Injury + Surgery Flashcards
what is the pathogenesis of avascular necrosis of the femoral head?
- increased venous pressure in femoral head
- pressure cuts off arterial supply
what are the 3 zones of cartilage?
superficial zone
transitional zone
deep zone
what is the orientation of the cartilage fibres in the superficial zone?
parallel to the surface
what is the orientation of the cartilage fibres in the transitional zone?
randomly orientated
what is the orientation of the cartilage fibres in the
perpendicular to the surface
what section of the cartilage must the damage reach for healing to occur?
the tidemark
what cartilage type is the hyaline cartilage replaced with during healing?
fibrocartilage
what is protrusio?
when the femur starts to protrude into the acetabulum itself
which is protrusio more common in- RA or OA?
rheumatoid arthritis
what is an osteotomy?
a controlled cut of the bone in order to realign or redistribute weight
what is a CAM bony feature of the hip joint? (abnormal)
a bigger bump of the femoral neck (no normal taper)
what is a pincer bony feature of the hip joint? (abnormal)
extra bone on the lateral side of the acetabulum
what is the surgical treatment of an asymptomatic pincer or CAM feature on a hip joint?
nothing
what is the surgical treatment of a symptomatic pincer or CAM feature on a hip joint?
shaving of the area of bone to reshape
what is the surgical management of early avascular necrosis?
decompression
drill a hole to let pressure escape
what are the 3 main non-surgical managements of an arthritic hip joint?
weight loss
analgesia
physiotherapy
when is proprioception more of an issue- hip or knee replacements?
knee replacements
compare hip arthritis pain to trochanteric bursitis pain?
hip arthritis pain: generalised achy pain, tender over groin
trochanteric bursitis: localised lateral hip pain, not tender over groin
why can only the peripheral 1/3 of a meniscus be expected to heal?
only the peripheral 1/3 has a blood supply
the rest of the meniscus is avascula
compare the medial and lateral menisci in terms of mobility?
medial menisci- fixed
lateral menisci- more mobile
which compartment does the knee mainly pivot on during flexion and extension?
medial compartment
due to the knee mainly pivoting on the medial compartment during flexion and extension, what way does the tibia slightly rotate during each movement?
flexion- slight internal rotation
extension- slight external rotation
why is the medial meniscus under greater stress than the lateral menisci?
because pivoting of the tibia mainly occurs on the medial compartment
which menisci is more likely to tear- medial or lateral?
medial menisci
what ligament in the knee is the main resistor of valgus stress?
medial collateral ligament
what ligament in the knee is the main resistor of varus stress?
lateral collateral ligament
what ligament in the knee is the main resistor of anterior subluxation of the tibia?
anterior cruciate ligament
what ligament in the knee is the main resistor of posterior subluxation of the tibia? (ie anterior subluxation of the femur)
posterior cruciate ligament
what ligament is the main resistor of excessive internal rotation of the tibia?
anterior cruciate ligament
what ligament is the main resistor of hyperextension of the knee?
posterior cruciate ligament
what ligaments are the main resistor of external rotation of the tibia?
posterolateral corner ligaments
what is the posterolateral corner made of
posterior cruciate ligament
lateral collateral ligament
smaller ligaments
popliteus
compare the medial and lateral collateral ligaments in terms of capacity to heal?
MCL- great capacity to heal
LCL- poor capacity to heal
what type of instability may a MCL rupture lead to?
valgus instability
what type of instability may a ACL rupture lead to?
rotatory instability (excessive internal rotation)
what type of instability may a PCL rupture lead to?
recurrent hyperextension
or
instability when descending staids
what type of instability may a posterolateral corner rupture lead to?
varus instability
and
rotatory instability [excessive external rotation]
when must a longitudinal tear in a meniscus be in order to heal?
peripheral
how do younger patients get meniscal tears?
trauma-
sporting injury (usually twisting)
getting up from squatting position
how do older patients get meniscal tears?
atraumatic spontaneous degenerate tears
what are 50% of ACL tears accompanied by?
meniscal tear
what is the investigation of choice for a suspected meniscal tear?
MRI
what main type of meniscal tears do not heal?
radial tears
when do you consider a arthroscopic menisectomy?
for meniscal tear with:
- mechanical symptoms (eg painful catching or locking)
- irreparable tears
- failed meniscal repair
what type of menisci tear can give you an acute locked knee?
bucket handle tear
what is the treatment for acute locked knee due to a bucked handle tear?
urgent surgery
-arthroscopic repair
what will happen to the knee of a patient with acute locked knee if the knee remains locked?
fixed flexion deformity
if the acute locked knee is irreparable, what is the next step to unlock the knee and prevent further damage?
partial menisectomy
what type of patients is surgery for degenerative meniscal tears reserved for?
patients with mechanical symptoms
not solely for pain
what is the grading system of ligament injuries?
grade 1 - sprain, some fibres are torn but all macroscopic structures intact
grade 2 - partial tear, some fascicles disrupted
grade 3 - complete tear
what type of injuries cause MCL tears?
valgus stressing injuries
what is the main treatment of MCL tears?
bracing, early motion and physio
rarely require surgery
what type of injuries cause ACL tears?
twisting injuries
what type of injuries causes LCL tears?
varus stressing injuries
hyperextension injuries
what type of injuries cause PCL tears?
direct blow to anterior tibia
hyperextension injuries
what type of surgery is used for the treatment of an ACL tear?
ACL reconstruction with a graft
ACL repair doesnt work
what is the most commonly used graft for ACL reconstruction?
autograft from hamstringe tendon
how can physiotherapy help to stabilise ACL deficient knees?
builds up the surrounding muscles
what is the ACL rupture rule of thirds?
1/3 patients compensate and are able to function well (no surgery needed)
1/3 patients can avoid instability by avoiding certain activities (no surgery needed)
1/3 patients do not compensate and have freq instability or cannot gt back into high impact sport (surgery might be needed)
what is the role of surgery (ACL reconstruction) in ACL rupture?
consider when:
- rotatory instability does not respond to physiotherapy
- young adult/adolescent
- patient keen on high impact sport
- when a meniscal repair also has to be done
does ACL reconstuction affect future osteoarthritis risk?
if you rupture your ACL you will get osteoarthritic changes within 10 years, regardless of surgery
ACL reconstruction may even accelerate the osteoarthritic process
what nerve is commonly affected in LCL injury?
common fibular (peroneal) nerve [palsy]
what is the treatment for a complete LCL rupture?
urgent repair (within 2-3 weeks)
where does knee pain and bruising occur in a PCL rupture?
popliteal fossa
when does PCL require reconstruction?
if part of a multiligament knee injury
this is more common than isolated PCL ruptures
what are the 3 major complications of knee dislocation?
