1: Orthopaedic trauma Flashcards
1
Q
What is compartment syndrome
A
Increase in pressure in a muscle fascial compartment leading to impaired tissue perfusion
2
Q
What is the main cause of compartment syndrome
A
Fracture (75%)
3
Q
What two fractures is compartment syndrome most commonly seen in
A
- Tibial diaphysis
- Distal radius diaphysis
4
Q
What else can cause compartment syndrome
A
- Compression of the limb for several hours
- Rhabdomyolysis
- Burns
- Iatrogenic
5
Q
What may lead to continuous pressure on a limb
A
Crush Injury
Lying on limb for several hours (elderly/ drug abuse)
6
Q
What may iatrogenically cause compartment syndrome
A
Too tight plaster cast. Hence why circumferential cases are not used in the first 2W
7
Q
How will compartment syndrome present
A
- Pain disproportionate to injury (physical symptoms)
- Worse on passive stretching
- Not relieved by analgesia, elevation
- Compartment may feel full/tight
8
Q
If compartment syndrome is missed how may it present
A
As an acute ischaemic limb
9
Q
Explain the pathophysiology of compartment syndrome
A
- There is a build up of pressure in a muscle compartment (contained by fascia)
- This causes compression of veins, increasing flow of blood into interstitium causing further build-up of pressure
- This pressure then compresses nerves causing symptoms in sensory/motor distribution
- As pressure in the interstitum equals diastolic BP, it stops arterial blood flow into the compartment causing ischaemia
10
Q
How should the diagnosis of compartment syndrome should be made
A
Clinically
11
Q
If clinical uncertainty what may be used to identify compartment syndrome
A
Intra-compartmental pressure monitor
12
Q
What should be done in initial management of compartment syndrome
A
- Keep leg in neutral position
- High-flow oxygen
- IV crystalloid to maintain BP
- Analgesia
- Remove dressings
13
Q
What should be done to manage compartment syndrome
A
Urgent fasciotomy
14
Q
Explain wound care following urgent fasciotomy
A
Wound is left open for 48-72h. Any devitalised tissue is debrided. Wound is then closed
15
Q
Why may renal function be monitored in compartment syndrome
A
Due to risk of renal damage from reperfusion injury or rhabdomyolysis
16
Q
What are 4 complications of compartment syndrome
A
- Ischaemia
- Volkmann contracture
- Gangrene
- Rhabdomyolysis and renal failure
17
Q
What is volkmann contracture
A
- Permanent shortening of the fore-arm muscles due to ischaemic injury
- Presents with claw-like hand
18
Q
What fracture are Volkmann contractures most associated with
A
Supracondylar humeral fractures
19
Q
What is septic arthritis
A
Infection of a joint
20
Q
What is the most common cause of septic arthritis in healthy adults
A
S. aureus
21
Q
What is the most common cause of septic arthritis in sickle cell disease
A
Salmonella
22
Q
What is the most common cause of septic arthritis in sexually active young adults
A
N. Gonorrhoea
23
Q
What are 6 risk factors for septic arthritis
A
- Cellulitus
- Diabetes
- Immunosupressed
- > 80y
- pre-existing joint disease
- prosthesis
- IVDU
- chronic renal failure
24
Q
How will septic arthritis appear clinically
A
- painful, erythematous swollen joint
- unable to weight bare
- pyrexial (60%)
25
What are two signs of septic arthritis
- swollen, erythematous, warm joint
| - painful on active and passive movement
26
Explain the pathophysiology of septic arthritis
Septic arthritis comes from bacteraemia which may be due to UTI, chest infection, cellulitis. The joint can be infected by direct inoculation or spreading from osteomyelitis
27
What can septic arthritis lead to
Irreversible cartilage damage causing OA
28
What investigations should be ordered in septic arthritis
- FBC (WCC)
- CRP + ESR
- Joint aspiration
- Blood cultures on two separate occasions
29
How should septic arthritis be managed
- If septic initiate sepsis 6 protocol
- Flucloxacillin for 4-6W. First 2W should be IV then switch to PO
- Native joints require irrigation and debridement
- Prosthetic joint = require wash out in theatre and revision of surgery
30
What are 2 complications of septic arthritis
- OA
| - Osteomyelitis
31
Define an open fracture
communication between fracture site and external environment
32
When should an open fracture be suspected
any limb where there is a wound in the same region as the fracture
33
Describe clinical presentation of open fracture
- painful
| - fracture with overlying wound punctum
34
What should be checked for all open fractures
Neurovascular status
35
What scoring system is used to evaluate open fractures
Gustilo-Anderson
36
What is Gustilo-Anderson 1 fracture
Laceration <1cm and clean. Low energy trauma,
37
What is Gustilo-Anderson 2 fracture
Laceration 1-10cm and clean wound. Low energy trauma
38
What is Gustilo-Anderson 3a fracture
Laceration >10cm
Adequate soft tissue coverage
Any high energy trauma
39
What is Gustilo-Anderson 3b fracture
Laceration >10cm
Inadequate soft tissue coverage
High energy trauma
40
What is Gustilo-Anderson 3c fracture
Any neuromuscular compromise
41
What teams are involved in
a. 3a fractures
b. 3b fractures
c. 3c fractures
a. orthopaedics
b. + plastic surgery
c. + vascular surgery
42
In 3c fractures what is used to predict the need for primary amputation
Mangled extremity scoring system (MESS)
43
What are 4 outcomes of open fractures
- Infection
- Soft tissue damage
- Wound (skin) damage
- Neurovascular compromise
44
What bloods may be performed in open fracture
FBC
Group + Save
Coagulation studies
45
What imaging may be performed in an open fracture
X-Ray
46
Explain 6 steps in the management of open fractures
1. Stabilise the patient (life > limb)
2. Reduce and splint
3. IV Antibiotics
4. Tetanus prophylaxis
5. Wound photography
6. Irrigation + debridement
47
What should be checked and documented before reduction and splinting of the limb
Neurovascular status
48
If an individual has not recently had their tetanus prophylaxis and has a very contaminated wound, what is given
