18- Orthopedics Explains Flashcards
What are the different types of fractures in pediatric patients?
The different types of fractures in pediatric patients include complete fractures, plastic deformity fractures, greenstick fractures, buckle fractures, and growth plate fractures.
What is a complete fracture?
A complete fracture is a type of fracture where both sides of the cortex are breached.
What is a plastic deformity fracture?
A plastic deformity fracture occurs when there is stress on the bone resulting in deformity without cortical disruption.
What is a greenstick fracture?
A greenstick fracture is a type of fracture where there is a unilateral cortical breach only.
What is a buckle fracture?
A buckle fracture is an incomplete fracture with only periosteal haematoma resulting from cortical disruption.
How are growth plate fractures classified?
Growth plate fractures in pediatric patients are classified according to the Salter-Harris system, which includes five types: Type I, Type II, Type III, Type IV, and Type V.
What is a Type I growth plate fracture?
A Type I growth plate fracture involves a fracture through the physis only, and the X-ray may often appear normal.
What is a Type II growth plate fracture?
A Type II growth plate fracture involves a fracture through the physis and metaphysis.
What is a Type V growth plate fracture?
A Type V growth plate fracture is a crush injury involving the physis, and the X-ray may resemble a Type I fracture and appear normal.
What is a Type III growth plate fracture?
A Type III growth plate fracture involves a fracture through the physis and epiphysis to include the joint.
What is a Type IV growth plate fracture?
A Type IV growth plate fracture involves a fracture involving the physis, metaphysis, and epiphysis.
Which types of growth plate injuries usually require surgery?
Injuries of Types III, IV, and V in the Salter-Harris classification system usually require surgery.
What is often associated with Type V growth plate injuries?
Type V growth plate injuries are often associated with disruption to growth.
What is osteopetrosis?
Osteopetrosis is a condition where the bones become harder and more dense. It is an autosomal recessive condition and is most commonly seen in young adults. Radiology reveals a lack of differentiation between the cortex and medulla, described as “marble bone.”
What are some signs of non-accidental injury in children?
Signs of non-accidental injury in children may include delayed presentation, a delay in attaining milestones, lack of concordance between proposed and actual mechanism of injury, multiple injuries, injuries at sites not commonly exposed to trauma, and being on the at-risk register.
What can cause pathological fractures in children?
Pathological fractures in children can be caused by genetic conditions such as osteogenesis imperfecta, which is characterized by defective osteoid formation and a failure of collagen maturation in all connective tissues.
What are the subtypes of osteogenesis imperfecta?
The subtypes of osteogenesis imperfecta are: Type I (normal quality but insufficient quantity of collagen), Type II (poor quantity and quality of collagen), Type III (poorly formed collagen but normal quantity), and Type IV (sufficient quantity but poor quality of collagen).
What is the bimodal age distribution of neck of femur (NOF) fractures?
Neck of femur (NOF) fractures, which are fractures in the hip, have a bimodal age distribution. They can occur as a result of high-energy trauma in young patients (e.g., road traffic accidents, horse riding), or as low-energy osteoporotic fractures in the elderly.
What are the management aims for young patients with NOF fractures?
For young patients with NOF fractures, the management aims are to treat them in accordance with Advanced Trauma Life Support (ATLS) principles, retain the patient’s own anatomy, and optimize their function. These patients often have associated injuries due to high-energy trauma.
What are the management aims for elderly patients with NOF fractures?
For elderly patients with NOF fractures, the management aims are to immediately regain patient mobility to avoid morbidity (infection, thromboembolic events, pressure sores) and mortality associated with prolonged bed rest. Left untreated, a neck of femur fracture can be considered a terminal event.
What is the mortality rate associated with elderly hip fractures historically?
Historically, the mortality rate associated with elderly hip fractures is 10% at one month, and 30% at one year. However, this has been improved in the UK with the introduction of multidisciplinary, orthogeriatric lead care and the National Hip Fracture Database and Best Practice Tariff.
What is the normal neck-shaft angle in the hip?
The normal neck-shaft angle in the hip is 130 +/- 7 degrees.
What is the normal neck anteversion in the hip?
The normal neck anteversion in the hip is 10 +/- 7 degrees.
What is the predominant blood supply to the femoral head and neck?
The predominant blood supply to the femoral head and neck is from the medial and lateral femoral circumflex arteries, which are branches of the profunda femoris artery. There is also a small vascular contribution from the artery of the ligament teres.
What are the typical signs of a neck of femur fracture?
