This is the lower end of a forearm cast - iiNet

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This is the lower end of a forearm cast. It is appropriate for:

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• A 'Colles' fracture Correct, The Colles' plaster is initially an incomplete slab, applied dorso-radially from just below the elbow, to the necks of the metacarpals. This is completed once the risk of swelling has receded. The thumb is left free. In order to immobilise the metacarpals one would have to include the proximal interphalangeal joint of the appropriate finger(s). In fact, this is seldom done because if the metacarpals need to be stabilised internal fixation is usually used. A Bennett's fracture is an intra-articular fracture of the proximal phalanx of the thumb, with separation of the insertion of the short abductor. A Bennett's plaster includes the proximal phalanx and the thumb is held in full abduction, in order to reduce the avulsed fragment.

• A fracture of the metacarpal shafts of the fingers

• A 'Bennett's' fracture

• A scaphoid fracture

• a 'mallet' fracture

Which of the following statements is FALSE? The lesion shown is:

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• An olecranon bursa

• Occasionally infected

• Resolves spontaneously Correct, This is an olecranon bursa. It may be produced by anything that causes repeated rubbing between the skin and the olecranon. An underlying bone spur is sometimes present over the tip of the olecranon at the insertion of the triceps tendon. Once established, the bursa may become inflamed to produce a bursitis. This may be bacterial of chemical, as in gout. The bursa does not resolve completely once formed but the size may vary, depending upon the degree of local irritation that it is exposed to.

• Commonly inflamed in gout

• Often accompanied by a prominence of the olecranon

The opacity seen in the sub-acromial bursa is:

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• Calcification Correct, The opacification seen is calcification. Calcification can be differentiated from ossification by the fact that ossification has a bony architecture, or a trabecular pattern of even a bony cortex. Pus is not evident on plane x-ray, pseudogout deposits itself in articular cartilage and minisci, and gouty-tophi aren't radio opaque.

• Ossification

• Pus

• Pseudogout

• Gouty-tophi

The fracture shown here is conventionally treated by:

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• Early mobilisation without surgery

• Plaster of paris immobilisation

• Open reduction and internal fixation Correct, This injury is an avulsion fracture of the olecranon. The triceps insertion will be attached to the proximal fragment and therefore will be non-functional following this injury. It is also an intra-articular injury. For those two reasons, it ought to be managed by open reduction and internal fixation with anatomical reconstruction of the joint.

• Fixation using a 'fixator externa'

• None of the above

The distal radius shows:

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• A chondrosarcoma

• A comminuted fracture through an otherwise normal bone

• A pathological fracture through an enchondroma Correct, The distal radius shows a pathological fracture. The underlying lesion shows areas of irregular calcification, without any visible bone trabeculae. The appearance is typical of a cartilage tumour. Because there is no evidence of malignancy and the tumour is within the confines of the radius this makes it an enchondroma. A fracture does not leave large cystic space that is evident, nor the calcification.

• Osteomyelitis

• A simple bone cyst

The problem shown in this slide is often associated with:

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• A Galeazzi fracture

• A Monteggia fracture Correct, A Monteggia fracture is a displaced fracture of the ulnar accompanied by a dislocation of the radial head. A Galeazzi fracture occurs when the radius is fractured and there is a dislocation of the lower end of the ulna. Both fracture-dislocations illustrate the maxim that if one of the bones of the forearm is fracture and displaced then there must also be dislocation of one of the assocated joints. There is no evidence of any of the other suggested alternatives on this radiograph.

• Fracture of both radial and ulnar metaphyses

• Dislocation of the wrist

• Multiple congenital dislocations of arthrogryposis

These three x-rays are taken at six monthly intervals. In relation to these radiographs, which of the following statements are NOT true?

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• There is an undisplaced subcapital fracture.Correct, The left part of this x-ray shows a displaced subcapital fracture. There are two alternative forms of treatment for this disorder which are commonly used. A closed manipulative reduction under anaesthesia, followed by internal fixation with screws is practised in some centres. However, in the elderly this has a very high complication rate and patients do not mobilise particularly well. The most effective form of treatment for elderly patients is to replace the upper part of the head of the femur with a hemiarthroplasty. This has been done here and a Thompson prosthesis is shown. There is progressive erosion of the medial wall of the acetabulum by the Thompson prosthesis. This complication is called protrusio acebuli. It can occur without infection but in the presence of infection it can be extremely rapid. The process causes mechanical pain and this occurs in about 10 to 20% of patients after one year.

• It has been treated by replacement with a Thompson hemi-arthroplasty.

• The complication shown is called protrusio acetabuli

• Erosion of the medial wall of the acetabulum may be aggravated by infection

• Both infection and erosion of the medial wall of the acetabulum may be associated with hip pain.

This man developed sudden pain in his upper arm whilst lifting a heavy weight. The most likely diagnosis is?

? the wrong picture ?