IVIg
49
What should be done prior to debridement
Photograph the wound
50
What is debridement
Removal of devitalised tissue
51
When should debridement be performed
- If evidence of contamination with sewage, marine or agricultural immediately
- If not evidence of this in <24h
52
When should soft tissue coverage of the wound be considered
contact plastics within 72h
53
If there is vascular compromise due to the open fracture what should be done
immediately contact vascular surgeons for surgical exploration
54
What is caudal equina
compression of the cauda equina
55
What are the 3 groups of caudal equina
1. Cauda equina syndrome with retention (CESR)
2. Cauda equina syndrome incomplete (CESI)
3. Cauda equina syndrome suspected (CESS)
56
What is the most severe form of caudal equina
Cauda equina with retention (CESR)
57
How will caudal equina with retention present
- Back pain
- Bilateral sciatica
- Bilateral Loss of sensation and weakness in legs
- Saddle anaesthesia
- Loss of anal tone
- Urinary retention, or incontinence
58
How will cauda equina syndrome incomplete present
Same as above, but with altered urinary sensation
59
What are 4 indicators of altered urinary sensation
- Loss of desire to void
- Poor stream
- Loss of satisfaction
- Need to strain
60
What is caudal equina suspected
- Severe back pain
| - Possible neurological signs
61
what is peak incidence of caudal equina
40-50y
62
what can cause caudal equina syndrome
1. Disc herniation
2. Trauma: fracture, spondylolisthesis
3. Neoplasm (1' or 2')
4. Infection: Pott's disease, disci tis
5. Ankylosing spondylitis
6. Haematoma secondary to spinal anaesthesia
63
What are 5 cancers than spread to the vertebrae
```
Breast
Lung
Thyroid
Kidney
Prostate
```
64
Will cauda equina cause UMN or LMN signs and symptoms and why
LMN. As the cauda equina is made of LMN (which have left the cord)
65
What are the symptoms of cauda equina
- Bilateral sciatica
- Back pain
- Saddle anaesthesia
- Faecal/Urinary incontinence
- Impotence
66
what are 5 signs of caudal equina syndrome
- Saddle anasthesia
- Lower limb anaesthesia
- Hyporeflexia
- Loss of anal tone
- Bladder distention
67
Where does the spinal cord terminate
L1/L2
68
What level is the caudal equina
L1-S5
69
What does the cauda equina contain
LMN that control:
- motor + sensory innervation to lower limbs
- parasympathetic supply to the bladder
- motor innervation to anal sphincter
70
What is gold-standard for cauda equina
MRI
71
What are 2 other investigations for caudal equina
post-void bladder scan
| rectal exam
72
How is caudal equina syndrome managed
- Urgent neurosurgical review (for surgical decompression)
| - High dose corticosteroids
73
How are fractured neck of femurs classified
Depending on position of the fracture line relative to the joint capsule
74
What are the two groups of hip fractures
- Intracapsular
| - Extracapsular
75
What are the two types of intra-capsular fractures
- Subcapital
| - Basocervical
76
What is a sub capital fracture
fracture through head and neck
77
What is a basocervical fracture
fracture below femoral neck
78
What are the two types of extra-capsular fractures
1. inter-trochanteric
| 2. subtrochanteric
79
What is a sub-trochanteric fracture
fracture <5cm distal to greater trochanter
80
What is an inter-trochanteric fracture
fracture between lesser and greater trochanter
81
What is the classification system used for intracapsular NOF fractures
Garden system
82
What is garden classification 1
Stable fracture with impaction in valgus
83
What is garden classification 2
Complete fracture with no displacement
84
What is garden classification 3
Complete fracture with displacement (angulation/rotation) but still with contact
85
what is garden classification 4
Complete bony disruption
86
which population are NOF's common
Elderly
87
What is the aetiology of NOFs
- Low energy trauma (elderly)
| - High energy trauma
88
In which population do low energy injuries cause NOFs
Elderly
89
How will a NOF present
- Severe pain
- Unable to weight bare
- Shortened and externally rotated leg
90
What blood vessel supplies the neck of femur
Medial femoral circumflex artery
91
Where does the medial femoral circumflex artery arise from
deep femoral artery
92
Why is the medial femoral circumflex artery vulnerable in NOF fractures
as it runs over the neck of femur
93
what is first-line investigation of a NOF fracture
Lateral and AP x-rays of the pelvic
94
what bloods may be ordered
- FBC
- U+E
- Coagulation screen
- G+S
- CK
95
why may creatinine kinase be ordered
if the patient has been on the floor for an extended period of time their is risk of rhabdomyolysis
96
what other investigations are typically ordered in complete pre-operative assessment of an elderly patient
CXR
Urinalysis
ECG
97
Describe management of hip fracture
1. ATLS
2. Sufficient analgesia
3. Surgical management
98
Which is more serious an intra capsular or extra capsular fracture and why
Intra-capsular fracture as there is a risk of disruption to the
99
How is a displaced intra-capsular fracture in someone <70y managed
Internal fixation
100
How is a displaced intra-capsular fracture in mobile >70y managed
Total hip arthroplasty
101
How is a displaced intra-capsular fracture managed if someone was immobile prior to or has other severe co-morbidities
Hemiarthroplasty
102
How is an undisplaced intra-capsular fracture managed in young patients with no-comorbidities
Internal fixation
103
How is an undisplaced intracapsular fracture managed in someone with co-morbidities including advanced organ specific disease
Hemiarthroplasty
104
How is an extra capsular fracture managed
Dynamic hip screw
105
How is a extra-capsular fracture managed if reverse, oblique, transverse or sub-trochanteric
Intramedullary Nail
106
What is used to manage a subtrochanteric fracture
Intramedullary Nail
107
What is a intramedullary femoral nail
