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Ortho ST3 Interview > Lower limb > Flashcards

Lower limb Flashcards

1
Q

What is the blood supply to the head of femur?

A

In adults it is a retrograde blood supply along the neck of femur from retinacular vessels which orginate from the medial/lateral circumflex femoral artery which come from the the profunda femoris

Nutrient vessels

In children there is also blood supply along the ligamentum teres but this is obliterated later childhood. acetbular branch of obturator artery

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2
Q

Where are the origins of the joint capsule?

A

Anterior aspect runs along intertrochanteric line
Posterior aspect 1.5cm proximal to intertrochanteric line

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3
Q

When do you consider offering a THR for a NOF?

A

NICE guidelines state:

If able to walk outdoors with no more than 1 stick
No bad medical comorbidities that makes procedure unsuitable
Expected to carry out ADLs for 2 further years minimum (HEALTH Trial- THR better functional outcomes if used for longer than 2 years compared to hemis)

In my practice I also consider if they drive, how far they walk, if they are able to follow hip precautions post op and patient preference

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4
Q

Cemented or uncemented hemis?

A

Cemented
Less loosening and periprosthetic fractures
Easier revision surgery

Increased risk of bone cement implantation syndrome- cardiopulmonary compromise from embolic shower during cementing

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5
Q

How do you reduce the risk of bone cement implantation syndrome?

A

Identify those at high risk:
Male, older, diuretics, cardiopulmonary disease

Inform anaesthetist of risk and pre cementing
Wash and dry femoral canal
Use cement restrictor and suction catheter
Do not use excessive manual pressurisation for those at high risk

Anaesthetic team to be aware the cardiopulmonary support may be required- vasopressors etc.

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6
Q

What are some of the BPT required for NOFs?

A

AMTS pre op
Theatre within 36 hours
FIB in ED and pre op
Orthogeris R/V
Bone health
PT day 1- FWB D1
Dietician review

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7
Q

What is the WHITE 11/FRUTI trial?

A

Fix or replace undisplaced IC NOF #- pragmatic trial

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8
Q

What are the approaches to the hip you know?

A

Anterior approach- internervous between sartorius + TFL and the rec femoris and gleut medius

Anterolateral- TFL and gleuteus medius

Direct lateral- Hardinge- muscle splitting approach, gleutues medius and minimus cuff, releasing vastus lateralis fibres proximally to expose LT. SGN runs 3-5cm proximal to GT in beneath gleutus minimus and medius

Posterior approach- gleuteus maximus splitting, detach short external (piriformis and Obturator internus) rotators, watch out for sciatic nerve and IGA

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9
Q

What type of hip dislocation is commonest?

How do they present on examination?

A

Posterior hip dislocation- 90%
Flex, Adducted, internal rotation

Anterior- extended, abducted, external rotated

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10
Q

When do posterior hip dislocations happen and what are the associated injuries?

A

Dashboard injuries classical

Look for:
Posterior wall acetabular injuries
Femoral head #s- Pipkin
NOF#s- do not reduce if present
Sciatic nerve injury- 10-20%
Ipsilateral knee injuries
Aortic injuries- deceleration tear

ATLS approach needed
Trauma CT?

CT pelvis at least pre/post reduction

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11
Q

How do you reduce a closed hip dislocation?

And when should you do so?

A

Check there is not a NOF #!!

Explain and consent the patient for the procedure
Ensure you have a suitably trained ED/anaesthetic doctor to perform sedation- propofol ideally
Brief
Supine
Counter traction on ASIS
Flex + in line traction of hip + adduction + internal rotation- Allis vs CM technique

Check xray and then CT pelvis to assess for acetabular/head/neck fractures

Placing in traction afterwards if associated acetabular #

Reduced within 6 hours

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12
Q

How do you classify femoral head fractures?

A

Pipkin classification

1- fracture below fovea- non weight bearing surface affected
2- above fovea- weight bearing surface affected
3- involving femoral neck
4- involving acetabulum

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13
Q

What is the subtalar joint?

A

Synovial joint
Calcaneus and talus
Eversion and inversion

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14
Q

What is the Hawkins classification of talar fractures?

