Hip and spine Flashcards
Describe the anatomy of the proximal femur
Head of femur
Neck of femur
2 trochanters- greater + lesser
-Between them is intertrochanteric line on Ant side
Describe the types of NOF and the clinical relevance
Broadly divided into
-Intracapsular: above the intertrochanteric line. Displaced vs non-displaced (Garden classification 1-4)
-Extracapsular: including or below the intertrochanteric line up to 5cm
Due to the blood supply to the femoral head (majority via circumflex arteries), intracapsular NOF risks avascular necrosis as it compromises blood supply. Therefore, these #s require different management
Describe the epidemiology + risk factors for NOF
- Elderly
- F > M
- Osteoporotic
- Frail/frequent falls
- Multiple comorbidities eg. AF
Describe the presentation of NOF
- Low energy fall +/- cardiac/syncopal episode
- Hip/groin pain: constant, severe, exacerbated by movement, radiates to knee
- Inability to weight-bear
Describe the signs of NOF on examination
-General: in pain, hypovolaemic
-Inspection: leg shortened + externally rotated, bruising, swelling
-Tenderness over the hip area
-Unable to SLR or weight-bear
+/- distal pulses or sensation
Describe the immediate management of suspected NOF
A to E approach
- Examine hip + look for additional injuries
- Analgesia ASAP (usually opioid)
- Assess fluid status + resus if required
- IV access + bloods: FBC, CRP, U+Es, clotting, G+S, glucose
- ECG
- Imaging: Xray hip AP and lateral views (or CT if traumatic) + CXR
- Assess cognitive impairment eg. 4AT
Describe the overall management of confirmed NOF
- Ortho referral
- Make NBM
- Analgesia regularly
- IV fluids, IV antibiotics (prophylactic)
Conservative vs surgical management
- Conservative not frequently offered, 6-8 wks bedbound
- Surgical depends on type of fracture
Describe the types of surgical management of NOFs
Intracapsular:
- Non-displaced: internal fixation w cannulated screws
- Displaced: young- internal fixation, old-THR, unfit- hemiarthroplasty
Extracapsular:
- Dynamic hip screw (trochanteric)
- Intramedullary nail (subtrochanteric)
What are the important things to assess/consider in someone with hip fracture and why?
- Type of fracture (influences Mx)
- Cause of fall/injury (eg. arrhythmia? pneumonia?)
- Cognitive impairment (cause, consent?)
- Anticoagulation
- Fitness for surgery eg. ECG, FBC, clotting
Describe the post-op management of hip fractures
- Pain management
- Monitor bladder + bowels
- Wound care
- DVT prophylaxis
- Early mobilisation
- MDT input with orthogeris: physio, OT, PT
- Identify + treat underlying cause
- Osteoporosis Mx eg. Vit D/Ca, DEXA, bisphos.
Describe the presentation of trochanteric bursitis
- Gradual onset pain and swelling over lateral hip (greater trochanter)
- Pain worse on movement, standing, lying on side
- Stiffness
Describe the management of trochanteric bursitis
Conservative:
- Rest + ice
- Analgesia
- Physio
Describe the complications of hip fractures
- VTE
- Avascular necrosis
Surgical/post-op:
- Intra-op, anaesthetic
- Non-union, failure of fixation
Describe the prognosis for hip fractures
10% die within 1 month, 30% within 1 year
Frequent loss of functional ability
Describe the classic presentation of transient synovitis
Child
Presenting w acute limp, hip pain, swelling + stiffness following viral infection
Not acutely inflammed eg red/hot
Describe the management of pubic rami fractures
Usually conservative, heal within 6-8 weeks
What is disc prolapse?
Occurs when the nucleus pulposus herniates through the annulus fibrosis (inside of the disc through the outside eg. like jelly donut)
Describe the presentation of disc prolapse
- Low back pain: mechanical-achy, intermittent, exacerbated by movement, +/- radiation
- Nerve root compression (radiculopathy) typically in L5 and S1 roots due to prolapse of L4/5 and L5/S1
What is radiculopathy? What are some causes?
The clinical syndrome caused by nerve root compression
-Low back pain
-Pain in dermatomal distribution
-Shooting/tingling/numbness
-Decreased/absent reflexes
-Muscle weakness
Caused by narrowing/compression of the nerve root eg. disc degeneration, bony spurs, disc prolapse, tumour, stenosis. Overall, OA is typically responsible for these
Describe the management of disc prolapse
Conservative:
- Rest, heat, physio
- Analgesia
Surgical:
-Discectomy, laminectomy
Define spinal stenosis
Spinal stenosis is narrowing of the spinal canal
Describe the aetiology of spinal stenosis
Typically caused by wear and tear (due to OA)
- > specifically, facet joint OA
- *Spondylosis
May also be caused by: iatrogenic (eg fusion), congenital, post-traumatic
Define spondylosis. What are the potential consequences?
Spondylosis refers to degeneration of the spine eg. discs, facet joints
Spondylosis can lead to spinal stenosis and cord compression which present as myelopathy, radiculopathy, cauda equina syndrome etc.
Describe the presentation of spinal stenosis
Presents with neurogenic claudication or radiculopathy
Claudication:
-Intermittent aching buttock/LL pain or heaviness when walking +/- numbness or tingling
-**Eased by leaning forward, worse on extension
-Progressively worsening
Describe the signs of spinal stenosis on examination
- Usually unremarkable
- Stooped posture when walking
- No major neuro deficits
- Normal peripheral pulses
What is the best imaging technique for spinal problems?
MRI
Describe the management of spinal stenosis
Conservative:
- Rest in acute episodes
- Physio, heat, massage
Medical:
- Course of NSAIDs
- Transforaminal steroid injections
- Chronic pain meds eg. gabapention
Surgical:
-If no improvement w medical. Decompression
Define spondylosis, spondylolysis and spondylolisthesis
Spondylosis: generalised OA degeneration of the spine
Spondylolysis: stress fracture through the pars of the lumbar vertebrae
Spondylolisthesis: when a pars fracture ^ allows the affected vertebrae to slip anteriorly to the inferior vertebrae
Describe the presentation of spondylolysis and spondylolisthesis
-May be asymptomatic
-Back pain common: worse on activity, radiates to bum
+/- myelopathy/radiculopathy in severe slips
Describe the management of spondylolysis and spondylolisthesis
Conservative: often enough
- Rest
- NSAIDs
- Physio, brace
Surgical:
-Spinal fusion
Describe the aetiology of spinal fractures
- Trauma
- Osteoporosis
- Tumours
- Metabolic bone disease
Where is the most common location for spinal fractures?
Lower thoracic spine, lumbar spine
Commonly thoracolumbar junction (trauma)
Describe the types of spinal fracture and when they occur
-Compression: common in osteoporosis
-Fracture-dislocation: trauma
+ others
Describe the presentation of spinal fracture
-Back pain: worse on movement, may radiate
+/- radiculopathy or myelopathy
What does spinal decompression surgery mean? When is it used?
Any surgical procedure to relieve compression of the spinal cord/nerves eg. laminectomy, discectomy, foraminectomy
Used in conditions causing symptoms of compression:
-MSCC
-Spinal stenosis
-Spinal fracture
-Disc prolapse
-Spondylosis
Describe the presentation of discitis
Low back pain: constant, non-mechanical, felt at night
Fever, unwell
Weight loss
RFs: IVDU, immunosuppression, DM
Describe the investigations for discitis
Bloods: FBC, CRP, U+Es, LFTs, VBG, culture
Imaging: Xray lumbar spine, MRI
