Nerve Damage

By Melissa Snyder,2014-02-10 03:04
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Nerve Damage

    Fracture Description Picture Monteggia Fracture of ulna shaft with

    dislocation of proximal

    radioulnar joint

    Galeazzi Fracture of radial shaft with

    dislocation of distal radioulnar


    Mnemonic: Medics Under Pressure Get Really Drunk

    Monteggia: Ulnar shaft + Prox Radio-ulnar Joint; Galleazzi = Radial shaft + Distal RUJ

    Colles’ and Transverse fracture of radius Smith’s within 2.5 cm of wrist


    In Smith’s there is palmar (or

    volar) displacement of the

    distal fragment (Pic to right)

    In Colles there is dorsal

    displacement of the distal

    fragment (bottom right and

    X-ray below)

Scaphoid 75% of all carpal fractures

    Tenderness in snuffbox

    Pos prox avascular necrosis

    Request scaphoid x-ray

    Fractured Hip (Fractured neck of femur)

    Classically, this is a fracture of old age, affecting women in their eighth or ninth decade of life.

    Usually the bone has been weakened by underlying disease - most commonly, osteoporosis but also osteomalacia, diabetes, alcoholism and other conditions associated with osteopenia. There is usually a history of trauma but in severely weakened bone, direct injury may be trivial or absent. There is a debate as to whether "patients fall because they fracture or fracture because they fall".

Rarely, fractures of the femoral neck are seen in children.

    Generally the fracture is displaced and unstable. If some of the fragments have been impacted then the patient may be able to walk with some pain and discomfort.


Femoral neck fractures most commonly follow a fall or blow on the greater trochanter which

    may be quite trivial. In severely osteopenic bone, the femoral neck may fracture on weightbearing, for example, on rising from a chair. Rarely, a femoral neck fracture follows severe traumatic injury in a child.

    Differentials and clinical features


    Posterior dislocation Yes Int Add Yes Common in drivers / Rotation

    passengers of head-on

    collision Adduction/ Anterior dislocation No Ext Abd Yes Rare adduction Neck of femur fracture Yes Ext Abd Yes May be able to stand

    Blood supply poor

    Mal / non-union common Flexion Avascular necrosis risk

    Intertrochanteric fracture Yes Ext + Abd Yes Cannot stand

    Cannot raise leg

    Blood supply good

    Good union

    Rare avascular necrosis

    Subtrochanteric fracture Yes Ext Abd Yes Swollen thigh

    Intensely painful

Investigations X-ray Pelvis CT if doubtful

     X-ray femoral shaft + knee Scintigram


    Ligamentum teres: a branch of the obturator

    artery (absent in 20% of the population) this

    artery is insufficient to supply the head of

    the femur in adults.

    Retinacular arteries:

     One enters posteriorly from the Medial

    femoral circumflex artery which is a

    branch of femoral artery greatest

    supply of blood to the femoral head

     Two enter anteriorly from the Lateral

    femoral circumflex artery which is a

    branch of femoral artery lesser (but

    important) supply of blood to femoral


    Nutrient artery: This is a branch of profunda

    femoris and supplies the shaft of the bone.


     Capsular {

     In the subcapital fracture the main arterial In the intratrochanteric (pertrochanteric)

    supply is lost to the head this is likely to fracture the main arterial supply to the head

    result in avascular necrosis of the head. is intact.

    Management may be via replacement of the Management may be via internal fixation e.g.

    head (hemiarthroplasty). with a dynamic hip screw.

Fracture Management

Any fracture is, almost by definition a trauma and there are certain protocols to follow:




    When these are done the limb itself can be assessed

     Blood supply is the most important factor to confirm Neural function should be next

    If the fracture is open then the following need to be considered (SATS)

     Immediate washout with sterile Saline

     Antibiotic cover (usually augmentin)

     Tetanus booster ? tetanus immunoglobulin Surgical wound debridement under anaesthesia (reduces infection risk)

There are three principles to fracture management (The 3 R’s)

     Reduction: Via traction

     Retention (or fixation) this is the most effective pain relief in fracture.