A metal rod that is inserted in the medullary cavity of the femur
108
Who manages NOF in elderly patients
Orthogeriatricians
109
What is % mortality of hip fractures
30%
110
What is a pubic rams fracture
type A pelvic ring fracture
111
What can cause pubic rami fractures
- High energy blunt trauma
| - Low energy falls from standing
112
What are investigations of pubic rami fractures
- AP pelvic x-ray
| - CT
113
How are pubic rami fractures managed
ATLS
| Surgically
114
What is a main complication of pubic rami fractures
Intraperitoneal or retroperitoneal blood loss
115
In which gender are ACL tears more common
Female
116
When do ACL injuries tend to occur
During landing a jump or direct contact
117
How will ACL injury present
Rapid swelling and pain
118
Why do ACL injuries present with rapid swelling
ACL is highly vascularised and therefore results in haemoarthroses
119
What are two signs of ACL injury
Positive Lachman test
| Positive anterior draw test
120
What is the most sensitive test for ACL injury
Lachman test
121
What is the role of ACL
It prevents anterior translation of the tibia relative to the femur
122
What mechanism of injury results in the unhappy triad
Lateral blow to the knee
123
What injuries occur in the unhappy triad
ACL Tear
MCL Tear
Medial meniscus tear
124
How are ACL tears initially investigated
AP and lateral x-ray to look for bony injuries as a cause of joint effusion
125
What is gold-standard imaging for ACL injury
MRI
126
What is first line management for ACL tears
```
(POLICE)
Protection
Optimal Loading
Ice
Compression
Elevation
```
127
What are the two ways to manage ACL tears
1. Conservative - involves rehabilitation to strengthen the quadriceps and canvas knee splint
2. Surgical = arthroscopic surgery that reconstructs the ACL from tendon or artificial graft
128
What is a complication of ACL tear
secondary OA
129
In which gender are patella fractures more common
Male
130
What is the peak incidence of patella fractures
20-50y
131
What causes patella fractures
Direct trauma to the patella (eg. RTA)
132
How do patella fractures present
- Palpable defect
| - Unable to perform straight leg raises
133
Why may an individual with patella fractures not be able to perform straight leg raises
Due to weakness in knee extensors
134
What is first-line investigation for patella fractures
AP and Lateral view X-ray
135
What are the two management strategies for a patella fracture
1. Conservative
| 2. Surgical
136
What are the indications for conservative management of patella fractures
- Individual can perform straight leg raises
| - Articular step is <2mm
137
What is conservative management of patella fractures
Brace for 4-6W
138
What are the indications for surgical management of patella fractures
K-wires for cerclage
139
What is surgical management for patella fractures
Unable to perform straight leg raises. Or, articular step >2mm
140
How can ankle fractures be classified anatomically
- isolated medial malleolus
- isolated lateral malleolus
- bimalleolar
- trimalleolar
141
What classification system is used for lateral malleolus fractures
Weber's
142
What is weber's classification used for
Fractures of the lateral malleolus
143
What is a weber's A fracture
Below syndesmosis
144
What is a weber's B fracture
Level of syndesmosis
145
What is a weber's C fracture
Above syndesmosis
146
Dave presents with a fracture at the level of the syndesmosis, what Weber grade are they
Weber B
147
Tim presents with a fracture above the syndesmosis, what Weber grade are they
Weber C
148
Mike presents with a fracture below the syndesmosis, what Weber grade are they
Weber A
149
What is a maisonneurve fracture
Spiral fracture of the fibula that extends to the syndesmosis widening the ankle joint
150
in which gender do ankle fractures occur more
Young males or Overweight middle-aged females
151
how will ankle fractures present
Diffuse ankle pain
Unable to weight bare
Tenderness @ site of injury
152
what is a syndesmosis
fibrous joint between bones held together by ligaments
153
what is the main differential for an ankle fracture
ankle sprain
154
where is the syndesmosis between in the ankle
between tibia and fibula
155
what rules are used to determine if someone should receive an x-ray following ankle trauma
Ottawa Ankle Rules
156
why were the ottawa rules developed
To reduce unnecessary imaging
157
what do the ottawa rules state
That if an individual has pain over the malleolar region and one of the following they should receive an x-ray:
1. Unable to walk 4-steps
2. Pain on palpation of posterior edge or tip of medial malleolus
3. Pain on palpation of posterior edge or tip of lateral malleolus
158
what investigation is performed if ankle fracture is suspected
AP and Lateral X-Ray
159
what is first line management of suspected ankle fracture
Reduce the fracture under analgesia
160
why are ankle fractures promptly reduced
To prevent overlying skin necrosis
161
what is then put on following reduction of the ankle fracture
Below-knee back slab cast
162
what should be done prior to putting on a below the knee back-slab cast
1. Check Neurovascular status
| 2. X-ray post reduction
163
what are the two management strategies for ankle fracture
Conservative
| Surgical
164
when is conservative management for ankle fracture indicated
- Elderly patients
| - Weber A or B fractures with no talar displacement
165
why do elderly patients undergo conservative management of ankle fractures
As their bones are weaker and do not hold compression plates well
166
when is surgical management for ankle fractures indicated
- Young patients
- Webers B or C
- Open fracture
167
what is surgical management of ankle fracture
Compression plate
168
what is a long-term complication of ankle OA
Secondary OA
169
what is a stress fracture
cracks in the bone caused by repetitive use that are insufficient to cause a fracture themselves
170
what is a stress fracture also referred to as
hairline fractures
171