- popliteal artery tear
- nerve injury (common fibular)
- compartment syndrom
what needs to be done ASAP with a knee dislocation?
emergency reduction
check neurovascular status
why do you only operate on a knee dislocation a few weeks after the trauma?
wounds don’t close so leave fracture blisters
what are the 4 main causes of weakened tendons that can lead to extensor mechanism rupture?
- previous tendonitis
- steroids
- chronic renal failure
- drugs (eg ciprofloxacin)
what is the main clinical test that indicates extensor mechanism rupture?
unable to perform straight leg raise
what is the treatment of extensor mechanism rupture?
surgical repair
what does a pop at the time of knee trauma suggest?
ACL rupture
what does a haemarthrosis (within an hour) within the knee joint suggest?
ACL rupture
what does an effusion (within a day) within the knee joint suggest?
meniscal or chondral injury
why can haemarthrosis cause generalised knee pain?
blood is an irritant to the knee capsule
why does ACL rupture cause a haemarthrosis?
because the ACL has a big blood vessel through it which can rupture
what does knee locking suggest?
bucket handle meniscal tear
what does localised pain on joint line suggest?
meniscal tear
what are the 4 main substances which comprise hyaline cartilage?
water
collagen
proteoglycans
chondrocytes
what type of strength do the proteoglycans provide the hyaline cartilage with?
compressive strength
what type of strength does the collagen provide the hyaline cartilage with?
tensile strength
how do the proteoglycans provide compressive strength to hyaline cartilage?
hydrophillic so attract water and expand like a balloon
what are the 2 main categories of articular cartilage defects?
traumatic
atraumatic
what are the 3 main subgroups of atraumatic articular cartilage defects?
- osteochondritis dissecans
- osteoarthritis
- inflammatory arthritis
what is osteochondritis dissecans?
a joint condition causing necrosis of subchondral bone due to lack of blood supply
the bone and cartilage fragment can then break free and cause pain/hinder joint motion
who most commonly gets osteochondritis dissecans?
adolescence
what is the name of the surgical techniques used for a defect in the articular cartilage (that wont heal itself)?
cartilage regeneration techniques
what are the 4 main cartilage regeneration techniques?
- drilling/ microfracture
- osteochondral autograft/allograft
- mosaicplasty
- membrane-induced autologous chondrocyte implantation (MACI)
what is the purpose of drilling/ microfracture for the treatment of a defect in articular cartilage?
causes bleeding which stimulates stem cells to come in and differentiate into chondroblasts
(cartilage regeneration technique)
what is osteochondral autograft or allograft?
taking cartilage from other areas of the bodyfrom donors
what is mosaicplasty?
taking small fragments of cartialge from low-weight bearing surfaces and inserting them into the bigger section of defective cartilage
which of the cartilage techniques is used in the NHS?
microfracture
simplest and cheapest technique
compare the causes of shoulder pain of a young adult, middle aged adult or elderly adult?
young adult- instability
middle aged- rotator cuff tear or frozen shoulder
elderly- glenohumeral OA
what is impingement syndrome?
when the tendons of the rotator cuff muscles (especially supraspinatus) are compressed within the tight subacromial space during movement producing pain
why does a patient with impingement syndrome typically have a painful arc between 60 to 120 degrees of abduction?
painful as the inflamed area of supraspinatus tendon passes through the subacromial space
what are the 3 main causes of impingement syndrome?
- tendonitis subacromial bursitis
- acromioclavicular OA with inferior osteophyte
- a hooked acromion
what are the 2 clinical tests for suspected impingement syndrome?
painful arc
Hawkins-Kennedy test
what is the first line treatment of impingement syndrome?
NSAIDs
analgesics
physio
subacromial steroid injections
if non-operative management of impingement syndrome is ineffective, what surgical management can be carried out?
subacromial decompression surgery
what is the non-operative management for rotator cuff tears?
physiotherapy and subacromial steroid injections
what is the operative management for rotator cuff tears?
rotator cuff repairs with subacromial decompression
why do rotator cuff repairs fail in a 3rd of patients?
the tendon is usually disease or retracted too far
why do middle aged patients commonly get rotator cuff tears?
because rotator cuff muscles can tear with minimal or no trauma as a consequence of degenerate changes in te etendons
what are the 3 muscles most commonly involved in rotator cuff tears, and which out of theses is the most common?
supraspinatus (most common)
subscapularis
infraspinatus
how are rotator cuff tears confirmed?
ultrasound or MRI
what is frozen shoulder?
when the capsule and glenohumeral ligaments become inflamed and so thicken and contract
(adhesive capsulitis)
what is the principle clinical sign of frozen shoulder?
loss of external rotation
what are the 3 conditions associated with frozen shoulder?
diabetes
hypercholesterolaemia
dupuytren’s disease
how long does frozen shoulder usually last?
18-24 months
pain first, then stiffness
what is acute calcific tendonitis?
calcium deposition in the supraspinatus tendon which causes acute severe shoulder pain
what can you see on xray of acute calcific tendonitis?
calcium deposition in the supraspinatus tendon just proximal to the greater tuberosity
how is acute calcific tendonitis managed?
pain relief- subacromial steroid and local anaesthetic injections
(condition is self-limiting)
what are the 2 types of shoulder instability?
traumatic
atraumatic
in traumatic instability of the shoulder what direction of dislocation mainly occurs?
anterior dislocation
in atraumatic instability of the shoulder what direction of dislocation occurs?
multidirectional
inferior, anterior or posterior
what type of patients get atraumatic instability of the shoulder?
patients with generalised ligamentous laxity
what surgical treatment can be done for a patient with a shoulder dislocation which didn’t stabilise? (ie now has instability)
bankart repair
(open or arthroscopic)
which reattaches the labrum and capsule to the anterior glenoid
what forms the carpal tunnel?
