Capsule Flashcards
how to initially manage pt with NOF #?
ABCDE
- consider o2 but no need if sats maintained
- IV access and bloods (fBC, U&Es, G&S, x-match, clotting) as may need procedure
- IV fluids if dehydration
- analgesia
- anti-emetics + ECG
if bloods show low hb in a stable pt with a NOF #, what is the management?
pt must be optimised before operation, so must transfuse blood
no need to take to theatre immediately, so send to ward and wait for next available list for ORIF
if pt was unstable, emergency ORIF
another name for stage I garden classification?
abducted or impacted NOF #
stage IV garden classification?
complete femoral NOF # with full displacement
prox fragment free and lies in acetabulum, so trabeculae appear normally aligned
kocher classification purpose?
helpful in distinguishing between septic arthritis and transient synovitis in child with painful hip
benefits/risks of hemi?
quicker, lower risk of postop dislocation
a/w long-term pain and worse mobility
why are older pt initially treated with hip replacement?
risks of non-union and AVN are too high with attempted fixation
types of hemiarthroplasties?
unipolar
bipolar
austin-moore
(are these are all of the different types? and that you can recognise on xray)
difference between a cemented and uncemented prosthesis?
cemented - prosthesis held in place by epoxy cement that attaches metal to bone
uncemented - prosthesis has fine mesh on surface allowing bone to grow into it and attach metal to bone
NOF # are a/w what?
osteoporosis
in the <___ age group, NOF # are more common in ___?
60
men
overall, NOF # are more common in?
elderly women
what is an immediate complication a/w hip replacement surgery?
PE
what is an early complication a/w hip replacement surgery?
infection - as it develops some time after the surgery itself
what is a late complication a/w hip replacement surgery?
loosening of prosthesis
what does avn of scahpoid look like on xr?
whiter colour of proximal part of scaphoid
conditions a/w carpal tunnel syndrome?
OCP
hypothyroidism
RA
pregnancy
cardiac failure
prev wrist trauma
demyelination
what is allens test?
used to assess patency of blood vessels to hands (radial and ulnar arteries)
put thumbs on radial and ulnar arteries and ask to clench hand 3x quickly
then ask to extend fingers - hand should be blanched
release radial artery and note if return of colour is delayed >3s
do again for ulnar artery
what is finkelstein test?
assess for de quervain’s tenosynovitis
thumb flexed and other fingers flexed around it
wrist moved to ulnar deviation actively or passively (i.e. tilt hand down)
pain/crepitation above styloid suggests tenosynovitis of APL and EPB
how is carpal tunnel managed?
splintage
steroid injection
NSAIDs (NOT ANALGESIC)
most will need surgical release of carpal tunnel (can be done under LA/RA/GA)
what must you ascertain from hx in pt admitted to ED with painful hip following a fall?
reason for her fall
comorbidities
current medications
mental state
premorbid mobility
physical signs of extracapsular fracture of femur?
shortened
externally rotated
swelling
classical findings in any NOF fracture - but may not always be present
initial mx of extracapsular fracture?
analgesia as needed
fbc, u&es, x-match
iv fluids
urinary cath (as may not be able to mobilise)
o2 mask as needed
skin traction
splintage of affected limb
NBM
check pedal pulses and for evidence of other injuries
not abx
how are extracapsular fractures fixed?
operative fixation - pin and plate
most heal within 3mo post-fixation
comps of femoral fracture?
haemorrhage
pe
fat embolism
vasc injury
delayed union or malunion
initial mx of a distal tibial fracture?
analgesia
splintage (to stabilise joint)
definitive mx of distal tibial fracture?
options include
- manipulation and plaster immobilisation (esp in young + minimally displaced)
- operation: internal fixation or external fixation
comps of distal tibial fracture?
compartment syndrome
delayed/mal/nonunion
achilles tendon rupture presentation?
sudden pain back of ankle
partial WB no plantarflexion
may be possible to palpate a gap in course of tendon but post-trauma oedema and pain prevent this usually
why no plantarflexion in achilles tendon rupture?
the Achilles tendon normally allows the gastrocnemius muscle to pull the calcaneum upwards at the ankle joint
dvt associations?
pregnancy
synthetic oestrogen - HRT/OCP
surgery - esp pelvic/lower limb
malignancy
obesity
immobility
diseases of hypercoagulability
traditional mx of achilles tendon rupture?
equinus cast - apply plaster of Paris cast on lower leg, but here foot held in plantarflexion to bring two ruptured ends of tendon as close together as possible
over time, degree of plantarflexion is reduced to allow tendon to resume normal length and position
alternative - operation (not usually done)
what is a back slab?
type of plaster used to stabilise fractures temporarily before definitive treatment (which would be reduction and fixation)
ulnar nerve roots?