what causes metatarsal stress fractures commonly
sudden increase in marching or running
172
explain how metatarsal stress fractures will present clinically
- gradual onset of dull foot pain which worsens on weight-bearing/use
- tender to palpation
173
how are stress fractures diagnosed
clinically
174
why is an x-ray not used to diagnose stress fractures immediately
as stress fractures do not immediately show on x-ray. They only tend to show once they start to heal
175
What is management of stress fractures
Conservative:
- Rest
- Orthoses
176
What is the lisfranc joint
Second metatarsal
177
What is a lisfranc fracture
Fracture/dislocaiton between second metatarsal and medial cuneiform
178
What can cause Lisfranc injuries
- RTA
- Fall from height
- Fall off the kerb
179
How will a lisfranc fracture present clinically
- Severe pain
- Inability to weight bear
- Bruising over medial bottom of the foot
- Collapsed foot arches
180
What is characteristic of lisfranc injury
bruising over medial plantar aspect
181
Where is the lisfranc ligament and what is its function
ligament that connects the second metatarsal and medial cuneiform. It maintains integrity of midfoot arch
182
How will a Lisfranc fracture present on x-ray
Widening between second meta-tarsal and medial cuneiform
183
What are the two management strategies for lisfranc injury
1. Conservative
| 2. Surgical
184
How are lisfranc fractures managed conservatively
Cast for 8W
185
How are lisfranc fractures managed surgically
ORIF
186
What is a complication of lisfranc fractures
Compartment syndrome of the medial foot
187
In which gender are achilles tendon ruptures more common
male
188
What is the peak incidence of achilles tendon ruptures
30-50y
189
What can cause Achille's tendon rupture
- Trauma during athletic sports
| - Achilles tendonitis
190
what are two risk factors for achilles tendon rupture
Fluroquinolones
| Glucocorticoids
191
how will achilles tendon rupture present
- Sudden 'snap/pop' at the time of injury
| - Sudden-onset severe pain at the achilles
192
what test will be negative in achilles tendon rupture
Simmond's test
193
what is the achilles tendon
It is a tendon formed from the convergence of the gastrocnemius and soleus
194
where is rupture of the achilles tendon most common and why
5cm from the calcaneus - as this is a vascular watershed area
195
how is achilles tendon rupture diagnosed
clinically
196
what may US be used for
identify swelling
197
what may MRI show
differentiate between partial and complete tear
198
what are two management strategies for achilles tendon rupture
1. Conservative
| 2. Surgical
199
when is conservative management of achilles tendon rupture indicated
- Older patients
- Unfit for surgery
- Relatively inactive
200
what is conservative management of achilles tendon rupture
Analgesia
Gravity equinus cast
4W rest
Rehabilitation
201
what are the indications for surgical repair of the achilles tendon
- Young, active patients
- Complete tear
- Delayed healing with conservative measures
202
What are the 3 directions the shoulder may dislocated
1. Anterior
2. Inferior
3. Posterior
203
What is the most common type of shoulder dislocation
Anterior (95%)
204
What % of shoulder dislocations are
a. anterior
b. inferior
c. posterior
a. 95%
b. 1%
c. 4%
205
what joint is most common to dislocate and why
shoulder (gleno-humeral) as the humeral head is too large for the glenoid fossa
206
in which age group are shoulders most likely to dislocated
20-50y
207
what gender has the highest incidence of shoulder dislocations
Male
208
what causes anterior shoulder dislocations
trauma: extension and lateral rotation
209
what typically causes posterior shoulder dislocations
un co-ordinated muscle contractions
210
give 3 possible causes of posterior dislocations
1. Epilepsy
2. Electric shocks
3. Lightening attacks
211
what is a risk factor for anterior shoulder dislocation
- Lax joint capsule
| - Rotator cuff tear
212
how will a shoulder dislocation present clinically overall
- Sudden onset shoulder pain
- Inability to move shoulder
- Unable to palpate humeral head in glenoid fossa
213
where will the humeral head be felt in anterior shoulder dislocation
BELOW the coracoid process
214
how will the arm present in anterior shoulder dislocation
it will be abducted and externally rotated
215
how will the shoulder look in posterior dislocation
flattening of the anterior shoulder with prominent posterior shoulder
216
what is a good mnemonic to remember how the arm will looks in posterior shoulder dislocation
PADI
217
how will the arm look in posterior shoulder dislocation
Posterior
ADducted
Internally rotated
218
what nerve is there a risk of damage in anterior dislocations
Axillary.N
219
how will damage to the axillary nerve present
Parasthesia over the lateral arm and inability to abduct the arm due to loss of motor control to the deltoid
220
Why is there a high incidence of shoulder dislocations
as the humeral head is too large for the shallow glenoid fossa
221
How are dislocations at the shoulder joint described
the glenohumeral joint is described in relation to the glenoid fossa
222
Why do superior dislocations at the shoulder not occur
due to obstruction by the coraco-arcomio arch
223
What movement causes anterior shoulder dislocations and why
extension and lateral rotation. as this forces the humeral head anteriorly and inferiorly - which is the weakest part of the joint capsule.
224
What lesions may be seen in anterior shoulder dislocations
Bankart and Hill-Sachs lesions
225
What is a hill Sachs lesion
compression fracture of postero-lateral humeral head against anteroinfeiror glenoid fossa seen in anterior dislocations
226
What is a bankart lesion
detachment of anterior-inferior labrum with or without an avulsion fracture
227
Where does the axillary nerve run and what does this mean for shoulder dislocations
around surgical neck of the humerus - therefore at risk of injury during dislocations and relocations.