Typical signs of a neck of femur fracture include pain in the hip/groin, a shortened, abducted, externally rotated leg (due to the unopposed pull of the muscles that act across the hip joint), and the inability to straight-leg-raise. In undisplaced fractures, the signs may be more subtle.
What imaging modalities are used to diagnose NOF fractures?
Anteroposterior and cross-table lateral plain radiographs are usually sufficient to diagnose the majority of NOF fractures. However, if there is a high index of suspicion of fracture but plain radiographs are inconclusive, an MRI is the gold standard investigation. CT can also be used if MRI is unavailable or the patient cannot tolerate it. Full length femur views are essential to plan surgery if the fracture extends below the level of the lesser trochanter or there is a possibility of pathological fracture.
What are the two main types of NOF fractures?
Intra-capsular and extra-capsular fractures
How are extra-capsular fractures further divided?
Pertrochanteric or subtrochanteric fractures (within 5cm distal to the lesser trochanter)
What are the three categories used to describe fractures?
Undisplaced, minimally displaced, or displaced
What is the difference in blood supply disruption between intra-capsular and extra-capsular fractures?
Intra-capsular fractures commonly disrupt the blood supply to the femoral neck and head, while extracapsular fractures rarely do
What is the recommended treatment approach for intra-capsular fractures?
Arthroplasty (joint replacement)
What is the recommended treatment approach for extra-capsular fractures?
Fixation (surgical stabilization)
Which named classification system is commonly used for elderly intracapsular fractures?
Garden Classification
Which named classification system is commonly used for young intracapsular fractures?
Pauvels Classification
Which named classification system is commonly used for intertrochanteric fractures?
Evans Classification
When should surgery for NOF fractures ideally take place to minimize complications?
Within 36 hours, as a delay greater than 48 hours is associated with increased morbidity and mortality
How can undisplaced fractures in the elderly be treated?
Internal fixation with cannulated screws
What is the suggested treatment for valgus impacted subcapital fractures in the elderly?
Arthroplasty (joint replacement)
According to NICE guidance, which surgical option should be offered to patients who meet certain criteria?
Total hip replacement
What is the recommended surgical approach for intertrochanteric fractures with intact trochanter and medial calcar?
DHS (Dynamic Hip Screw)
What is the recommended surgical approach for intertrochanteric fractures involving the trochanter and/or medial calcar?
Intramedullary device (e.g., nail or rod)
What is the post-operative management for NOF fracture patients?
Full weight-bearing mobilization, multidisciplinary care involving orthogeriatrician assessment, physiotherapy, occupational therapy, and secondary prevention measures for bone health
What is the main difference between rickets and osteomalacia?
Rickets occurs during growth before epiphysis fusion, while osteomalacia occurs after epiphysis fusion
What are the common causes of vitamin D deficiency leading to osteomalacia?
Malabsorption, lack of sunlight, and inadequate diet
What are the types of osteomalacia?
Vitamin D deficiency, renal failure, drug-induced (e.g., anticonvulsants), vitamin D resistant (inherited), and liver disease (e.g., cirrhosis)
What are the features of rickets?
Knock-knee, bow leg, and features of hypocalcemia
What are the features of osteomalacia?
Bone pain, fractures, muscle tenderness, and proximal myopathy
What are the typical findings in the investigation of osteomalacia?
Low levels of calcium, phosphate, and 25(OH) vitamin D; raised alkaline phosphatase; and x-ray findings of cupped, ragged metaphyseal surfaces in children and translucent bands (Looser’s zones or pseudofractures) in adults
What is the treatment for osteomalacia?
Calcium with vitamin D tablets
What is the mechanism and presentation of a ruptured anterior cruciate ligament?
Mechanism: high twisting force applied to a bent knee. Presentation: loud crack, pain, and rapid joint swelling (haemarthrosis)
How is a ruptured anterior cruciate ligament managed?
Intense physiotherapy or surgery
What is the mechanism and clinical finding of a ruptured posterior cruciate ligament?
Mechanism: hyperextension injuries with the tibia lying back on the femur. Clinical finding: paradoxical anterior draw test
What is the mechanism and instability associated with a rupture of the medial collateral ligament?
Mechanism: leg forced into valgus via force outside the leg. Instability: knee unstable when put into valgus position
What are the characteristics and symptoms of a meniscal tear?
Characteristics: rotational sporting injuries. Symptoms: delayed knee swelling, joint locking, and recurrent episodes of pain and effusions
Who is commonly affected by chondromalacia patellae and what are the typical symptoms?