C8-T1 (medial cord)
ulnar nerve injury signs
froment’s sign
claw hand deformity
main fucntion of acl?
prevent ant translocation of tibia at the knee
what is a + patella tap
if enough joint effusion is present, might be possible to ballot patella against underlying bone
most common cause of knee joint effusion in clinical practice?
osteoarthritis
how to test for medial collateral ligament injury?
knee flexed to 20-30o to relax posterior capsule
hold and abduct ankle with one hand
put other hand behind knee and push it medially
reverse movement for lateral collateral ligament
can also palpate over MCL with fingers whilst testing the ligament
most common cause of rupture of MCL?
trauma
what does the MCL connect?
medial femoral condyle to medial tibial condyle
one of 4 ligaments which stabilise joint
main function of MCL?
resist valgus force - this occurs if tibia/foot is forced outwards in relation to knee
muscles for shoulder abduction?
supraspinatus - first 15o
deltoid - thereafter
what is painful arc?
pain on abduction
commonly due to:
- tendonitis of supraspinatus tendon (usually secondary to impingement at the level of the acromion)
- osteoarthritis of acromioclavicular joint
nerve roots of axillary nerve?
C5-C6
deltoid origin and insertion?
origin:
anterior clavicular head - anterior lateral clavicle
middle acromial head - acromion and spine of scapula
insertion: deltoid tuberosity of humerus
what is homan’s sign?
forces dorsiflexion of foot to assess presence of DVT
if pain -> +
not commonly used as thought to be a risk of forcing a PE
what is thomas’ test?
assess fixed flexion deformity of hip and psoas syndrome
pt lies supine
pt flexes hip and knee - holding onto knee
the other leg should rise up
INDICATES FIXED FLEXION DEFORMITY OF THE OPPOSITE SIDE TO THE ONE BEING HELD
most common cause of + thomas’ test?
osteoarthritis
radial nerve roots?
C5-T1 (posterior cord)
how to test for wrist drop?
ask pt to flex elbow and pronate forearm - hands hanging down
ask to extend wrist
radial nerve palsy presentation?
weakness of extension of wrist/fingers/elbow
sensory changes over dorsum of hand on radial side/web space (superficial br of radial n)
median nerve roots?
C5-T1 (medial and lateral cords)
most common cause of wrist drop?
trauma - humeral fracture specifically
most commonly closed injury
compression can also cause neuropraxia - saturday night palsy (as object directly compresses nerve in spiral groove)
what is clark’s test?
used to test patellofemoral joint
what is lhermitte’s sign?
how long are wrists hyperflexed for in phalen’s test?
1-2 mins
when is pain worse in carpal tunnel syndrome?
at night
recognised treatment for carpal tunnel syndrome medically?
diuretics
why is lateral palmar sensation spared in carpal tunnel syndrome?
nerve branch leaves median nerve before carpal tunnel at the wrist
what is a hangman’s fracture?
normal thickness of prevertebral soft tissue space?
c1-c4/c5 - max of 7mm
c4/c5-t1 - max of 21mm (one vertebral body width)
soft tissue thickening may be the only sign of a vertebral fracture
typical width of a vertebral body?
21mm
what should a lateral cspine xray show?
occiput to t1
cervicothoracic junction must be shown for it to be adequate and exclude dislocation at c7/t1
how to check bony alignment in cspine xr?
3 longitudinal lines - anterior, posterior, spinolaminar
anterior and posterior run along anterior and posterior borders of vertebral bodies respectively
spinolaminar links anterior aspects of spinous processes
how to tell if cspine xray is in a child?
vertebral bodies not yet fully formed
secondary ossification centres
signs of degenerative disease in spine?
loss of intervertebral disc space height
osteophytosis
important causes of lytic bone lesions in males?
carcinoma of lung, kidney, myeloma
so if bony mets seen on spine, pt should have cxr
open mouth view is done to assess what?
can show odontoid peg
what three views must be done to assess cspine in trauma?
ap
lateral
open mouth view
common cause of artefact in cspine xray?
overlying hard collar
what is wedge compression fracture severity grading?
severe - >40% vertebral body height loss
mild - 20-25% vertebral body height loss
what are the three types of compression fractures?