228
what is used to diagnose shoulder dislocation
lateral and AP x-ray of the shoulder
229
what sign may be seen on x-ray in posterior dislocations
Lightbulb sign
230
what is the lightbulb sign
On dislocation of the humerus it internally rotates causing the head to project from the glenoid fossa and look like a lightbulb anterior
231
what % of anterior shoulder dislocations have hill Sachs lesions
40%
232
what is a hill Sachs lesion
fracture of the postero-lateral humeral head
233
what is a bankart lesion
avulsion fracture of the anterior-inferior glenoid labrum
234
what other imaging modality may be used and why
MRI
235
what are the two management approaches of shoulder dislocation
1. Conservative
| 2. Surgical
236
what are 3 indications for closed reduction of shoulder dislocation
1. Anterior or inferior dislocation
2. No fracture
3. Posterior shoulder dislocation <6W ago
237
what should be done after reduction and why
X-ray: to confirm position
| Check neuromuscular status
238
what are 3 indications for surgical management of dislocations
1. Unsuccessful closed reduction
2. Concomitant fracture
3. Recurrent dislocation
239
what is a major problem with shoulder dislocations
once the joint capsule is damaged there is a higher risk of re-dislocation
240
what are 3 complications of shoulder dislocation
1. Axillary nerve damage
2. Brachial plexus damage
3. Axillary artery/vein damage
4. Rotator cuff tear
241
how will axillary nerve damage present
Parasthesia over lateral shoulder and inability to abduct arm to 30'
242
What is acromio-clavicular joint separation
Injury to acromio-clavicula joint with disruption of acromio-clavicular ligaments with or without disruption of coracoacromio ligaments
243
What causes AC joint separation
Direct trauma to the AC joint
244
How does AC joint separation present
Severe pain over the AC joint which may refer to the trapezius
245
What is used to investigate AC joint separation
Lateral and AP x-ray
246
What does management of AC joint separation depend on
The degree of displacement
247
If separation is <200% what should be done
Sling for 1W
248
if separation >200% what should be done
surgery: excise distal 1/3 clavicle and reconstruct ligaments
249
What system is used to classify clavicular fractures
Allman
250
What does the Allman classification system grade clavicle fractures based on
Location of the fracture along the clavicle - where the clavicle is divided into 1/3s
251
What is type I Allman fracture
Fracture in the middle 1/3 of the clavicle
252
What % of fractures are Allman Class 1 and why
75%. As the middle 1/3 of the clavicle is the weakest point
253
Are class I fractures stable or unstable
Stable but often significant deformity is present
254
What are class 2 Allman fractures
Fracture of lateral 1/3 of the clavicle
255
What % of clavicular fractures are class 2
20%
256
are class 2 fractures stable or unstable
unstable
257
what are class 3 allman fractures
fracture in middle 1/3 of the clavicle
258
what causes class 3 Allan fractures
often associated poly trauma
259
why are class 3 fractures often associated with polytrauma
as mediastinum lies behind the medial 1/3 of the clavicle predisposing to pneumothorax and haemothorax
260
Tim fractures medial 1/3 of the clavicle, what Allman class is this
Class 3
261
Dave fractures middle 1/3 of the clavicle what Allman class is this
Class 1
262
Josie fractures the lateral 1/3 of her clavicle, what Allman class is this
Class 2
263
When is the peak incidence of clavicle fractures
Bi-peak:
- Adolescents
- >60y
264
Why doe clavicle fractures happen in over 60y
Due to weakened bone
265
What are the two etiological mechanisms causing clavicle fractures
- Direct Injury
| - Indirect injury
266
what is direct injury
Trauma to the clavicle
267
what is indirect injury
Fall onto the shoulder
268
how will a clavicle fracture present
- Pain over the clavicle
| - Worse on moving the arm
269
what should be examined for in clavicle fractures and why
- Neuromuscular injury: due to risk of damaging brachial plexus
- Open wounds as the clavicle is subcutaneous and therefore is a risk of open fractures
270
how will medial fragment in clavicle fracture present and why
pull upwards due to action of the SCM
271
how is a suspected clavicle fracture investigated
AP and modified oblique x-ray
272
what are the indications for CT scanning of clavicle fractures and why
Allman 3 fracture - due to unable to visualise on x-ray
273
What is mainstay treatment of clavicle fractures
Conservative
274
What are indications for surgical management of clavicle fractures
- Open fracture
- Comminuted
- Does not heal with conservative management alone
- >100% displacement
275
What surgery is performed for clavicle fractures
ORIF
276
What is the average healing time for clavicular fractures
4-6W
277
What is a complication of Allman 2 fractures
- Brachial plexus injury
| - Non-union
278
What is a complication of Allman 3 fractures
- Haemothorax
| - Pneumothorax
279
What is bicep tendon rupture
Injuries to the bicep causing complete or partial rupture of the tendon
280
What are the two types of bicep tear
1. Proximal biceps tear
| 2. Distal biceps tear
281
What is a proximal biceps tear
Rupture at the origin of the long head of biceps brachii
282
What % of biceps tears are proximal
95%
283
What are distal bicep tears
Tear at the insertion point of the biceps brachii
284
What % of biceps tears are distal
5%
285
What is the most common type of biceps tendon rupture
Proximal biceps tendon rupture
286
What may cause proximal biceps tendon rupture
Minimal trauma in presence of underlying disease
287
What are 5 risk factors for proximal biceps tear
- Elderly
- Smoking
- Glucocorticoids
- Pre-existing shoulder disease
- Over-head activities
288
What causes distal biceps tear
Excessive eccentric loading of the biceps
289
How will a proximal biceps tear present
- Painless
- No loss of function
- May be palpable tenderness in intertubercular sulcus
- Popeye sign
290
What is popeye sign
Distal displacement of biceps belly on contraction
291
how will distal biceps tear present
- Sudden onset acute stabbing pain
- Painful pop followed by weakness
- Haematoma in middle region
- Limited flexion and supination
292
what movements does a distal biceps tear limit
Flexion and supination
293
what test is used to look for distal biceps tear
