Clinical T&O Flashcards
Cauda equina
The Cauda equina is a collection of nerve roots within the spinal canal below termination of spinal cord (conus medullaris). The compression can be caused by intervetebral disc herniation, tumours, inflammatory conditions and spinal stenosis.
The red flags in history of cauda equina are:
Bilateral sciatica
Saddle Anaesthesia
Reduced anal tone
Urinary retention or incontinence
Faecal incontinence
Saddle anaesthesia is a worrying finding is a worrying finding. Together with urinary incontinence or retention and reduced anal tone suggests possibility of CE.
The CE is composed of nerves and therefore lower motor neurones. Findings on examination include:
1) Reduced anal tone
2) Reduced power and altered sensation
3) Reduced or absent reflexes
4) Down going planters
5) Bowel, bladder and sexual dysfunction
Choice of investigation is MRI lumbar spine. MRI will provide detailed images of soft tissue including the thecal sac, spinal cord, cauda equina, exiting nerve roots and intervebral discs. Whole spine if patient known to have metastatic disease.
A 12 hour history of severe back pain with bilateral sciatica, saddle anaesthesia and loss of anal tone with a central disc compressing the CE on MRI would be indication for emergency decompression.
Malignant depositis causing CE are often managed with corticosteroids and radiotherapy.
Spinal fractures
Stable fractures can usually be managed conservatively but unstable fractures require surgical fixation.
Ant column is ant longitudinal ligament and the anterior 50% of vertebral body. Middle column is posterior 50% of vertebral body and posterior longitudinal ligament and posterior column includes all the posterior structures (pedicles, facet joints, laminae and spinous process) and the interspinous ligaments. If 2 or more columns are affected then fracture is considered unstable.
Anterior wedge fracture with <50% wedging is a stable injury. With this injury only anterior column is affected so is stable.
Burst fracture is more serious caused by axial compression of the spine. The vertebral body is compressed and bursts apart, with both anterior and middle columns being involved. So is an unstable fracture. Important bone fragments from comminuted vertebral body may be located in the spinal canal, resulting in potential spinal cord injury
Chance fracture typically seen in RTA. Caused by hyperflexion injury and involved L2 and L3 levels. They are transverse fractures through the vertebral body (ant and middle) columns and involve the posterior elements as well. Making the injury unstable. Fracture line may run through the intervertebral disc space rather than vertebral body. Chance fractures are also known as lap belt injuries. They are associated with abdominal and retroperitoneal injuries
Jefferson fracture is a fracture of the C1 where there are fractures of the anterior and posterior arches of C1 with displacement of the lateral masses on the odontoid peg view. This is unstable and requires stabilisation.
Spinal shock is loss of sensation, motor function and relfexes and occurs initially following spinal injury.
Neurogenic shock refers to patients with a spinal injury who are hypotensive, bradycardic and unable to mount a tachycardic response to hypovolmemia.
Central cord syndrome is a greater loss of motor strength in upper limbs than lower limbs with variable sensory loss. Most frequent with hyperextension injuries of C spine.
C spine fractures
Any patient with a cervical spine injury should be immobilised with a hard collar and blocks to prevent flexion, extension or rotation of the cervical spine and potential damage to spinal cord.
Breast, lung, prostate, thyroid and renal tumours metastasise to bone. Commonest primary tumour is myeloma.
Ant vertebral line, posterior vertebral line, line of spinous processes, spinolaminar.
A Jefferson fracture is a burst fracture of C1. Most easiliy diagnosed on peg view. Look for widening of the gap between the peg and lateral masses and overhanding of lateral margins of C1 in relation to C2.