the carpal bones of the wrist and the flexor retinaculum
what nerve passes through the carpal tunnel?
median nerve
what is the cause of carpal tunnel syndrome?
median nerve compression in the carpal tunnel
why can rheumatoid arthritis cause secondary carpal tunnel syndrome?
synovitis causes reduced space which causes compression of the median nerve
why do conditions sch as pregnancy, diabetes, chronic renal failure and hypothyroidism cause secondary carpal tunnel syndrome?
fluid retention which causes compression of the median nerve
who is more affected by carpal tunnel syndrome-F or M?
females
fractures of the wrist/around the wrist can cause carpal tunnel syndrome, what particular fracture is especially likely?
colles fracture
what do patients with carpal tunnel syndrome present with?
parasthesia (tingling), loss of sensation or clumsiness in the median nerve innervated digits (thumb and radial 2.5 fingers)
what are the 2 tests which reproduce the symptoms of carpal tunnel syndrome?
tinel’s test
phalen’s test
what is tinel’s test?
percussing over the median nerve (or ulnar nerve)
if positive, this will reproduce the symptoms of carpal tunnel syndrome (or cubital tunnel syndrome)
what is phalen’s test?
holding the wrists hyper-flexed
if positive this will reproduce the symptoms of carpal tunnel syndrome
how do you confirm the diagnosis of carpal tunnel syndrome?
nerve conduction studies
what are the non-operative ways to manage carpal tunnel syndrome?
night splints to prevent flexion
corticosteroid injections
what is the surgical management of carpal tunnel syndrome?
carpal tunnel decompression
what does carpal tunnel decompression involve?
division of the transverse carpal ligament under local anaesthetic
what is the cause of cubital tunnel syndrome?
compression of the ulnar nerve in the cubital tunnel
what do patients with cubital tunnel syndrome present with?
paraesthesia in the ulnar 1.5 fingers and weakness of the muscles innervated by the ulnar nerve
what tests can be used for detecting cubital tunnel syndrome?
tinel’s test (of cubital tunnel)
froment’s test
what does Froment’s test assess?
weakness of the adductor pollicis
seen in cubital tunnel syndrome
why might there be compression of the ulnar nerve in the cubital tunnel?
due to a tight band of fascia forming over the roof of the tunnel (osborne’s fascia)
or
tightness at the intermuscular septum as the nerve passes between the two heads of flexor carpi ulnaris
how is he diagnosis of cubital tunnel syndrome confirmed?
nerve conduction studies
what causes lateral epicondylitis?
-repetitive strain
-degenerative enthesopathy
causing microtears in common extensor origin
what is an enthesopathy?
inflammation at the origin or insertion of a tendon or ligament into bone
what are the clinical features of lateral epicondylitis?
painful and tender lateral epicondyle
pain on resisted middle finger and wrist extension
what is the treatment of lateral epicondylitis?
usually resolves with: period of rest NSAIDs steroid injections elbow clasp (ultrasound therapy) surgical treatment of refractory cases
what causes medial epicondylitis?
-repetitive strain
-degenerative enthesopathy
causing microtears in comon flexor origin
which is more common- medial or lateral epicondylitis?
lateral epicondylitis
why can steroid injections not be used in the treatment of medial epicondylitis?
risk of ulnar nerve injury when injectinf this area
what is the surgical treatment of RA/OA of the elbow which has failed non-operative management?
surgical excision of the radial head
or
total elbow replacement
what is the major con of total elbow replacement?
lifting weight restriction of 2.5kg
what are dupuytren’s contracture?
a proliferative connective tissue disorder where the specialised palmar fascia undergoes hyperplasia
normal bands form nodules and cords and progress to contractures
which joints are commonly affected in dupuytren’s contractures?
MCP and PIPs of ring finger and little finger
in dupuytren’s contractures, what type of cells proliferate and what abnormal substance do they produce?
myofibroblast cells
abnormal type 3 collagen (should be type 1)
who more commonly gets dupuytren’s contractures- M or F?
males
dupuytren’s contractures can sometimes be familial, what sort of inheritance is it?
autosomal dominant (with variable penetrance)
what condition can dupuytren’s contractures be a feature of?
alcoholic cirrhosis
what drug can dupuytren’s contractures be a side effect of?
phenytoin
what population with a chronic condition is dupuytren’s contractures seen more commonly in than the normal population? (ignoring other fibromatoses)
diabetics
up to what degrees of contracture in dupuytren’s contractures can be tolerated at the MCP and the PIP joints?
MCP can tolerate 30 degrees
PIP readily stiffens (any contracture here is usually an indication for surgery)
what are the indications of surgery for dupuytren’s contractures?
- contractures interfering with function
- PIP joint involvement
what is the surgical treatment of dupuytren’s contractures?
fasciectomy (removal of diseased tissue) or fasciotomy (division of cords) or amputation
what is trigger finger?
tendonitis of a flexor tendon causing a nodular enlargement distal to the A1 fascia pulley of the metacarpal neck
movement of finger causes clicking noise
why does movement of a trigger finger cause clicking?
clicks happen as the nodle catches on and then passes underneath the A1 pulley
why can a trigger finger lock in a flexed position?
nodule passes under the pulley but can go back through on extension
what is the treatment for trigger finger?
steroid injections
surgery for persistent cases (division of A1 pulley to allow tendon to move freely)
what is arthrodesis?
artificial ossification of two bones at a joint (fusion)
what is arthroplasty?
surgery to restore integrity of a joint
an artificial joint can be used, or bones might just be resurfaced
what surgical technique can be done to prevent tendon rupture in a RA patient?
tenosynovecomy (excision of synovial tendon sheath)
what is the surgical treatment for the rupture an extensor tendon to the wrist/fingers in a patient with RA?
tendon transfer joint fusions (repair is not possible)
why do all total hip arthroplasty eventually fail?
due to loosening of the prosthetic components
what is revision hip replacement?
a re-do replacement after a hip replacement has failed
more complex than first time hip replacement
if avascular necrosis of the femur head is detected early (pre-collapse) what is the treatment?
decompression by drilling holes into the abnormal area
if avascular necrosis of the femur head is detected late (collapse) what is the treatment?
only option is total hip replacement
what injury does a direct blow to the anterior tibia with the knee flexed suggest?
PCL rupture
what confirms the diagnosis of a meniscal tear?