Teenage girls, following an injury to the knee (e.g., dislocation of the patella). Typical symptoms: pain when going downstairs or at rest, tenderness, and quadriceps wasting
What are the risk factors and clinical features of a dislocation of the patella?
Risk factors: genu valgum, tibial torsion, and high riding patella. Clinical features: traumatic primary event, valgus and external rotation of the knee, skyline x-ray views required, and 20% recurrence rate
What are the two types of fractured patella and how do they occur?
i. Direct blow to the patella causing undisplaced fragments. ii. Avulsion fracture
Who is commonly affected by tibial plateau fractures and what is the mechanism of injury?
Elderly individuals or following significant trauma in the young. Mechanism: knee forced into valgus or varus, resulting in knee fracture before ligament rupture
How are tibial plateau fractures classified?
Using the Schatzker system
What is the Schatzker Classification system used for?
Classification of tibial plateau fractures
What are the features and characteristics of a Type 1 tibial plateau fracture?
Anatomical description: Vertical split of lateral condyle. Features: Fracture through dense bone, may be undisplaced or condylar fragment pushed inferiorly and tilted
What are the features and characteristics of a Type 2 tibial plateau fracture?
Anatomical description: Vertical split of the lateral condyle combined with an adjacent load bearing part of the condyle. Features: Wedge fragment displaced laterally, widened joint. Untreated cases may develop a valgus deformity
What are the features and characteristics of a Type 3 tibial plateau fracture?
Anatomical description: Depression of the articular surface with intact condylar rim. Features: The split does not extend to the edge of the plateau, depressed fragments embedded in subchondral bone, stable joint
What are the features and characteristics of a Type 4 tibial plateau fracture?
Anatomical description: Fragment of the medial tibial condyle. Features: Two injuries seen - depressed fracture in osteoporotic bone in the elderly, or high-energy fracture with a condylar split from the intercondylar eminence to the medial cortex. Associated severe ligamentous injury may be present
What are the features and characteristics of a Type 5 tibial plateau fracture?
Anatomical description: Fracture of both condyles. Features: Both condyles fractured, but the column of the metaphysis remains in continuity with the tibial shaft
What are the features and characteristics of a Type 6 tibial plateau fracture?
Anatomical description: Combined condylar and subcondylar fractures. Features: High-energy fracture with marked comminution
What is avascular necrosis?
Cellular death of bone components due to interruption of the blood supply, causing bone destruction
Is avascular necrosis the same as non-union?
No, avascular necrosis is different from non-union. In avascular necrosis, the fracture has usually united
Which are the main joints commonly affected by avascular necrosis?
Hip, scaphoid, lunate, and talus
What can occur in the affected bone in avascular necrosis in terms of vascular ingrowth?
Vascular ingrowth into the affected bone may occur, but many joints will develop secondary osteoarthritis
What is the typical appearance of avascular necrosis on radiological imaging?
Radiological evidence is slow to appear
What are some causes of avascular necrosis?
Pancreatitis, lupus, alcohol, steroids, trauma, idiopathic factors, infection, caisson disease, collagen vascular disease, radiation, rheumatoid arthritis, amyloid, Gaucher disease, sickle cell disease
What is the usual presentation of avascular necrosis?
Pain, often despite apparent fracture union
Which imaging modality can show changes in avascular necrosis earlier than plain films?
MRI scanning
What is the key in the treatment of fractures at high-risk sites in avascular necrosis?
Early, prompt, and accurate reduction
How can non-weight bearing help in avascular necrosis?
Non-weight bearing may help facilitate vascular regeneration
In some cases, what may be necessary or preferred as a treatment option for avascular necrosis, especially in the elderly?
Joint replacement, for example, hip replacement in the elderly
What are the risk factors associated with pseudogout?
Hyperparathyroidism, hypothyroidism, haemochromatosis, acromegaly, low magnesium, low phosphate, and Wilson’s disease.
What is pseudogout?
Pseudogout is a form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate in the synovium.
What can be observed during joint aspiration in pseudogout?
Weakly-positive birefringent rhomboid-shaped crystals can be seen.
Which joints are commonly affected by pseudogout?
Knee, wrist, and shoulders are the most commonly affected joints.
What can be seen on x-ray in pseudogout?
Chondrocalcinosis, which refers to the presence of calcium deposits in the joint cartilage, can be seen on x-ray.
What are the management options for pseudogout?
Joint fluid aspiration is performed to exclude septic arthritis. NSAIDs or intra-articular, intra-muscular, or oral steroids can be used, similar to the treatment approach for gout.