wedge fracture - most common (50%)
burst fracture
crush fracture
what is a wedge compression fracture?
hyperflexion injury due to axial loading
usually affects anterior vertebral body, collapsing bone in front of spine
posterior aspect unchanged - so vertebrae looks like a wedge
considered stable/single-column fracture
what is a crush compression fracture?
if entire bone breaks
what is a burst compression fracture?
some loss of height in both front and back walls of vertebral body
are unstable and can lead to progressive deformity or neuro compromise
what is a compression fracture?
decreased vertebra height by 15-20% due to fracture
what are the three vertebral columns?
anterior - anterior longtiduian ligament, ant 2/3 of body and disc
middle - posterior longitudinal ligament, 1/3 body and disc
posterior - everything behind posterior longitudinal ligament
what is the most commonly fractured tarsal bone?
calcaneus
most often due to compressive force following fall from height
calcaneal fracture is a/w?
contralateral calcaenal fracture - 10%
wedge compression fracture of spine due to moi
what % of calcaneal fractures are intraarticular, involving which joint?
75%
subtalar joint
what may be the only sign of a stress fracture on plain film?
periosteal reaction
differentials for solitary localised periosteal reaction?
trauma
inflammatory process
neoplastic process
stress fracture
what may suggest significant trauma in foot xr?
soft tissue swelling
esp important with ankle joint effusion as suggests ligament damage which can cause sig morbidity
is ankle joint effusion suggestive of occult fracture?
no - unlike elbow joint effusion and lipohaemoarthrosis of knee
chronic disability a/w which types in salter harris?
type 3 and 4
presence of talar shift suggests?
displacement of talus in relation to tibia
indicates deltoid ligament injury?
= unstable and needs reduciton
fat appears ? on xray
lucent
lat view of knee in trauma usually taken with?
horizontal beam with pt supine or sitting
so xray beam is parallel to floor
used to demonstrate presence of fat-fluid level
what does fat fluild level mean?
fat has leaked out of medullary bone cavity so there is fracture even if occult
the ligamentum teres is often completely ____ post-puberty
atretic
the most common primary malignancy resulting in sclerotic bony metastases in adult female is?
breast carcinoma
most common causes of osteoblastic/sclerotic metastases in adult?
prostate - male
breast - female
primary malignancies resulting in mixed (sclerotic/lucent) bone metastases?
breast
prostate
lymphoma
myeloma causes ___ bony lesions
lytic
the presence of an anterior fat pad can be ?
normal
the presence of a posterior fat pad can be ?
always abnormal
indicates joint effusion
elbow fractures are more common in
children
the most common is a supracondylar fracture
how to identify pneumothorax on xr?
collapsed lung + black area around lung
injuries of ____ indicate significant trauma?
first rib
scapular fractures are a/w?
95% a/w other injuries
scapular fracture mx?
usually conservative unless intraarticular involvement or sig displacement
what is a bankart lesion
as humeral head dislocates may impact on anterior inferior glenoid rim
what is a hill-sachs deformity
posterolateral humeral fracture occurring when soft head impacts against anterior glenoid
in the wrist/hand, skin wounds may communiate directly with?
the mcp joint
digits should be ___ not ____
named not numbered
thumb, index finger, middle finger, ring finger and little finger
most scaphoid fractures occur through
waist of scaphoid (70%)
most commonly injured carpal bone
scaphoid
then triquetral
colles mx?
reduced under local or regional anaesthesia
set in plaster
torus fracture prognosis
good
greenstick fracture age range
usually 4-10y
incomplete fracture due to a child’s bones being more pliable than an adults - results in buckle of cortex AND cotical break
usually isolated injuries
buckle fracture mx
immobilisation
then treated in cast
what does O on radiograph suggest
put by radiographer
think there is a fracture
l5/s1 disc impinges on?
s1 nerve root in 95% cases (note - traversing)
5% - lateral disc will catch l5 root
l2/l3 disc causes what symptoms?
upper thigh pain and hip/knee weakness
cauda equina syndrome presentation
perianal reduced sensation
altered bowel/bladder function
usually bilateral
mx of sciatica?
conservative treatment for 6wks - most will settle
so first line:
- anti inflammatory
- physio
- muscle relaxants
- analgesia
what is done if symptoms fail to settle within 6 weeks?
referral to specialist
possibly surgery
why is mobilisation important in acute sciatica?
reduce muscle spasm
increase spinal mobility
bed rest slows recovery
What percentage of sciatica cases settle within 6-8 weeks?