MRI
what is the treatment for a traumatic meniscal tear?
- repair (doesn’t usually work)
- partial menisectomy
why should a degenerative meniscal tear not be treated with a menisectomy?
removal of meniscal tissue may cause increase stress on already worn surfaces
how can chronic MCL instbility be treated? (ie MCL hasn’t healed)
MCL tightening or reconstruction with tendon graft
why are regular checks of the foot circulation essential after a knee dislocation?
intimal tears can later thrombose
Vacular stenting or by-pass would be required
in a knee dislocation, what ligaments are torn?
ACL, PCL, MCL and LCL
after prolonged ischamia due to a knee dislocation, what may reperfusion result in? (and how can this be treated)
compartment syndrome
fasciotomy
what is the most likely extensor mechanism of the knee rupture in a patient under 40?
patellar tendon rupture
what is the most likely extensor mechanism of the knee rupture in a patient over 40?
quadriceps tendon rupture
why should steroid injections for tendonitis of the extensor mechanism of the knee be avoided?
high risk of tendon rupture
how do you determine whether the extensor mechanism of the knee is intact?
straight leg raise
what is the treatment of complete or substantial partial tears of the knee? extensor
surgical treatment (tendon repair or reattachment)
what is patellofemoral dysfunction?
a group of disorders of the patellofemoral articulation resulting in anterior knee pain
what is chondromalacia patallae?
softening of the hyaline cartilage around the patella
patellofemoral dysfunction
what exacerbates the anterior knee pain of pseudofemoral dysfunction?
going downhill
what does physiotherapy of pseudofemoral knee dysfunction aim to do?
rebalance quadriceps
strengthens vastus medialis
what type of locking does patellofemoral dysfunction cause?
pseudo-locking
knee acutely stiffens in flexed position
what direction does the patella almost always dislocate in?
lateral direction
what type of fluid builds up within the knee joint after patellar dislocation?
lipo-haemarthrosis
how does the risk of recurrent instability vary with age?
risk decreases as age increases
what is hallux valgis?
a deformity of the great toe where 1st metatarsal moves medially and big toe moves laterally
who is hallux valgis more common in- M or F?
females
why does a bunion form over the medial 1st metatarsal head in hallux valgus?
medial aspect of 1st metatarsal will end up rubbing on shoes resultin in inflamed bursa
what may happen to the second toe with hallux valgus?
1st toe may override it
ulceration and skin break down (due to rubbing)
surgical treatment of hallux valgus should be considered with caution, what is the treatment?
osteotomies to realign bones
and
soft tissue procedures to tighten slack tissues and release tight tissueshallu
what is hallux rigidus?
OA of the 1st MTP joint
what is the gold standard surgical treatment of hallux rigidus?
arthrodesis (fusion)
what does arthrodesis of hallux rigidus prevent women doing?
wearing heels
what is the surgical management of morton’s neuroma?
excision
where do metatarsal stress fractures most commonly occur?
2nd metatarsal most commonly
followed by 3rd metatarsal
what is the treatment for metatarsal stress fractures?
rest for 6-12 weeks in a rigid soled boot
what is achilles tendonitis caused by?
repetitive strain or degenerative process (microtears)
what is the treatment of achilles tendonitis?
rest, physio, heel raise, splint or boot
resistant cases may benefit from tendon decompression
why should steroid injections not be administered around the achilles tendon?
risk of rupture
what age groups does achilles tendon rupture tend to occur in?
middle aged or older groups
what clinical signs are present in achilles tendon rupture?
weakness of plantar flexion
palpable gap in tendon
simmonds test positive
what is simmonds test?
squeeze calf and ask patient to plantar flex
positive test if no plantarflexion
(achilles tendon rupture)
what is plantar fasciitis caused by?
repetitive stress or degenerative
what tendon do flat footed people have a higher risk of tendonitis of?
posteiror tibialis tendon
what are the 3 most coommon causes of acquired flat foot?
- posterior tibialis tendon rupture or stretch
- RA
- diabetic neuropathic joint destruction
how is pes cavus treated?
if supple: soft tissue release and tendon transfer
if rigid: calcaneal osteotomy
severe cases may require arthrodesis
explain claw toes?
hyperextension at MTPJ
hyperflexion at PIPJ
hyperflexion at DIPJ
explain hammer toes?
hyperextension at MTPJ
hyperflexion at PIPJ
hyper extension at DIPJ
what is the surgical treatment of claw or hammer toes?
tenotomy (division of overactive tendon)
tendon transfer
arthrodesis (esp of PIP joint)
toe amputation
where does pain from achilles tendonitis present?
achilles tendon itself
insertion on calcaneus
what is the Heston table top test?
where the patient is asked to place their palm flat on the table
failure to do so- fixed flexion contracture at MCPJs (quick screening tool for whether patient with dupuytren’s may benefit from surgical management)
what are ankle fractures most commonly cause by?
twisting forces (commonly inversion or twisting on a planted foot)
what Weber’s classification indicated the ankle fracture is definitely unstable?
Weber’s C
what means an ankle fracture is unstable?
talar shift
if an ankle fracture is stable (ie no talar shift) what is the treatment?
cast or boots
if an ankle fracture has no talar shift but is a suspected fracture what is the treatment?
cast or boots and X-ray again in a week to see if talus has shifted
what are the 2 types of giant cell tumour of the tendon sheath?