     Rehabilitation (intended to preserve function of joints above and below)


    Non-operative management Operative management

    Internal Fixation External Fixation

    Mnemonic: COT Nail (through shaft of long bone) A quick procedure performed in

     damage control orthopaedics for

    Cast / backslab Interlocking nail (a nail fixed by polytrauma. SE include poor (backslab plaster of Paris or screws to limit movement) cosmesis and infection risk.

    fibreglass former is more

    moldable while latter is lighter) Screw (brings bone pieces into Can also be used when increasing

     tight opposition) bone length and correcting

    Orthotics deformity

    (e.g. callipers, knee brace, collar Plate (resists forces of rotation

    & cuff, sling, corset) often used with screw) Fine wire frames

     Half pins

    Traction Pin e.g. K-wire (small bones,

    (Skin if <24 hours and little wt; little weight bearing)

    Skeletal otherwise)

    Nerve Damage upper limb

    Nerve Mechanism Motor Sensory Upper brachial plexus Excessive forceful Erb-duchenne palsy Lateral side of arm

    displacement of head and (waiters tip) Suprascapular N.

    shoulder away from each Subclavius

    other (e.g. from a Limb hangs limp, Axillary

    motorcycle injury) medially rotated with Musculocutaneous forearm pronated. Traction or tearing of

    C5 and C6 roots

    Lower brachial plexus Traction from excessive All small nerves of the Medial side of arm

    abduction of arm (e.g. hand clawed appearance. First thoracic nerve

    clutching at object when

    falling from a height)

    Long thoracic Radical mastectomy Paralysis of serratus

    Blow or pressure to anterior difficulty in

    posterior triangle of neck raising arm above head.

    Winged scapula.

    Axillary Badly adjusted crutch in Impairment of abduction ‘Regimental patch’

    axilla. of arm (now done just by

    Shoulder dislocation. supraspinatus).

    Fractured surgical neck of Muscle wasting and loss

    humerus. of shoulder contour.

    Radial (in axilla) Badly adjusted crutch in Unable to extend elbow

    axilla. joint, wrist joint and

    Falling asleep with arm fingers.

    over back of chair. Wristdrop disabling as

    Fracture or dislocation of it prevents a tight grip

    proximal humerus. with the hand concerned.

    Radial (in spiral groove) Fractured shaft of If beyond branch to Lateral dorsal surface of

    humerus or involved in triceps and anconeus: hand and up to DIP on

    the callus during repair. Unable to extend wrist latera 3.5 digits (dorsal)

    joint and fingers.


    Musculocutaneous Rarely injured as Biceps and Sensory loss on lateral

    protected by biceps. coracobrachialis paralysed side of forearm

    brachialis weakened.

    Flexion preserved via

    brachialis (also supplied

    by radial nerve) and

    forearm flexors.

    Median (at wrist) More common than at Paralysis and wasting of Dorsal aspect lateral 3.5

    elbow due to stab wounds thenar eminence leading digits and lateral half of

    or broken glass. to loss of ability for palmar aspect

    ‘pincer’ movements

    between thumb and

    fingers disabling.

Nerve Mechanism Motor Sensory

    Median (at elbow) Supracondylar fracture Pronators and long flexors Dorsal aspect lateral 3.5

    of forearm (except FCU digits and lateral half of

    and medial FDP). Forearm palmar aspect

    is kept supine and wrist

    flexion is weak and

    accompanied by

    adduction. No flexion at

    IP joints of index and

    middle fingers.

    Paralysis and wasting of

    thenar eminence.

    Ulnar Medial condyle fractures FCU and medial half of medial 1.5 fingers.

     FDP are paralysed.

    Flexion of wrist joint Froment’s sign

    results in abduction.

    Unable to adduct and

    abduct fingers.

    Small muscles of hand

    except LOAF will be

    paralysed unable to

    adduct thumb.

    Claw’ deformity

    Nerve Damage lower limb

Nerve Mechanism Motor Sensory

    Femoral Knife or bullet wound Quadriceps muscle Anterior and medial thigh,

    complete division rare. paralysed cannot extend medial leg, medial foot to

    knee (aided in walking by base of great toe.


    Sciatic Badly placed IM Footdrop due to paralysis All in below knee except

    injections. of all lower leg muscles. as supplied by femoral

    Penetrating wounds Hamstrings paralysed but nerve.