A

1- non displaced talar neck fracture
2- subtalar dislocation
3- subtalar and tibiotalar dislocation
4- subtalar, tibiotalar and talo-navicular dislocation

AVN risk increases and type increases

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15
Q

What are the complications of a hip dislocation?

A

AVN
Sciatic nerve injury- most neuropraxia
Recurrent dislocators- place in cricket pad splint to prevent hip flexion
Post traumatic arthritis
#s

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16
Q

What displacement of the parts of femur do you get in a sub troch fracture?

A

Proximal part flexed and ER by attachments from Iliopsoas and SERs

Distal fragment is ADDucted and shortened
Adductors causes this

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17
Q

What are the ligaments of hip capsule?

A

Iliofemoral- strongest prevents hyperextension
Pubo femoral
Ischiofemoral

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18
Q

What is the iliotibial band?

A

Longitudinal band of fibres formed from gleut max + Tensor fascial lata
Inserts into femoral condyle
Stabilises knee during extension

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19
Q

What are the short external rotators?

A

Pirformis
Gemellus sup
Obturator internus
Gem inf
Obturator ext
Quadratus femoris

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20
Q

Describe the course of the sciatic nerve?

A

L4-S3 origin
Exits via the greater sciatic foramen
90% time below piriformis
10% through piriformis
1%< above
Lies beneath gleut max
Post surface of QF

1/3 way between IT and GT
Runs in post compartment behind adductor magnus
to Popliteral fossa
Divides into tibial and common peroneal nerve at superior point of fossa

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21
Q

Describe the contents of the greater sciatic foramen?

A

Greater- 10 structures, 7ns, 3 vessels

Above Piriformis
SGN + vessels
Below piriformis
Sciatic nerve
IGN + vessels
Internal pudenal vessels
Pudendal nerve
Post femoral cutaneous nerve
N to quadratus femoris
N to obt internus

Lesser sciatic N (PINT)
Pudendal N
Internal pudendal vessels
N to obt internus
Tendon to obturator internus

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22
Q

What is the aim with a young NOF #

A

ATLS- high energy injuries- exclude other injuries

Aim to reduce and fix rather than replace
Avoid AVN- achieve bony union

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23
Q

How can you classify young NOFs

A

Pauwel’s

Degree of angulation of fracture
<30o- stable
30-50- ?stability
>50o- unstable

Determines risk of non union and AVN

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24
Q

How do you manage a young NOF?

A

Next trauma list as a priority
Closed reduction if possible-Leadbetter’s technique- The affected leg is flexed to 45° with slight abduction and then extended with internal rotation while longitudinal traction is applied.
?Capsulotomy- remove tamponading effect of joint haematoma
Open reduction if unsuccessful- ant approach to the hip + bone hooks/k wires/traction

Garden1/2- Cannulated screws
Garden 3/4- DHS
Pauwels 3- add in derotational screw

Cannulated scews- 6.5mm

Analgesia post op
Protected weight bearing + follow up

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25
Q

Describe the anatomy of the PCL and ACL?

A

LAMP

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26
Q

What is the blood supply to the knee joint?

A

Popliteal A gives off the genicular arteries
Superficial femoral a gives off descending genicular as
Anterior tibial branch gives off recurrent branch

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27
Q

Boundaries and contents of popliteal fossa?

A

Boundaries

Superomedially- semimembranosus/semitendionsus

Superolaterally- biceps femoris

Inferomedially- gastroc medial
Inferolaterally- gastroc lateral

Contents (superficial to deep)

Common peroneal + tibial N
Popliteral vein + short saphenous
POpliteal A
LNs

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28
Q

Differential diagnosis of swelling in popliteal fossa

A

Trauma
DVT
cellulitis/abscess
Baker’s cyst
Aneurysm
Varicose Vein
Bony cancer/lesion

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29
Q

Describe the lower leg compartments

A

Anterior- DPN + anterior tibial A
Anterior tibialis
EHL
EDL
Peroneus tertius

Lateral- SPN + peroneal A
Peroneus brevis + longus

Posterior- Tibial N + posterior tibial a

Superficial
Plantaris
Gastroc
Soleus

Deep
Post tib
FHL
FDL
Popliteus

30
Q

What are the major concerns with acute knee dislocations?