(and which is most common)
localised and diffuse
localised is more common
what is the presentation of a giant cell tumour of the tendon sheath?
firm, discreet swelling on volar aspect of digits
what is the managment of giant cell tumout of tendon sheath?
usually left alone
if functional issue- marginal excision
what is the treatmend of acromioclavicular joint dislocation?
conservatively with NSAIDs, analgesics and steriod or local anaesthetic injections
what is the mainstay of treatment of a frozen shoulder?
physio
what part of the glenoid labrum is damaged in a SLAP tear?
superior labrum
why do young people rarely get rotator cuff tears?
because normal, healthy rotator cuff muscles don’t tear (even with trauma)
what is the difference between a painful arc and crescendo arc?
painful arc- pain on abduction from around 50- 120 degrees (no pain at the very top) : think rotator cuff impingement
crescendo arc- increasingly painful as you abduct : think ACJ pathology
what biglaini grading is a hooked acromion?
biglaini grade 3
as the biglaini grade increases what happens to the risk of impingement?
risk of impingemnet increases
when are reverse arthroplastys used?
massive rotator cuff tears
what is the purpose of a bankart repair?
fixes the defect in the glenoid labrum to prevent from recurrent dislocation
which is always abnormal on x-ray of elbow- anterior or posterior fat pad?
posterior fat pad
why can anterior and posterior fat pads of the elbow be displaced?
elbow joint effsion
why is the growth plate of a bone prone to injury? (ie in children’s bone)
the growth plate is the weakest part of the developing bone
what is a Salter-Harris fracture?
a fracture that involves the growth plate of a bone (physis)
what is a hemiarthroplasty?
only replace one side of the joint
ie operate on humeral head, leave glenoid alone
who tends to get radial buckle fractures?
children with soft bones
who tends to get scaphoid fractures?
young males
where is the most common area of the scaphoid to fracture?
the mid-scaphoid (waist)
what is a bennett’s fracture?
a fracture of the base of the first metacarpal bone which extends into the carpometacarpal joint (nearly always associated with subluxation of the carpometacarpal joint)
what is the most common fracture of the thumb?
a bennett’s fracture
why can lower limb fractures appear sclerotic?
because they often involve axial force with bone impaction
what direction do hips typically displace in?
posterior direction
compare treatment of intra-capsular femoral fractures to extra-capsular femoral fractures?
intra-capsular: hemiarthroplasty (young person- reduction and screw fixation may help)
extra-capsular: internal fixation
what space does the effusion accompanied by significant knee soft tissue tend to fill?
the suprapatellar space
lipohaemarthrosis collecting within the suprapatellar recess of is a specific sign of what type of fracture?
(can be seen on x ray)
an intra-articular fracture
what condylar side is most commonly fractured in a tibial plateau fracture?
lateral condyle fracture
how do you treat swan-necking?
splintage
when fusing a joint what is the main pro and what is the main con?
- reduced pain
- reduced range of movement
when fusing the wrist joint, what movements are taken away? (but what movements remain?)
flexion /extension removed
pronation and supination remain
what type of movement is especially lost in glenohumeral joint OA?
external rotation
what is a hemiarthroplasty?
only operate on one side of the joint
ie operate on humeral head, leave glenoid alone
what is the most common operation for glenohumeral OA?
hemiarthroplasty
-resurfacing the humeral head
what does a reverse arthroplasty allow the deltoid to do?
to initiate abduction (ie without the supraspinatus)
what are the 4 main surgical strategies for the management of an arthritic joint?
- arthroplasty (joint replacement)
- excision or resection arthroplasty
- arthrodesis
- osteotomy
why will a joint replacement eventually fail?
will eventually either loosen or the components will break down
what can metal within the joint replacement cause?
can cause the formation of inflammatory granulomas (pseudotumours) which lead to muscle and bone necrosis
what can polyethylene within the joint replacement cause?
an inflammatory response within the bone causing osteolysis which leads to loosening
what can ceramics within the joint replacement cause?
shattering of the joint replacement
what is the treatment of a deep joint infection if diagnosed within the first 2-3 weeks?
surgical washout and debridement
+ prolonged parenteral antibiotics
(in attempt to salvage joint)
what is the treatment of a deep joint infection if diagnosed after 3 weeks’;
removal of infected implants and all foreign material
6 weeks with no joint and parenteral antibiotics
re-do joint replacement once infection is under control
what is an excision or resection arthroplasty?
removal of bone and cartilage of one or both sides of a joint
what do the vast majority of soft tissue inflammatory problems settle with?
rest, analgesia and anti-inflammatory medications
what is surgical debridement?
removal of diseased tissue
what is radiculopathy caused by?
compression or irritation of a nerve as it exits the spinal column
why is a flexor tendon sheath infection a surgical emergency?
can cause loss of finger function (which could be permanent)
what is the management of flexor tendon sheath infection?
wash out tendon sheath
what is a laceration?
blunt wound with a break in the skin
how do you relieve the pressure of a subungual haematoma?
heat a paper clip and use it to melt through the nail
what finger is fractures in a boxers fracture?
little finger
what is the treatment of a boxer’s fracture?
‘buddy strap’ + early mobilisation
how do you make a rotational finger deformity more obvious?
ask patient to flex fingers
what is the treatment for a mallet finger?
splint (prevents DIP from moving)
why does holding the distal phalanx of the middle finger allow isolation of the FDS when flexing the index finger?
because FDP muscle bellies are all one, so holding the 3rd distal phalynx prevents the FDP being flexed
so flexing the index finger will only be flexing the FDS of that finger
what is eschar?
thick, leathery, inlastic skin which can form after burns
when would primary bone healing occur vs secondary bone healing?
primary- minimal fracture gap (less than 1mm)
secondary- gap at fracture site
what are the 4 main steps of secondary bone healing?
- inflammation
- soft callus
- hard callus
- remodelling
what 4 things are required for good secondary bone healing?
- good oxygen supply
- good nutrient supply
- stem cells
- a little movement or stress
what type of non-union occurs in attempted secondary bone healing with a poor blood supply?
atrophic non-union
what type of non-union occurs in attempted secondary bone healing with no movement?
atrophic non-union
what type of non-union occurs in attempted secondary bone healing with too big a fracture gap?
atrophic non-union
what type of non-union occurs in attempted secondary bone healing with tissue trapped in the fracture gap?
atrophic non-union
what type of non-union occurs in secondary bone healing with excessive movement?
hypertrophiic non-union
why may smoking severely impair fracture healing?
vasospasm
what are the 5 basic fracture patterns?
- transverse fractures
- oblique fractures
- spiral fractures
- comminuted fractures
- segmented fractures
which pattern of fracture is most likely to shorten?
oblique fracture
which 2 patterns of fracture are the most unstable?
comminuted fracture and segmental fracture
what is a comminuted fracture?
fractures with 3+ fragments
what type of energy injries cause comminuted fractures?
high energy injuries
which patterns of fractures can interfragmentary screws potentially be used in?
oblique fractures
spiral fractures
how is a segmental fracture satbilised?
with long rods or plates
which type of fracture has a greater risk of stiffness, pain and post-trauma OA- intra-articular fracture or extra-articular fracture?
intra-articular fracture
what fragment of fractured bone does displacement describe the direction of translation of?
displacement describes the direction of translation of the distal fragment
what are the 4 main clinical signs of a fracture?