    Fractures of pelvis weak flexion of knee

    Dislocation of hip. possible by sartorius and


    Common peroneal Fracture of neck of fibula Footdrop due to paralysis All in below knee except

    (e.g. car bumper) of muscles in anterior and as supplied by femoral

    Pressure from casts or lateral compartments of nerve.

    splints. leg.

    Tibial Rarely injured deep and Sole of foot trophic Dorsiflexion and

    protected under soleus. eversion of foot from ulcers usually develop.

    paralysis of muscles in

    back of leg and sole of


    Obturator Rare anterior hip disloc. All adductor muscles Minimal on medial side of

    fetal head during birth. except one head add mag. thigh.

    Diseases of Bone

     Osteoporosis Paget’s disease Rickets / osteomalacia Osteogenesis imperfects Definition Low bone mass and enhanced A focal disorder of bone Inadequate mineralisation of Defects in type I collagen

    fragility. remodeling excessive bone matrix (osteoid) resulting in fragile and brittle

    Mineralisation occurs as normal absorption followed by bones

    compensatory abnormal new

    bone formation

    Risk factors Female, increasing age, Genetic (gene on 18q) Vitamin D deficiency or Genetic defects in one of the

    Caucasian or Asian race, resistance Type I collagen genes

    early menopause, small frame,

    lack of exercise, smoking, Deficient diet

    excess alcohol, Poor sun exposure (shift work,

    low calcium intake. dress style, sun block, staying


    Clinical features Fracture is only cause of Mostly asymptomatic. Adults (osteomalacia): vague Fragile and brittle bones

    symptoms. Vertebral crush bone or muscle pain

    fractures may lead to pain, Pathological fractures possibly a ‘waddling’ gait. Type I:

    increasing kyphosis, height Nerve compression: CN II, V, Mild bone deformities

    loss and protuberant abdo. VII and VIII (deafness) Children (rickets) blue sclera

     Bone pain (esp spine / pelvis) Defective dentine

    Colle’s fracture and fractured Joint pain Early-onset deafness

    head of femur more common Hypermobility of joints

    Heart valve disorder Investigations Radiographs for fractures ; Alkaline phosphatase with ; Alkaline phosphatase

    DXA scan for bon density normal calcium and phosph. Serum 25-OH-vit D low 3

     (except in Vit D resistant


    X ray

    Notes Prevention vis: diet, exercise, Rarely may be due to low More severe forms may present

    smoking cessation, and fall phosphate (hypophosphatemic with multiple fractures and

    reduction rickets) gross deformities

    Pathological disorders of Joints

     Osteoarthritis Ankylosing Spondylitis Rheumatoid arthritis Juvenile polyarthritis Presentation Nodular arthritis Pain and back stiffness Bilateral, symmetrical Typically

    Assymetrical polyarthritis temporomandibular +

    Affects DIP Affects spine and cervical spine

    Osteophytes on x-ray sacroileac joints PIP, MCP, wrists Sometimes mirrors RA Prevalence up to 0.2% 1 3% 1/1000 Male : Female 1 : 1 2-10: 1 1: 3-4 1 : 1 Age of onset 40s 50s 15 25 40s 50s Usually below 6 yrs RF present (anti IgG) - - 80% 15% Course Load too much for Genetic susceptibility Genetic susceptibility

    cartilage (load high,

    cartilage weakened or Inflammation, granulation Immunologic reaction

    subarticular bone and bone erosion focused on synovial tissue


     Fibrosis of granulation Inflammatory reaction in

    Progressive cartilage tissue joints and tendon sheaths


    Capsular fibrosis Ossification of fibrous anti IgG produced

     tissue ankylosis

    Perpetuation of Four X-ray signs

    inflammatory reaction Subarticular cyst


    Articular cartilage Sclerosis of surrounding

    destroyed bone (white edges)

    Osteophyte formation

    Reduction in joint space

    Notes Increase in water content 90% HLA-B27 +ve RF is not diagnostic but it This is a rare subtype of

    of cartilage stress on does indicate a worse juvenile chronic arthritis

    collagen network prognosis

    The Shoulder Joint

Stability is provided by:

     The rotator cuff muscles (the most important factor)

     The glenoid labrum

     The joint capsule and tendons

     The long head of biceps

     The long head of triceps (reinforces inferior margin)

Painful arc syndrome:

    Adhesive capulitis (frozen shoulder):

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