>7mm displacement of lateral masses the transverse ligament is likely ruptured and C spine is unstable. May require further immobilisation via halo
Fractures occuring with no or minimal trauma raises suspicion of bone abnormality. e.g osteoporosis/malignancy
When suspecting a pathological fracture of the spine
1) Hx and exam- systemic features of malignancy, fractures other locations
2) CT scan +/- CT TAP. MRI if suspecting metastatic deposits
Cervical myotomes
C2 Dermatome- occiput, myotome neck flexion/extension
C3- Dermatome Supraclavicular fossa, lateral neck flexion
C4 - Over the ACL joint. Shoulder elevation
Shoulder dislocation
Anterior dislocation is the most common. 90-95% of shoulder dislocations seen in A&E. Humeral head is displaced anteriorly into the axilla. Normal contour of shoulder is lost and the most lateral bony structure palpable is acromion.
Humeral head will be in a subcoracoid position, no longer articulating with the glenoid.
Inferior and posterior dislocations are also possible. Patient holds arm in internal rotation and locked in this position.
On AP x ray shoulder may appear to be in the joint. Light bulb rather than normal humeral head
Kocher’s - Patient is relaxed and with elbow flexed to 90 deg the shoulder is slowly externally rotated
Hippocratic- Hold arm slightly abducted with elbow fully extended. Traction is then applied with counter traction by a second person holding a sheet around the axilla. This method works for both ant and post dislocations with a lower incidence of nerve injury.
Axillary nerve is commonly injured following shoulder dislocation/reduction. It wraps very closely around surgical neck of the humerus. Supplies the deltoid muscle and sensation to regimental badge patch.
Ant dislocations is associated with Hill sachs lesion which is a depressed fracture created in the cortex of the posterolateral aspect of humeral head. Occurs as the dislocated humeral head impacts against the inferior edge of the glenoid. As the humerus dislocates, it often injures the labrum. If the labrum comes away from glenoid with a small fragment of bone this is a Bankart lesion
Main concern in young person following shoulder dislocation is instability
Supracondylar fracture
Important to check NV status.
Is there an open fracture. Open fractures need washout with 0.9% saline, IV Abx, Photos to prevent repeated exposure and wound coverage with saline soaked gauze. Tetanus prophylaxis.
Check for signs of compartment syndrome
Examine for other injuries and take a history
Gartland classification is used to for supracondylar fracture
In Gartland 1- undisplaced and often difficult to detect. Assess for presence of elbow effusion. When there is a fracture bleeding causes an effusion which elevates the ant and post fat pad. A dark area is just visible around the distal end of the humerus on lateral x ray
Gartland 2- Only partially displaced, with the posterior cortex of the humerus, visible on the lateral x ray, still intact. NV injury less common
Gartland 3- Posterior cortex is completely displaced and fracture is off ended. No contact between the 2 fracture fragments. Can often cause NV comprimise and compartment syndrome
Key points in elbow x rays:
1) Ant humeral line
2) Radiocapitellar line
3) Elbow joint effusion by assessing ant and post fat pads
Most common nerve injured in supracondylar fractures is anterior interosseous nerve
Cubital fossa anatomy - Median nerve, brachial artery, Biceps tendon
Cubitus varus. Varus means delivation to midline. Forearm is deviated towards midline when elbow is extended and occurs most commonly from supracondylar fractures. Crucial that fracture is accurately reduced to stop this. Pins are used to hold fracture while it heels.
Distal radius fracture children
Physis is the medical term for growth plate.
Epiphysis is name given to part of bone next to joint.
Metaphysis is the area of bone where shaft meets the growth plate (physis)
Diaphysis is the shaft of the bone
Salter Harris fracture describes fractures around the growth plate. Correct management is important as these injuries have potential to close the physis and arrest growth prematurely
Type1- Slipped or straight across the physis. Transverse fracture through growth plate
Type2- Above the physis in the metaphysis or away from the joint. Fracture through the growth plate with a small metaphyseal element. Most common
Type 3- Lower - fracture below the physis. Fracture through the growth plate and through the epiphysis into the joint. Intraarticular fracture
Type 4- Through the metaphysis, physis and epiphysis. Intraarticular needs reduction
Type 5- Rammed or ruined physis (compression of the physis)
Type 3,4,5 are most associated with growth disturbance.