Hook's test
294
what is the difference between clinical presentation of proximal and distal biceps muscles
```
Distal = painful, LOF
Proximal = painless, no LOF
```
295
explain anatomy of biceps brachii
Biceps brachii has two heads. Long head attaches to supraglenoid tubercle of the scapula. Short head attaches to the coracoid process. Both then insert onto the radial tuberosity via bicipital aponeurosis
296
how are biceps brachii tears diagnosed
- Clinically
| - MRI may be used to distinguish complete and partial tears
297
how are proximal tears in biceps brachii managed
Conservative or surgically if highly active patient
298
how are distal tears in biceps brachial managed
Surgical re-fixation
299
when is surgical re-fixation of distal biceps brachii tears repaired
2-3W
300
What is the age-distribution of olecranon fractures
young (high-energy) and old (low-energy)
301
What may cause olecranon fractures
- direct trauma
| - fall onto outstretched hand
302
How will olecranon fractures present clinically
- elbow pain
| - unable to extend the arm
303
What is a sign associated with olecranon fractures
- pain on palpating posterior elbow
304
What should be checked in olecranon fractures
- Neurovascular status
| - For other injuries (as FOOSH can cause wrist fractures)
305
What type of fracture is an olecranon fracture
Intra-articular
306
What muscle inserts on olecranon
Triceps
307
Why do olecranon fractures happen on falling onto an outstretched hand
FOOSH - causes sudden pull on the triceps may lead to fracture
308
What imaging modality is used to investigate olecranon fractures
Lateral and AP x-rays
309
What does the management of olecranon fractures depend on
Degree of displacement
310
If displacement is less than 2mm, how should the olecranon fracture be managed
Conservative
311
What is non-operative management of olecranon fractures
Immobilise at 60-90 degrees of flexion for 1-2W then start to move
312
Which population is non-operative management of olecranon fractures increasingly used for
>75y, regardless of displacement
313
What is the criteria for operative management of olecranon fractures
>2mm displacement
314
When is tension band wiring used to repair olecranon fractures
if olecranon fractures are proximal to the coronoid process
315
When is olecranon plating used to repair olecranon fractures
If olecranon fractures are distal to the coronoid process
316
If there is an olecranon fracture distal to the coronoid process what should be used to repair it
Olecranon plating
317
If the is an olecranon fracture proximal to the coronoid process what should be used to repair it
Tension band wiring
318
Why is metal work typically removed later in olecranon fractures
Due to superficial nature of the injury
319
What is the most common fracture at the elbow
radial head fracture
320
What mechanism of injury causes a radial head fracture
fall onto outstretched hand - with the arm extended and pronated
321
How will radial head fracture present
- pain in elbow following FOOSH
| - bruising and swelling of the elbow
322
What are two signs of radial head fracture
- tenderness on palpation over posterior elbow
| - crepitus on supination and pronation
323
What is an Essex-Lopresti Fracture
fracture of the radial head with dislocation at the distal radio-ulna joint
324
Explain how radial head fractures occur
radial head is pushed against the capitulum of the humerus when there is axial loading of the fore-arum particularly when the arm is extended and pronated
325
How are radial head fractures investigated
lateral and AP x-ray
326
What sign may be seen in radial head fractures on x-ray
Sail sign
327
What is sail sign
Elevation of anterior fat pad (appears as a sail) due to elbow effusion
328
What system is used to classify radial head fractures
Mason system
329
What is type I Mason fracture
There is no or <2mm displacement
330
What is a type II Mason fracture
Partial articular fracture with >2mm displacement
331
What is a type 3 Mason fracture
Comminuted fracture
332
How is a type 1 Mason fracture repaired
Conservative management. 1W sling and early mobilisation.
333
How is type 2 Mason fracture treated
Depends on mechanical blockage: either treated via ORIF or conservatively.
334
How is type 3 mason fracture managed
ORIF
335
What is a complication of radial head fractures
Secondary OA
336
How can elbow dislocations be divided
simple + complex
337
What is a
a. simple
b. complicated
elbow fracture
a. no associated fracture
| b. associated fracture
338
what is the main mechanism of injury of elbow dislocations
fall onto outstretched hand
339
what type of dislocations are the majority of elbow dislocations
posterior dislocations
340
what % of elbow dislocations are posterior
90%
341
in which age group do elbow dislocations not tend to occur
Children - if child presents with elbow pain suspect supracondylar fracture
342
how will elbow dislocations present
- Painful and deformed joint
- Swollen
- Loss of function
343
what is the terrible triad
Elbow dislocation with:
- LCL injury
- Radial head fracture
- Coronoid process fracture
344
what causes the terrible triad
Fall onto outstretched hand with rotational force causing a posterior-lateral dislocation
345
what is the problem with terrible triad
Leads to a very unstable elbow and person is likely to have recurrence
346
how are elbow dislocations diagnosed
AP and lateral x-rays
347
how is elbow dislocation managed
closed reduction with sufficient analgesia
348
if there is an elbow dislocation and fracture how should it be managed
ORIF
349
What are 5 fractures affecting the radius
```
Colle's
Smith's
Barton's
Galeazzei's
Monteggia's
```
350
What is a Colle's fracture
Fracture of the distal radius with dorsal displacement and angulation of the fragments
351
When does a colle's fracture commonly occur
FOOSH
352
What is a smith's fracture
Fracture of distal radius with dollar angulation of the distal fragment
353
what cause's a smith's fracture
falling backwards onto outstretched hand or falling onto flexed wrists
354
What is a Barton's fracture
fracture of radius with associated dislocation of the radio-carpal joint
355
What causes a Barton's fracture
Fall onto extended and pronated wrist
356
What is Monteggia's fracture
fracture of ulna with dislocation of proximal radio-ulna joint
357