What is Colles’ fracture?
Colles’ fracture is a fracture of the distal radius characterized by a transverse fracture located 1 inch proximal to the radio-carpal joint, resulting in dorsal displacement and angulation. It is often associated with a “dinner fork deformity.”
How is Colles’ fracture typically caused?
Colles’ fracture is commonly caused by a fall onto an extended outstretched hand.
What is Smith’s fracture?
Smith’s fracture, also known as a reverse Colles’ fracture, is a fracture of the distal radius characterized by volar angulation of the distal radius fragment, resulting in a “Garden spade deformity.” It is typically caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed.
What is Monteggia’s fracture?
Monteggia’s fracture is characterized by a dislocation of the proximal radioulnar joint associated with an ulna fracture. It is typically caused by a fall on an outstretched hand with forced pronation. Prompt diagnosis is crucial to prevent disability.
What is Bennett’s fracture?
Bennett’s fracture is an intra-articular fracture of the first carpometacarpal joint. It is caused by an impact on a flexed metacarpal, commonly seen in fist fights. On an x-ray, a triangular fragment can be observed at the ulnar base of the metacarpal.
What is Galeazzi fracture?
Galeazzi fracture is a radial shaft fracture associated with a dislocation of the distal radioulnar joint. It is caused by a direct blow.
What is Holstein Lewis fracture?
Holstein Lewis fracture is a fracture of the distal third of the humerus that results in entrapment of the radial nerve. The radial nerve innervates the muscles in the extensor compartments of the arm. Conservative treatment includes reduction and use of a functional brace. Vascular injury may require open surgery.
What is Pott’s fracture?
Pott’s fracture is a bimalleolar ankle fracture caused by forced foot eversion.
What is Barton’s fracture?
Barton’s fracture is a distal radius fracture (Colles’ or Smith’s fracture) associated with radiocarpal dislocation. It is caused by a fall onto an extended and pronated wrist. Involvement of the joint is a defining feature.
What are the symptoms of a dorsal column lesion?
Loss of vibration and proprioception
What are the characteristics of Tabes dorsalis (SACD)?
Lesion in the spinothalamic tract resulting in the loss of pain, sensation, and temperature
What are the symptoms of a central cord lesion?
Flaccid paralysis of the upper limbs
Which region of the spine is commonly affected by osteomyelitis in intravenous drug users (IVDU)?
Cervical region
Which region of the spine is typically affected by tuberculosis (TB)?
Thoracic region
Thoracic region
Dorsal column signs, such as loss of proprioception and fine discrimination
What are the signs of Brown-Sequard syndrome?
Hemisection of the spinal cord results in ipsilateral paralysis and loss of proprioception and fine discrimination, as well as contralateral loss of pain and temperature.
What areas does the C2 dermatome cover?
The C2 dermatome covers the occiput and the top part of the neck.
Which area does the C3 dermatome cover?
The C3 dermatome covers the lower part of the neck to the clavicle.
What area does the C4 dermatome cover?
The C4 dermatome covers the area just below the clavicle.
Which areas are innervated by the C5 to T1 dermatomes?
The C5 dermatome covers the lateral arm at and above the elbow. The C6 dermatome covers the forearm and the radial (thumb) side of the hand. The C7 dermatome represents the middle finger. The C8 dermatome covers the medial aspect of the hand. The T1 dermatome covers the medial side of the forearm.
Which area is innervated by the L1 dermatome?
The L1 dermatome represents the hip girdle and groin area.
What areas are covered by the thoracic dermatomes (T2 to T12)?
The T2 to T12 dermatomes cover the axillary and chest region. T3 to T12 cover the chest and back to the hip girdle. The nipples are situated in the middle of T4. T10 is located at the umbilicus. T12 ends just above the hip girdle.
Which areas are covered by the L2 and L3 dermatomes?
The L2 and L3 dermatomes cover the front part of the thighs.
Which areas are innervated by the S1 dermatome?
The S1 dermatome covers the heel and the middle back of the leg.
Which area is innervated by the S2, S3, and S4-5 dermatomes?
The S2 dermatome covers the back of the thighs. The S3 dermatome covers the medial side of the buttocks. The S4-5 dermatomes cover the perineal region.
Which dermatome innervates the anal sphincter?
The anal sphincter is innervated by the S2, S3, and S4 dermatomes.
Which myotome is responsible for elbow flexion (biceps)?
Elbow flexion (biceps) is controlled by the C5 myotome.