> 60%
What would be the most appropriate investigation if symptoms and signs fail to settle within 6 weeks?
mri spine scan - identifies if disc bulge, what level, and if impingement on nerve roots
why is discography not used to assess refractory sciatica symptoms?
invasive and level specific
wont show nerve impigment
why is ct spine not used to assess refractory sciatica symptoms?
CT scans used to be the investigation of choice however you need to choose the correct level to scan or you may miss a disc
Radiation also involved
why is bone scan not used to assess refractory sciatica symptoms?
does not show required soft tissue pathology
why is lumbar spine xray not used to assess refractory sciatica symptoms?
very few indications for lumbar spine x-rays these days, they use a large radiation dose and provide little information
initial ix: 42F, 6-week history of pain in and around her left hip, previously fit and well. This pain is worsening and keeps her awake at night. She has been losing weight.
urgent pelvic radiograph
check bloods (FBC, bone profile, ESR)
red flag sx bone cancer
prev well pt
worsening pain
pain keeping pt awake at night
osteosarcoma typical age group?
young: 10-30
myeloma tends to cause what on xr?
bony lucencies
esp in ribs and long bones
commonest source of secondary malignant bone tumours?
breast, prostate, kidney and lung cancers
multiple myeloma and lymphoma
commonest sites for bony mets?
spine, ribs and pelvis followed by the proximal femur and proximal humerus
what does periprosthetic lucency suggest?
may occur with prosthetic loosening or infection
infection more likely if night sweats, pyrexia
imaging modality of choice in diagnosing joint prosthesis infection
xrays
- wideband of radioluncency at cement-bone interface or meta-bone interface if uncemented
- bone destruction
mx of joint prosthesis infection?
prosthetic removal
prolonged abx treatment
options:
- debridement and implant retention
- single stage revision
- two stage revision
- excisional arthroplasty
most cases of periprosthetic infection occur when
within 3 months of injury
some happen later due to haematogenous spread
why are bacteria in a periprosthetic infection difficult to eradicate?
form protective biofilm so need to be physically removed using radical debridement
debridement and implant retention clears periprosthetic infection in what % of cases?
60%
removal and replacement of the implants in either a one or stage stage revision clears periprosthetic infection in what % of cases?
80%
Which two are the commonest causative organisms of infected hip replacement?
streptococcus
coagulase -ve staphylococcus
usually sensitive to vanc and rifampicin
what types of fractures are included in ‘extracapsular’ fractures?
trochanteric, intertrochanteric and subtrochanteric
broadly speaking, what are the 2 treatment options for intracapsular fractures?
reduction and internal fixation
or
prosthetic replacement
a/w intracapsular femoral neck fracture?
limb shortening
external rotation
fracture non-union
comps of intracapsular fracture?
avn
non union
DVT
symptoms suggestive of thigh abscess formation
pain
swelling
heat
fever
gas in soft tissues (crepitus)
can be secondary to groin injection with contaminated needle
initial ix for thigh abscess formation
blood cultures
radiographs of region + chest - exclude femoral bone destruction, confirm soft tissue air, exclude lung comps (e.g. infarct)
uss of vessels - exclude DVT and aneurysm formation at injection site
needle aspiration of fluctuant area - MC&S
venous lactate - need to assess for sepsis
when may ct be considered in thigh abscess workup
ct more helpful in demarcating size and extent of abscess prior to surgery compared to uss
when would arteriography be indicated in thigh abscess workup
presence of possible distal embolus - e.g. ischaemic foot
xr signs of osteomyelitis
loss of bone density
loss of cortex
obvious bone destruction
xr signs of abscess
extensive air present in soft tissue
marked soft tissue swelling
examples of gas forming organisms
e. coli
klebsiella
what does air present in soft tissues indicate
infection with gas forming organism
mx of thigh abscess
urgent iv broad spectrum ABX
analgesia as needed
mri scan for assessment of abscess thigh and extent
urgent discussion with microbiology
liaise with anaesthetics if IV access difficult
liaise with surg to consider incision and drainage
may also need to seek advice abt drug therapy to manage substance withdrawal which wiill occur during inpatient stay and heroin replacement agents (e.g. methadone) may be required
when may iv access be difficult
IVDU
comps of IV drug abuse?
spinal epidural abscess
dvt
infective endocarditis
hepatic cirrhosis (hep b/c untreated)
false aneurysm formation
pericarditis is usually…
viral or idiopathic in nature