Displaced salter harris 2 fractures of distal radius are best managed with gentle manipulation under anaesthesia followed by application of plater cast.
Scaphoid fractures
Typically occur after FOOSH. On exam pain in anatomical snuff box, pain over the scaphoid tubercle and pain on telescoping the thumb.
May present with distal radius pain following a fall on outstretched hand.
Scaphoid fractures need to be accurately diagnosed and managed due to risk of AVN
Scaphoid series of X rays should be performed if suspecting scaphoid fracture. Four views instead of the usual 2 are performed
Best managed with 6 weeks in a scaphoid cast with repeat x rays at 6 weeks to check for signs of union.
Distal radius fractures
Take history, Examine joint above and below, ensure it’s not an open fracture, Check NV status and assess for other injuries.
The nerve most likely to be affected is median nerve.
Best managed with analgesia, manipulating the fracture with sedation and repeat x rays to confirm realignment.
Smiths fracture is a fracture of the distal radius with volar angulation and displacement. Patient likely to have fallen onto back of hand.
Colles fracture - More common dorsally angulated distal radius fracture.
Normal radiological measurements of distal radius are: 12 degrees of volar angulation, between +/- 2mm ulnar variance. 22deg radial inclination.
Hip Osteoarthiritis
LOSS (loss normal joint space, Osteophytes, Subcondral sclerosis, Subchondral cysts)
Trendelenburg sign- Ask the patient to stand and hold younr hand. Ask them to stand on their good leg and watch for pelvic tilt. Then do the same on the affected side. This tests the function of the abductor muscles (gluteus medius and minimus). These muscles normally pull opposite side of pelvis up, stopping it from dipping down.
In a positive test the patient will not be able to stand on one leg. Will lean over to the affected side or will apply pressure on your hand to steady their balance. in OA this is positive due to pain inhibiting the abductor muscles from working normally.
In OA. Degree of pain, night pain, pain on standing from sitting and x ray changes
Majority of those with severe OA who are fit and well are best treated with a THR. Head and neck of femur are excised and replaces with a new ball and socket. Both acetabular and femoral parts of joint are replaced.
Limp in child
X ray is mainstay for diagnosing and following up perthes disease. AP and Lateral. For children the lateral is best obtained with frog view lateral
Perthes disease is a form of AVN where femoral head loses blood supply. Usually presents in children 4-8. There is pain and limp.
Features of Perthes disease on X ray.
Widening of the joint space. Typically medial joint space is widened
Increased density of ossification centre of the femoral head. This is where necrosis occurs
Flattening of the femoral head. Necrosis of bone has lead to femoral head losing it’s structural integrity
Fragmentation some bone will reform and some replaced by fibrous tissue
Narrowing of joint space
Septic arthritis of hip: Presents with fever, inability to weight bear and raised inflammatory markers. X ray may show an effusion of the hip
Osteomyelitis of the femur: Fever and pain at affected side. It’s progressive rather than intermittent
Developmental dysplasia of the hip: More common in breech. Caused by deformity of hip joint such that femoral head is not held within the acetabulum. Instead it subluxes/dislocates.
0-4: DDH, Transient synovitis
4-10: Perthes disease, transient synovitis, Juvenile RA
14-16: SUFE
Perthes disease is a condition which generally resolves over 4 year period with limited long term functional problems. After AVN there is new bone formation. Perthes disease presenting at later stage has worse prognosis with more complications.
Treatment- Reassurance and analgesia, early operative intervenion, abduction brace, THR is a last resort
Pelvic fractures
Inititial trauma series it is important to obtain Portable AP chest and Pelvis x rays. Pneumothorax, rib fractures, flail chest, effusion suggestive of haemathorax.
Pelvic injuries can be classed on type of force leading to injury. Open book fractures are caused by AP compression force. There is disruption to pubic symphysis and injury to posterior ligaments of pelvis. Associated with major haemorrhage.