What is Galeazzi's fracture
fracture of ulna with dislocation of distal radio-ulna joint
358
What is the most common wrist fracture
Colle's (90%)
359
Which age group does colle's fracture tend to occur
Children (5-15) and Elderly People
360
What is a major risk factor for colle's fracture
Osteoporosis
361
How will colle's fracture present
Pain in the wrist following trauma
362
What investigation is used to look for radial fractures
X-ray
363
How are radius fractures managed
1. Closed reduction under conscious sedation with Bier's block. Then backstab case
364
When is surgery required for radial fractures
Unstable fracture or signficantly displaced
365
What are 2 complications of radial fractures
Mal-union: can lead to shorted radius compared to ulna causing pain and LOF
366
In which gender are scaphoid fractures more common
Male
367
What causes scaphoid fractures
High-energy trauma
368
How do scaphoid fractures present clinically
Sudden-onset pain in the wrist with bruising
369
What sign indicates scaphoid fracture
Pain on palpating the anatomical snuffbox
370
How does the scaphoid received its blood supply
From dorsal brach of the radial nerve
371
Explain why scaphoid fractures are serious
dorsal branch of the radial nerve passes form the proximal pole of the of the scaphoid to the distal pole. This means if blood supply is disrupted at the proximal pole (due to fracture) there is de-nervation of distal pole and can lead to avascular necrosis
372
What is first line investigation for scaphoid fracture
x-ray (order scaphoid series)
373
What is a scaphoid series of x-ray
Lateral
AP
Oblique
374
What is the problem with scaphoid fractures on x-ray
Scaphoid fractures are NOT always visible on x-ray immediately
375
If a high suspicion of scaphoid fracture, but x-ray is negative, what should you do
Immobilise the first an repeat the x-ray in 10-14d
376
when may an MRI wrist be ordered for scaphoid fracture
If very high clinical suspicion of scaphoid fracture, but both x-rays have returned negative
377
what does management of scaphoid fracture depend on
degree of displacement
378
is scaphoid fracture is displaced, how is it managed
percutaneous variable pitched screws
379
if not displaced how is scaphoid fractures managed
strict immobilisation with thumb sica splint
380
when may an undisplaced scaphoid fracture go through surgical treatment and why
if proximal pole fracture due to high risk of AVN
381
what is the main risk with scaphoid fracture
avascular necrosis
382
what increases the risk of scaphoid fractures
more proximal
383
why do scaphoid fractures have a higher risk of non-union
due to poor blood supply
384
What tendon is affected in Jersey Finger
Flexor digitorum profundus
385
What is the mechanism of injury for FDP injury
forced extension of finger at the DIPs or damage to FDP at it s insertion on the ulna
386
How will FDP injury present
- swelling of the DIPS
| - inability to flex the DIPS
387
What finger is most commonly affected in 'jersey finger'
- ring (4th) finger
388
what is used to repair jersey finger
Kessler's technique for surgical repair
389
where does FDS insert
MCP and PIPs
390
what will FDS injury cause
inability to flex at PIPs
391
what causes mallet finger
damage to extensor digitorum tendon
392
how will mallet finger present
inability to extend at the DIPs
393
where does FDP originate
ulna surface
394
where does FDP tendon pass through
carpal tunnel
395
what is the action of the FDP
it is the only muscle to cause flexion and the DIPS
Dips - fDp
396
where does FDS originate
It has two heads - one originates from the medial epicondyle and other from the ulna
397
what is the action of FDS
causes flexion at the PIPs and MCPs
398
what is traumatic spinal cord injury
traumatic injury that results in spinal cord damage resulting in a permanent or temporary change to neurological function, including paralysis
399
how can traumatic spinal cord injury be divided
incomplete and complete
400
what is complete traumatic spinal cord injury
injury across the entire width of the spinal cord resulting in both loss of sensation + paralysis
401
what is incomplete spinal cord injury
injury across part of the spinal cord, leading to partial loss of sensation or movement below the level of injury
402
what system is used to classify spinal injuries
AO Spine Injury Classification
403
What causes traumatic spinal cord injury
Falls (40%)
RTA (35%)
Sports Injuries (12%)
404
what can be used to classify the degree of injury to the spinal cord
American Spinal Injury Association classification
405
What is ASIA A
Complete: transection across the entire width of the spinal cord causing loss of sensory and motor function
406
What is ASIA B called
Sensory incomplete
407
What does ASIA B entail
Motor function is not preserved below the level. Sensory function is preserved
408
What is ASIA C called
Motor Incomplete
409
What does ASIA C entail
Motor function is preserved. More than half of muscles have MRC grade <3
410
What is ASIA D
Motor incomplete
411
What dose ASIA D entail
Motor function is preserved. At least half of muscles have MRC grade <3
412
What is ASIA E
Sensory and Motor Function are preserved
413
What are the 2 mechanisms by which trauma causes injury to the spinal cord
1. Initial acute impact
| 2. Compression of spinal cord
414
What does initial acute impact cause
Initial impact causes contusion of the spinal cord
415
What causes compression of the spinal cord
Displaced rigid structures (eg. IV disc) increase pressure which may block venous return and cause oedema. Oedema can compromise arterial supply resulting in ischaemia. Ischaemia to the spinal cord causes a pattern of injury termed gliosis
416
How can spinal cord injury be classified
1. Primary
| 2. Secondary
417
What are primary injuries
Destructive forces that damage neural structures
418
What are secondary injuries
Vascular, cellular and biochemical events that occur following injury which may worse the primary injury
419
How is suspected spinal trauma managed
ATLS approach
420
What is the ATLS approach
C, A-E
421
how is the cervical spine immobilised
using a 3-point immobilisation technique
422
how is suspected cervical spine injury investigated for
- CT scan in adults
| - MRI in children
423
what criteria is used to determine if individuals need a CT scan
Canadian Cervical C Spine Rules