A

These are high energy injuries with high rates of neurovascular injuries

Vascular injuries- 7-14%
Nerve- CPN -25%
#s- 60%
Patella tendon rupture
Ligamentous injury

31
Q

How can you classify acute knee dislocations?

A

High energy vs ultra low energy (obese)

Direction of dislocation
Ligamentous injury

32
Q

What are you looking for on examination of acute knee dislocation?

A

Thorough examination of neurovascular status pre relocation

Dimple sign- medial aspect- buttonhole throughing of medial femoral condyle through the medial capsule- unreducible closed

33
Q

What to do if pulses/absent pulses in acute knee dislocations?

A

Follow BOAST guidelines for arterial injury
Relocate
Re-examine
CTA + involve vascular
If still absent post reduction then for immediate surgical exploration- do not wait for imaging

If present pulses
ABPI and <0.9 for CTA
Need serial ABPI to monitor
Genicular arteries can mask popliteal injury

34
Q

How to reduce/maintain reduction in acute knee dislocations?

A

Traction + reverse deforming forces +/- extension
Splint in 20-30o of flexion

35
Q

What are the associated injuries in tibial plateau fractures?

A

Can be high energy injuries
Compartment syndrome
Meniscal tears- schatzler 2/4
ACL rupture- 4/5
Neurovascular injury- 4

36
Q

Classify tibial plateau fractures?

A

Schatzker
1- lateral spit
2- split + depression
3- depression
4- medial plateau
5- bicondylar
6- dissociated shaft and plateau

37
Q

Which nerves are at risk during ankle fracture surgery?

A

SPN-10cm proximal to lateral malleolus
Medial approach- great saphenous nerve runs anteriorly, with tibial nerve running posteriorly in tarsal tunnel
Posterolateral- sural nerve

38
Q

Important points in history for ankle fractures?

A

Type 2 DM, decreased mobility, peripheral neuropathy, PVD, renal disease, smoking, alcohol abuse

39
Q

What to think if a isolated medial malleolus #?

A

Think maisonneuve!!
Knee xray

40
Q

Why do you need a mortise view?

A

15-20o of internal rotation

Assesses the articulation of the talus, fibula and tibia- ie. the mortise

Assess lateral joint and lateral talus

41
Q

What are the general management rules for ankle fractures?

A

If stable for treatment in a cast/boot and WBAT as tolerated
If uncertain stability for weight bearing xray at 1/2 weeks
If <60 years old and for operative intervention aim for a D0/1 fixation

42
Q

Which ankle fractures are considered unstable?

A

Weber B #s + talar shift
Weber C fractures
Bimalleolar/triamalleolar

43
Q

How do you manage unstable ankle fractures?

A

If <60 years old for ORIF

If >60 years old/medically comorbid:
If can get reduction and is maintained at 2 weeks for close contact casting for 6 weeks

If reduction lost for ORIF vs hindfoot nail

44
Q

What is the aim of surgery for ankle fractures?

A

To achieve reduction and stability of the ankle mortise

45
Q

How do you manage Pilon fractures?

A

With difficulty:
Span, scan and plan

Intra-articular fracture
So aim is to provide absolute stability and anatomical reduction of articular surface whilst maintaining soft tissues

46
Q

What are the classical Pilon fragments found on CT?

A

Medial malleolus fragment
Volkmann fragment- posterolateral from PITFL
Chaput fragment- anterolateral from AITFL

47
Q

Do you know any research that may guide your decision making about ankle fractures?

A

AIM study- >60 year olds, unstable ankle fractures- CCC vs ORIF- equivalent ankle fnx at 6 months- loss of reductio with CCC, more infections with ORIF. Awaiting long term follow up to see if long term complications/operations needed in either group

FAME has finished recruitment- same as AIM but for 18-60 year olds

48
Q

What do you need to assess in patients with a calcaneal fracture?

A

Think ATLS + CT scan
A lot of associated injuries
10% have contralateral calc and spinal injuries
60% of calc #s extend into joint
Hip and lower limb examination is necessary

49
Q

What are the different types of calcaneal #s?

A

Extra-articular
Sustenaculum tali #, calcaneal tuberosity #

vs Intra-articular
Tongue type and depression type #s

50
Q

How do you manage a calcaneal fracture?