Lateral compression- Compression on lateral aspect of the pelvis. Leads to reduction in the pelvic volume. Haemorrhage less common
Vertical shear- falls from height/shearing force through pelvis
Bladder and urethral injuries commonly associated with pelvic fractures
Internal fixation - definitive treatment method for a major pelvic fracture.
External fixation - Pins and rods are used to rigidly fix pelvis externally in a more anatomical position
SUFE
On examination of a patient with SUFE. Knee pain, external rotation, Inability to weight bear, shortening of the femur
SUFE occurs in children between 8-17. More common boys. Slip occurs during a phase of accelerated growth and therefore SUFE tends to occur earlier in girls. Endocrine disorders, obesity, afro caribbean are risk factors. Can occur acutely following trauma or subacutely following short period of pain.
The slip in SUFE occurs posteriorly and medially. Therefore frog leg lateral views are best for diagnosing SUFE.
Earliest finding of SUFE are widening of physis with irregularity of physeal margins and osteopenia of the metaphysis and osteopenia of the metaphysis, which occur before any slipping of the epiphysis. Trethowan’s sign is when line drawn along lateral cortex of the femoral neck does not intersect the epiphysis.
20% chance of contralateral slipping.
Management is analgesia and surgical. If subtle slip then cannulated screw fixation.
Neck of femur fractures intracapsular
Initially stabilise patient, identify medical issues, take a full history of mechanism and take full social history. Blood tests should be performed to asses for:
1) Pre operative anaemia
2) Pre operative renal failure or electrolyte derangement may affect anaesthesia and fluid mx
3) G&S
4) Inflammatory markers- sepsis
5) Clotting drugs or liver disfunction may affect this so would need to be corrected
Garden classification
Intracapsular fractures often need surgery to have femoral head replaced. Garden classification used to categorise degree of displacement
Garden 1- undisplaced, incomplete. Including valgus impacted fractures
Garden 2- undisplaced complete
Garden 3- Complete fracture that is undisplaced or <50% displaced
Garden 4- Complete fracture that is completely or >50% displaced
1,2 give it a screw. Can use cannulated screws
3,4 Arthroplasty.
Patients under 65 should be considered for surgical fixation of intracapsular NOF within 6hrs. Doing so may reduce risk of AVN and preserve femoral head, improving long term functional outcome.
Intracapsular displaced- Young then surgical fixation. Elderly assess mobility and medical state, if mobile and independent then THR, if requires walking aids, carers or care home then hemi.
Undisplaced - young surgical fixation, elderly assess mobility and patient medical state, independent and well then consider surgical fixation. Unwell, dementia in pain then consider hemi
Neck of femur fractures extracapsular
History important to exclude other injury. Ask about previous history of malignancy/pain prior to fall. Exclude pathological fracture. To ensure this was a mechanical fall and no other medical problems led to fall.
E.g any blackout, sepsis, infection, ECG. To make sure patient is not vulnerable adult. To prevent further falls.
DHS and IM nail are main ways of treated extracapsular NOFs
Tibial plateau fracture
Lipohaemarthrosis is a joint effusion which contains both fat and blood.
Signifies presence of fracture communicating with the joint. Fat in the joint suggests communication between inside of bone and joint. There is also haemorrhage within the joint due to injuries to vascularised structures. As fat is less dense than blood, it will form a layer on top of the haemorrhage and this will be seen as a fat fluid level on horizontal beam of x ray.
Knee aspiration- Do not aspirate if metal work unless in theatre. Skin is cleaned and draped. Sterile gloves used. LA used to numb skin. Needle inserted and syringe to aspirate. Sent to lab for microscopy.
Most common site is lateral and slightly superior to patella.
Ensure consent obtained and risk of pain and infection
Tibial plateau fractures are difficult to see on x ray. CT scan allows excellent assessment of bones and give precise morphology of fracture.