424
what is used to investigate thoracolumbar trauma
1. X-ray: if SCI with no neurological symptoms
| 2. CT: if abnormal x-ray or neurological signs
425
What is canadian cervical C spine rules used for
to determine who needs imaging of the spine following trauma
426
what does the Canadian cervical C spine rules divide individuals into
High risk + Low risk
427
what are the 3 criteria for high risk in Canadian C spine rules
1. >65y
2. Dangerous Injury Mechanism
3. Parasthesia in upper extremities
428
if high risk, how should the patient be managed with Canadian C spine rules
Immediate imaging prior to mobilisation
429
which patients are low risk
If no high-risk features
430
how should low risk patients in the Canadian C spine rules be managed
Do not need radiologic assessment prior to mobilising the spine
431
if imaging is not required what is done
assess range of motion in the spine
432
once cervical spine is stabilised what should be tested
regular neuromuscular assessments
433
what is osteomyelitis
infection of the bone marrow
434
what is vertebral osteomyelitis a form of
haematogenous spread of pathogen
435
what pathogen commonly causes vertebral osteomyelitis
staphylococcus aureus
436
which pathogen is the main cause in individuals with sickle cell disease
salmonella
437
what 5 conditions may predispose to osteomyelitis
- diabetes
- sickle cell anaemia
- IVDU
- HIV
- Alcohol excess
438
how does vertebral osteomyelitis present clinically
Back pain worse on activity and at night. Not relieved by rest
439
explain pathophysiology of vertebral osteomyelitis
Pathogens can spread haematogenously causing infection of the vertebrae
440
how is vertebral osteomyelitis investigated
- FBC (WCC)
- CRP, ESR
- X-Ray
- MRI
- CT-guided needle aspiration
441
what is the problem with x-rays for vertebral osteomyelitis
Often signs of infection are not visible until 2W after
442
what is the best imaging modality for vertebral osteomyelitis
MRI
443
how is vertebral osteomyelitis managed
IV antibiotics
444
what is discitis
Infection of vertebral disc
445
how will discitis present
- back pain
| - general features: riggers, fever, sepsis
446
what does neurological features in discitis indicate
epidural abscess
447
what is the most common cause of discitis
staphylococcus aureus
448
aside from bacterial, what else can cause discitis
- viral
- TB
- aseptic
449
what imaging modality is used for discitis
MRI
450
what other investigation is used for discitis and why
CT-guided aspiration. Be able to obtain a culture to determine antibiotic sensitivity
451
how is discitis managed
IV antibiotics for 6-8W
452
what else should patients with discitis be assessed for and how
Endocarditis - via trans thoracic or trans transoesophageal ECHO
453
what is the most common cause of spinal cord compression
metastatic cancer
454
what cancers typically metastasise to the spine
```
Breast
Lung
Thyroid
Kidney
Prostate
```
: haematogenous, myeloma
455
what are 3 other causes of spinal cord compression
- Infection
- Trauma
- Disc prolapse
456
what trauma can cause spinal cord compression
Vertebral fracture
457
how does infection result in spinal cord compression
Abscess formation can compress the spinal cord
458
why are disc prolapses a rare cause of spinal cord compression
Most common site of disc prolapse is L4-L5. This causes caudal equina compression and not spinal cord compression. As the spinal cord terminates at L1
459
explain risk factors for spinal cord compression
Any pathology which results in narrowing of the spinal canal increases the risk of compression
460
what conditions increase risk of spinal cord compression
- RA
- Ankylosing spondylitis
- Degenerative conditions
- Hypertrophy of ligamentous flavum
- Osteophyte formation
461
how will spinal cord compression present
- Back pain exacerbated by increase in pressure and lying down
- loss of sensation and proprioception
- bilateral or unilateral weakness
462
what do autonomic signs in spinal cord compression indicate
late phase
463
what are 3 autonomic features in spinal cord compression
- constipation
- bowel incontinence
- urinary incontinence
464
will the signs of SCC be UMN or LMN
UMN
465
why are signs of SCC UMN
as there is compression within the spinal cord (which contains upper motor neurons)
466
what are the UMN signs seen in spinal cord compression
Hyper-reflexia and hypertonia below the lesion. At the level of the lesion there will be a loss of tone and reflexes as the lower motor neurone in the ventral horn is compressed causing a LMN deficit
467
what is first-line investigation for for SCC
MRI spine
468
what are the NICE guidelines for imaging for metastatic spinal cord compression
If an individual is diagnosed with metastatic cancer they should receive an MRI of the spine within 1W
469
how is metastatic spinal cord compression managed
- Immediate high dose corticosteroids
| - Neurosurgical referral
470
what is the best prognostic factor for spinal cord compression
Mobility at the time of treatment
471
what is average survival rate for metastatic spinal cord compression
6 months
472
what is a pathological fracture
fracture that occurs in abnormal bone
473
what do pathological fractures commonly refer to
fractures secondary to malignancy
474
what are other causes of pathological fractures
- metabolic bone disease
| - osteomyelitis
475
what termed is used for fractures secondary to metabolic bone disease
insufficiency fractures
476
what are 5 metastatic tumours that go to bone
```
Breast
Lung
Thyroid
Kidney
Prostate
```
477
what are 3 bone diseases that predispose to pathological fractures
Osteogenesis imperfecta
Osteoporosis
Paget's disease
478
what are 2 local benign conditions
Osteomyelitis
| Solitary bone cysts
479
what are 3 primary malignant tumours of the bone
Ewing's sarcoma
Osteosarcoma
Chondrosarcoma
480
if an individual has bone metastasis what scoring system is used to predict their risk of pathological fracture
Mirel's scoring system
481
what is the range of scores in mirel's classification
4-12
482
what does a mirels score >9 indicate
Prophylactic fixation should be done
483
what does a mirels score <9 indicate
Treat with radiotherapy and continue cancer treatment
484
what are the 3 most common sites for pathological fractures
- Sub-trochanteric
- Junction of humeral head to metaphysic
- Vertebral body