- localised bony tenderness
- swelling
- deformity
- crpitus
what are the cardinal clinical signs of compartment syndrome?
- increased pain on passive stretching of teh involved muscle
- severe pain out with clinical context
what artery is risked in knee dislocation?
popliteal artery
what are the 4 main signs/symptoms of fracture healing?
- resolution of pain and function
- absence of point tenderness
- no local oedema
- resolution of movement at fracture site
what are the 3 main signs/symptoms of non-union of a fracture?
- ongoing pain
- ongoing oedema
- movement at the fracture site
what type of non-union occurs in attempted secondary bone healing with infection?
hypertrophic or atrophic non-union
what is fracture disease?
stiffness and weakness due to a fracture and subsequent splintage in a cast
how can you treat fracture disease?
should resolve with time
possibly physio
what is complex regional pain syndrome?
a heightened pain response after injury
what is type 2 complex regional pain syndrome caused by?
peripheral nerve damage
what is the principle late systemic complication after a pelvic/lower limb fracture?
pulmonary embolism
what is the gold standard imaging of the rotator cuff?
ultrasound
which head is preominantly affected in biceps tendinopathy?
predominantly long head of biceps
where is the pain in biceps tendinopathy?
anterior shoulder radiating to elbow
what movements exacerbate the pain of biceps tendinopathy?
shoulder flexion
elbow flexion
pronation of forear
where does the most inflammmation of biceps tendinopathy occur and why?
where the long head of biceps passes through the bicipital groove ]due to friction
what does the popeye sign indicate?
biceps tendon rupture
what movements exacerbate the pain of medial epicondylitis?
wrist flexion, pronation
grasping actions
what 2 tendon sheaths are affected in De Quervain’s tenosynovitis?
abductor pollicis longus
extensor pollicis brevis
(extend and abduct the thumb)
what are the 2 main clinical findings of knee extensor mechnaism tendon rupture?
palpable gap
no straight leg raise
what is spinal shock?
a physiological response to injury with complete loss of sensation, motor function and reflexes below the level of the injury
what is the bulbocavernous reflex?
a reflex contraction of the anal sphincter in response to a squeeze of the glans penis, tapping the mons pubis or pulling on a urethral catheter
when does spinal shock usually resolve?
after 24 hours
what does neurogenic shock occur secondary to?
temporary shutdown of sympathetic outflow from T1- L2
what is the difference between complete and incomplete spinal injuries?
complete- no sensory or motor function below the level of injury
incomplete- some sensory or motor function below the level of injury
what type of spinal cord injury (complete or incomplete) does sacral sparing suggest?
incomplete spinal cord injury
compare prognosis of complete and incomplete spinal cord injury?
complete- poor prognosis
incomplete- better prognosis
what type of shock (organ hypoperfusion) in the presence of spinal injury is most likely?
hypovolaemic shock (don't assume neurogenic shock)
what are the 3 main patterns of pelvic injury?
lateral compression fracture
vertical shear fracture
anteroposterior compression injury
a RTA will most likely give you what pattern of pelvic injury?
lateral compression fracture
a fall from height will most likely give you what pattern of pelvic injury?
vertical shear fracture
what pattern of pelvic injury is an ‘open-book’ pelvic fracture?
anteroposterior compression inury
as the degree of wide disruption of a anteroposterior pelvic fracture increases what happens to the pelvic volume?
increases
in a lateral compression fracture, where is the affected hemipelvis displaced?
medialy
in a vertical shear fracture, where is the affected hemipelvis displaced?
superiorly
why is a PR mandatory in a patient with a pelvic injury?
to assess sacral nerve root function
to look for the presence of blood
what does the presence of blood on a PR exam following pelvic injury suggest?
rectal tear
higher risk of mortality
in a fracture of the surgical neck of the humerus, what is the typical displacement of the humeral shaft?
and why?
medially
due to pull of pectoralis major
how are minimally displaced proximal humeral fractures treated?
conservatively with a sling and gradual mobilisation
how are persistently displaced fractures of the proximal humerus treated?
internal fixation
how are humeral head splitting fractures usually treated? (and when would this not be the case?)
shoulder replacement
unless patient is young with very good bone quality
which is more common- anterior or posterior traumatic shoulder dislocation?
anterior shoulder dislocation
what are the main 2 movements/actions which may cause anterior shoulder dislocation?
excessive external rotation
fall onto the back of the shoulder
what is a bankart lesion?
detachment of the anterior glenoid labrum and capsuls
what is a Hill-Sachs lesion?
when the posterior head impacts on the anterior glenoid producing an impaction fracture of the posterior head
in anterior shoulder dislocation, the axillary nerve can be stretched as it passes through what space?
quadrilateral space
what is the principle sign of axillary nerve injury?
loss of sensation in the regimental badge area
what is the mainstay of treatment for atraumatic shoulder dislocations?
physiotherapy
what movement can cause posterior shoulder disloctions?
posteiror force on the adducted and internally rotated arm
what does the light bulb sign on X ray suggest?
posteiror shoulder dislocation
when the ACJ is subluxed what ligaments are ruptures?
acromioclavicular ligaments
when the ACJ is dislocated what ligaments are ruptures?
acromioclavicular ligaments and coracoclavicular ligaments (conoid and trapezius ligaments)
what is a nightstick fracture?
an isolated fracture of the ulna
what are nightstick fractures caused by?
a direct blow
what is a monteggia fracture?
an isolated ulna fracture with dislocation of the radial head at the elbow
why do you need to take an x-ray of the elbow joint after finding an isolated ulna fracture?
may be a monteggia fracture dislocation
ulna fracture and dislocation at elbow
what is the treatment for monteggia fractures?
ORIF of ulna
that should result in reduction of radio-capitellar joint
what is a galeazzi fracture?
an isolated fracture of the radius with dislocation of the ulna at the distal radioulnar joint
why do you need to take a lateral x-ray view of the forearm after finding an isolated radial fracture?
may be a galeazzi fracture (radius fracture and dislocation at distal radioulnar joint)
what is the treatment for galeazzi fractures?