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• Rupture of the biceps tendon at its distal end

• A lipoma

• Rupture of the long head of biceps Correct, This patient demonstrates a lump in the distal third of the upper arm anteriorly and based on his history and clinical signs, the most likely diagnosis would be rupture of the long head of the biceps. The biceps uncommonly ruptures at its distal end and if it did, the muscle mass would not be displaced distally.

• A ganglion from the elbow

• A fracture of the lower humerus

Your management of this fracture would be to:

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• Reassure patient and parent that the bone will remodel satisfactorily and rest the limb in a short arm plaster.

• Admit for manipulation under anaesthesia and splint in an above elbow plaster with the elbow in full extension

• Admit for manipulation under anaesthesia and splint in a short arm plaster

• Admit for manipulation under anaesthesia and splint in an above elbow plaster with the elbow at 90 degreesCorrect, The majority of displaced fractures of the radius and ulnar are treated by open reduction and internal fixation, simply because it is very difficult to get perfect alignment and to maintain it by any other means. However, if the displacement is pure angulation and there is a periosteal bridge left, then the manipulation is relatively easy and the position is subsequently stable. Therefore, in this case, the patient would be manipulated under anaesthetic and the position checked. If an ideal position was achieved by the manipulation, it would then be left in a plaster of Paris cast. The cast would have to extend above the elbow and below the wrist. I would anticipate that manipulative reduction in this particular child would be easy. There is no question of remodelling in the mid part of a long bone. Remodelling only occurs close to the end of a long bone.

• Admit for open reduction and internal fixation

This patient had a fall on to their outstretched arm. You would:

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• Rest the limb in a sling and see in one week at the fracture clinic

• Refer to Physiotherapy for exercises as painful elbows rapidly lose movement

• Make arrangements to take the patient to the Operating Theatre Correct, This xray shows a dislocation of the radial head. The only reason for the radial head to be dislocated is because of Monteggia fracture. Therefore, one would expect the ulna to be fractured and the radial head to be dislocated because of the displacement in the ulna. Treatment for this is reduction of the ulnar fracture and this usually results in a relocation of the radial head. Occasionally, soft tissue blocks the replacement of the radial head and therefore this has to be openly reduced as well.

• Splint the arm in an above elbow plaster with the elbow at 90 degrees

• Reassure the patient that the elbow is just bruised.

This injury was caused by a fall onto the outstretched arm. It is most likely to be:

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• A Monteggia fracture/dislocationCorrect, The xray shows a dislocation of the radial head. This is most commonly part of a Monteggia fracture/dislocation in which the ulna is fractured, displaced and therefore shortened. The paired bone therefore is forced out of its articulation in order to accommodate the shortening. Isolated dislocations of the radio-ulnar joint are excessively rare.

• A Galeazzi fracture/dislocation

• An isolated dislocation of the elbow

• An isolated dislocation of the radio-ulnar joint

• An isolated dislocation of the radial head

This patient has had a fracture of the distal radius manipulated and put into plaster. The current position is:

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• Satisfactory and should be left alone for a total of 6 weeks

• Unsatisfactory and should be openly reduced and internally fixed

• The position of flexion of the wrist is excessive and plaster should be changed to place the wrist in not more than 20 degrees of flexion Correct, The fracture of the distal radius has been well reduced and the position is adequate. The problem is that there is an excessive degree of flexion at the wrist. This is very painful for the patient. It produces a marked weakness of grip so that the patient cannot use the hand satisfactorily in plaster, and it may cause ultimate loss of joint range. For this reason, the plaster should be changed and the wrist flexed to no more than approximately 20 degrees.

• Should be left alone and the pateint x-rayed at weekly intervals for a total of 6 weeks.

• There is no fracture and the patient should be taken out of plaster as soon as possible

The x-ray shows:

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• A fracture dislocation of the elbow

• A Monteggia fracture dislocation Correct, This x-ray shows a fracture of the ulna and a dislocation of the radial head. The main part of the elbow joint is not affected. The ulna is still articulating normally with the humerus. This deformity is a Monteggia fracture dislocation.

• A Galeazzi fracture dislocation

• A radio-ulnar diastasis

• None of the above

The injury shown by this man should be treated by:

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• Immobilisation of the arm

• Open surgery

• Active physiotherapy

• Open exploration and biopsy

• None of the above Correct, This man has a rupture of the long head of biceps. There is no treatment which has any effect like this. Any form of surgery makes the situation worse and the local damage caused by the surgery prolongs rehabilitation. Active physiotherapy is useful once the local bleeding has stopped. The usual form of surgery for this is local application of ice and rest of the arm for a few days, followed by gentle mobilisation after approximately one week, building up to active muscle exercises after 3 - 6 weeks.

This form of immobilisation is used to:

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• Support the shoulder joint

• Reduce dislocations of the shoulder

• Exert traction on fractures of the humerus Correct, This is a collar and cuff. It is used in order to exert traction on the humerus. It does not support the shoulder joint nor, in fact any part of the arm. It is useful to maintain the length of fractures of the humeral shaft.

• Maintain the position of avulsion fractures of the medial epicondyle

• Guarantee elevation of the elbow so as to reduce oedema

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