easiest way to test median nerve function?

Make the “OK” sign

(the patient, not you)

What are six significant complications of fractures?

(think vascular complications, infectious complications, bone problems, sudden death problem)

1. Compartment syndrome

2. Fat emboli

3. Nonunion or malunion

4. Arthritis

5. Avascular necrosis

6. Osteomyelitis

What is compartment syndrome?

Too much pressure in a closed space cuts off the arterial supply to that area – soft tissues die

What is a Volkmann’s contracture?

When compartment syndrome kills off the soft tissues in the forearm

(most common after supracondylar fracture)

What are the “5 Ps” that indicate your patient might have compartment syndrome?

1. Pain (earliest finding – more pain than expected)

2. Pallor

3. Paresthesia

4. Paralysis

5. Pulselessness (late finding)

What are the two main complications of a coccygeal fracture?

1. Coccydynia (chronic pain)

2. Rectal injury (from the sharp bone fragment)

How is a coccygeal fracture diagnosed?

Rectal exam

(feel for the fragment)

What is de Quervain’s tenosynovitis?

A painful overuse syndrome of the radial flexor tendons

How is de Quervain’s treated?

Rest

Splint

NSAIDs

What is “Finkelstein’s test?”

What diagnosis does it suggest?

1. Make a fist

2. Bend the wrist toward the ulnar side

3. PAIN!!!

(Ulnar deviation of the wrist, with the hand in a fist, produces pain)

De Quervain’s tenosynovitis

What type of shoulder dislocation is most common?

Anterior dislocation

What is the most common complication of a shoulder dislocation?

Axillary nerve damage

How do you test for axillary nerve damage?

Sensation over the deltoid

OR

Arm abduction

What medical condition is most likely to cause a posterior shoulder dislocation?