ORIF of radius
should cause distal radioulnar joint reduction
what is a colles fracture?
an extra-articular fracture of the distal radius within 1 inch of the articular surface wit dorsal displacement or angulation
why do colles fractures occur? (what action?)
usually fall onto outstretched hand
what nerve is particularly susceptible to compression in a colles fracture? (how is this resolved)
median nerve
reduction of radius or carpal tunnel decompression
what is a specific late local complication of a colles fractures?
extensor pollicis longus tendon rupture
how is extensor pollicis longus tendon rupture secondary to a colles fracture treated?
tendon transfer
why should all Smith’s fractures undergo ORIF using a plate and screws?
as they are highly unstable and malunion with excessive volar angulation reduces grip strengthn and wrist extension
what is a Smith’s fracture?
an extra-articular fracture of the distal radius which causes volar displacement or angulation
what action commonly causes smith fractures?
falling onto the back of a flexed hand
what are bartons fractures?
intra-articular fractures of the distal radius causing subluxation of the carpal bones
what are the 2 main classifications of bartons fractures?
- volar barton fractures (intra-articular Smith’s fracture)
- dorsal barton fractures (intra-articular Colles fractures)
what is the treatment of a barton’s fracture?
ORIF
what is the treatment of a comminuted intra-articular distal radius fracture?
external fixation with supplementary wires
what action causes scaphoid fractures?
fall onto outstretched hand
where does tenderness tend to occur in scaphoid fractures?
anatomical snuff box
if a scaphoid fracture is suspected clinically but there are no signs on X-ray what is the management?
splint wrist then re-do x-ray after 2 weeks
what is the treatment of undisplaced scaphoid fractures?
plaster cast
what is the treatment of displaced scaphoid fractures?
special compression screw (to avoid non-union)
what is the treatment of non-union of the scaphoid following fracture?
screw fixation and bone grafting
what is the treatment of symptomatic avascular necrosis of the scaphoid following fracture?
partial or total wrist fusion
what 3 structures do penetrating volar hand injuries risk damage to?
- flexor tendons
- digital nerves
- digital arteries
what structures do penetrating dorsal hand injuries risk damage to?
-extensor tendons
what is mallet finger?
an avulsion of the extensor tendon from its insertion into the terminal phalanx
what is mallet finger caused by?
forced flexion of the extended DIPJ
can be caused by a ball at sport
what is the treatment of mallet finger?
mallet splint
after a flexor tendon injury, the fingers are splinted in a flexed position with an elastic traction. What movements does this allow? (and why?)
active extension
passive flexion
to prevent stiffness and adhesions within the tendon sheath
compare treatment of intra-capsular hip fracture and extra-capsular hip fractures?
intra-capsular- hemiarthroplasty or THR
extra-capsular- internal fixation
femoral fractures can cause fat embolism, where does the fat come from?
the medullary canal of the femur
what is the initial management of a femoral fracture?
resuscitation
analgesia
femoral nerve block
thomas spint
what is the purpose of a thomas splint for use of femur shaft fracture?
stabilises fracture to minimise further blood loss and fat embolism
what is the definitive management of a femoral shaft fracture?
closed reduction and stabilisation with an IM nail
sometimes plate fixation can be used
why is multi-ligament reconstruction typically required for a dislocated knee?
because in order for the knee to dislocate, multiple ligaments are usually torn
which are more common- true knee dislocations or patellar dislocations?
patellar dislocations
who tends to get patellar dislocations?
female adolescents
what are the 4 main predispositions to patellar dislocations?
- generalised ligamentous laxity-valgus alignment of the knee
- shallow trochlea groove
- rotational malaligment
are proximal tibia plateau fractures intra or extra-articular fractures?
intra-articular
a valgus stress to the knee may cause what plateau fracture?
lateral plateau fracture
what nerve injury is indicated in foot drop?
common fibular nerve
a varus stress to the knee may cause what plateau fracture?
medial plateau fracture
what is required to fill the void in the bone once a depressed tibial plateau fracture has been elevated?
bone graft
what displacement of the tibial shaft after fracture is especially poorly tolerated?
internal rotation
if the tibia shaft is fractured with the fibula unaffected what alignment does the tibia drift into?
varus
if the tibia shaft is fractured and the fibula is also fractured what alignment does the tibia drift into?
valgus
what are the 2 major cons of external fixation?
pin-site infection
loosening
is an isolated fracture of the distal fibula stable or unstable?
stable
is a fracture of the distal fibula with rupture of the deltoid ligament stable or unstable?
unstable
are bimalleoli ankle fractures stable or unstable?
unstable
what is the treatment for an unstable ankle fracture?
ORIF
what is a lisfranc fracture/dislocation?
fracture of the base of the 2nd metatarsal with dislocation of the base of the 2nd metatarsal from the medial cuneiform
(other metatarsals may also be dislocated at the tarso-metatarsal joints)
how does a patient with a lisfranc fracture usually present?
grossly swollen and bruised foot which they are unable to weight bear
what is the treatment of a lisfranc fracture?
closed or open reduction with fixation using screws
what movement causes fractures of the 5th metatarsal?
inversion injury
what is the usual treatment of toe fractures?
protection in a stout boot
why do children’s fracture heal more quickly than adults?
thicker periosteum which is a rich source of osteoblasts
why are greater degrees of displacement or angulation accepted in children’s fractures compared to adult fractures?
children have a greater potential to remodel so can correct angulation
at what age do fractures start to be treated as an adult fracture?
once child has reached puberty (12 - 14)
as the salter-harris classification of physeal fractures increases, what happens to the prognosis?
decreases
which salter-harris classification is the commonest of physeal fractures?
salters harris II
which salter harris fractures are intra-articular with the fracture splitting the physis?
salter harris III and IV
what type of injury occurs to the physis in a salters harris V fracture?
compression injury to the physis
what happens to the growth of the bone after a salters harris V fracture?
growth arrests
what happens in a salter harris I fracture?
pure physeal separation (metaphyseal intact and still attached to the shaft)
where are salter harris II fractures especially common?
distal radial physis
in children, are complete fractures more likely to displace/angulate volar or dorsal?
dorsally
how are monteggia and galeazzi fractures treated in children?
reduction and rigid fixation with plates and screws
how are fractures of both bones in the forearm treated in children?
flexible IM nail
which are more common- flexion or extension supracondylar fractures of the elbow?
extension supracondylar fractures
what is a simple test to check if the median nerve is working?
ask patient to make an ok sign (flexor pollicis longus and flexor digitorum profunda)
what 2 structures are at risk of injury in a supracondylar fracture?
brachial artery median nerve (mainly anterior interosseous branch)
when in a supracondylar fracture is emergency surgery required?
if radial pulse is reduced (in volume) or absent
what are the 2 main reasons you should avoid ORIF in high energy fractures?