A

ATLS
CT scan
Cast + NWB + discuss with F&A specialist

Operative management depends on patient vs injury factors

Patient: Smoker, T2DM, alcohol, compliance
Injury: Intra-articularm Bohler’s and Gissane’s angle, open, skin necrosis- tongue type

Also note the UK HEEL trial from 2014

RCT Multicentre, looking at displaced intra-articular calc #s
No differences in outcomes between op and non op at 2 years

51
Q

What is a lis franc injury?A

A

Tarsometarsal # dislocation characterised by traumatic disruption between the medial cuneiform and 2nd metatarsal articulation

52
Q

How does lis franc injury occur?

A

Axial and rotational loading through plantar flexed foot

53
Q

What forms the lis franc joint?

A

Osseous components- transverse arch with 2nd metatarsal base as key stone

Ligamentous- lis franc lig runs from medial cuneiform to 2nd metatarsal
Strongest ligament- with plantar side stronger- so dorsal subluxation is common

54
Q

What to do when examining for a ?lis franc injury?

A

Plantar bruising is pathognomic for lis franc injury

Tender mid foot
Dorsal subluxation of 2nd metatarsal of stressing

55
Q

What would you see on imaging of a lis franc injury?

A

Fleck sign
Widening between 1st and 2nd ray of >2mm
Disruption of line from medial aspect of 2nd metatarsal to medial aspect of medial cuneiform
Dorsal displacement of metatarsals
Weight bearing xray if unsure- can guide non operative management if no displacement
CT scan for diagnosis/pre op management

56
Q

Management of lis franc injury?

A

Non op- if no displacement on weight bearing xray
Operative- ORIF vs percutaneous fixation vs tight ropes

57
Q

What are the ligaments around the ankle?

A

Laterally- lateral collateral ligament-
Anterior/post talofibular ligament
calcneofibular ligament

Medially- Deltoid ligament- superfiscial:
Ant tibiotalar, tibionavicular, tibiocalcanea;

Deep
Post tibiotalar

58
Q

What are the goals of a TKR?

A

Alleviate pain, enable ADLs, personal independence

Restore mechanical alignment, restore joint line, balance soft tissues

59
Q

What are the alternatives to a TKR?

A

Conservative- NSAIDs, activity mods, weight loss, PT, orthotics, injections

Osteotomies
Unicompartmental
Fusion

60
Q

What are the different types of knee replacements?

A

Unconstrained- PCL retaining or subsituting
Constrained- hinged- global ligamentous instability/trauma

61
Q

When is a patient suitable for a TKR/THR?

A

Trialled all conservative treatment options
Impacting ADLs
Night pain

62
Q

What to examine in a normal joint?

A

Gait
Skin
Range of movement
Stability
Leg lengths

63
Q

Post op PNI assessment?

A

CCRISP
A2E- + gather info
Sciatic nerve identified?
Patient fall post op?
Regional nerve blocks?

Expanding haematoma
Post op dislocation- leg length discrepancies
Excessive lengthening

Compression vs direct trauma

Release compressive bandages
Flex knee

64
Q

Classes of nerve injury?

A

Seddon’s
1- neuropraxia full recovery
2- axonotmesis-spontaneous recovery is possible
3- neurotmesis no spontaneous recovery

65
Q

Bedside diagnostic aids for NEc fasc diagnosis?

A

LRINEC and Finger sweep test

66
Q

Types of Nec Fasc?

A

1- polymicrobial
2- monomicrobial (GAS)
3- marine
4- fungal

67
Q

Management of Nec Fasc?

A

Extensive immediate aggressive debridement
Microbiologist
ITU
Plastics for recon

2 consultant decision if for primary amputation

68
Q

Pathophysiology of Charcot’s arthropathy?

A

Sensory neuropathy
Leads to to loss of protective sensation
Destruction of foot and ankle joint

69
Q

Classical signs of charcot?

A

Warm and erythematous foot that improves with elevation

Collapse of medial arch
On xray- fragmentation, subluxing and swelling

70
Q

How to manage charcot arthropathy?

A

Obs
Bloods
XRays
MRI- abscess vs soft tissue swelling
Bone scan- charcot vs abscess vs osteomyseltitis

Brace, osteotomies and fusion, or ampuation

Ortho ST3 Interview (12 decks)

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