- will struggle to get wounds closed
- bone blood supply is already very impaired (don’t want to damage it any further)
what is the most common nerve affected by compartment syndrome?
tibial nerve
which is more common- valgus stress causing lateral tibial plateau fracture or varus stress causing medial tibial plateau fracture?
valgus stress causing lateral tibial plateau
for a tibial shaft fracture, how long does there have to be without healing before you can say it has gone under non-union?
> 1 year
compartment syndrome is a clinical diagnosis, when would you do pressure readings?
only if patient is unconscious
what is a pilon fracture?
an intra-articular fracture of the distal tibia
how are nightstick fractures usually managed?
conservatively
what are the 3 degrees of nerve injury?
1st degree- neurapraxia
2nd degree- axonotmesis
3rd degree- neurotmesis
what is neurapraxia?
temporary conduction block/demyelination
when should neurapraxia resolve by?
28 days
what is axonotmesis?
nerve cell axon dies distally from point of injury, endoneurial tubes remain intact
how fast does axonotmesis regenerate?
1mm per day
what is neurotmesis?
nerve transection
no recovery without surgery
if there is apparent nerve injury, with no function returning, what is the management?
nerve conduction studies
nerve grafting
tendon transfers
what is volkmann’s ischaemic contracture?
missed compartment syndrome causing necrosis and contraction of the muscles and tendons
causes reduced function of the limb
what nerve is being tested by a thumbs up? (what muscles does it test?)
radial nerve
extensor policis longus
what nerve is being tested by a starfish sign of the hands? (what muscles does it test?)
ulnar nerve
interossei muscles
what nerve is being tested by an OK sign? (what muscles does it test?)
median nerve
flexor policis longus
flexor digitorum profundus and superficialis of index finger
what are the 2 main mechanisms of traumatic shoulder dislocations?
fall onto outstretched hand
traction injury
what is luxatio erecta?
an inferior glenohumeral dislocation
what is the main nerve at risk with anterior shoulder dislocation?
axillary nerve
what area of skin should be tested to assess if the axillary nerve is intact?
regimental badge area
what are the main two mechanisms of traumatic posterior shoulder dislocations?
fall with shoulder in internal rotation
direct blow to anterior shoulder
what movement is impaired with posterior dislocation of the shoulder?
external rotation
in inferior dislocation of the shoulder, what position is the patients arm stuck in?
abduction
what type of shoulder dislocation presents with squaring off of the affected shoulder?
anterior dislocation
shoulder dislocations are usually treated with closed reduction under sedation. what type of dislocations are open reduction saved for?
locked posterior dislocations
what is the main mechanism of injury causing elbow dislocations?
fall onto outstretched hand
what is the main way to reduce an elbow dislocation?
closed reduction
(traction in extension +/- pressure over olecranon)
under sedation
what is the recurrent instability risk of elbow dislocation?
low
what are the 2 main mechanisms of injury causing interphalangeal dislocations?
hyperextension injury
direct axial blow
what direction do IPJ dislocatioons usually occur in?
posterior dislocations
sudden contraction of what muscles with a flexing knee causes patella dislocation?
sudden quads contraction with a flexing knee
what direction do patella dislocations usually occur in?
laterally
what ligament is always torn in a lateral patella dislocation?
medial patellofemoral ligament
why does a big haemarthrosis and medial side tenderness occur in lateral patella dislocation?
due to torn medial patellofemoral ligament
tenderness also due to torn medial retinaculum
what does genu valgum or femoral neck anteversion do to the Q-angle?
increases Q angle
as the Q-anlge increases, what happens to the risk of patella dislocation?
increases
weakness of what particular quadriceps muscle can play a part in patella dislocation?
weak vastus medialis
under-development (hypoplasia) of which femoral condyle can play a part in patella dislocation?
hypoplasia of lateral femoral condyle
describe lines 1 and 2 whcih make up the Q-angle?
line 1: ASIS to midpoint of patella
line 2: tibial tubercle to midpoint of patella
who tends to have a larger Q angle- M or F?
females
what movements tend to reduce patella dislocation?
extension
why might you aspirate the haemarthrosis caused by a patella dislocation?
to make extension more comfortable
what should you suspect if there is lateral collateral ligament of the knee injury and common fibular nerve injury?
(transient) knee dislocation
which direction are knee dislocations most likely to be?
posterior
what nerve is at risk with a true knee dislocation?
common fibular nerve
what artery is at risk with a true knee dislocation?
popliteal artery
if assessment of vascular supply after a knee dislocation is normal, what should be done?
admit and observe in hospital
due to high likelihood of vascular injury
if assessment of vascular supply after a knee injury is abnormal, what should be done?
arteriogram/MRI
what direction are hip dislocations most commonly?
posterior
what position usually is the leg of a patient presenting with a posterior hip dislocation in?
hip flexed
hip internally rotated
knee adducted
what nerve is at risk of injury with a hip dislocation?
sciatic nerve
what is primus varus?
angulation of the 1st metatarsal towards the midline thus increasing the distance and angle between metatrsals 1 and 2
when does primus varus typically appear?
teen years
what is the driver of primus varus?
ligamentous laxity
what deformity of the big toe can primus varus lead to?
secondary hallux valgus
what is lesser toes metatarsalgia?
painful lesser metatarsal heads
where is the pain felt in lesser metatarsalgia?
plantar surface of foot
what heel alignment is common in pes planus?
heel valgus
what heel alignment is common in pes cavus?
heel varus
what does localised swelling of the olecranon suggest?
bursitis
what is the carrying angle of the elbow?
the angle between the shaft of humerus and shaft of forearm
compare a distal ulnar nerve lesion to a proximal ulnar nerve lesion in terms of patient presentation?
distal- ulnar clawing
proximal- ulnar paradox (hand looks normal)
