MSK and rheum Flashcards
What are the 3 peaks of age for fracture?
- Young child
- Young adult
- Elderly
How long does an upper limb fracture take to recover?
- 1 unit of time (where a unit its 6 weeks)
- I.e. 6 weeks
How long does a lower limb fracture take to recover?
- 2 units of time
- I.e. 12 weeks
How long to children’s fracture take to recover compared to adults?
About half the time
What is the mot commonly fractured bone?
Clavicle
What classification system is used for open fractures?
Gustillo-Anderson classification
What are the levels of Gustillo-Anderson classification?
1) Low energy wound <1cm
2) >1cm wound with moderate soft tissue damage
3a, b, c) High energy wound >1cm with extensive soft tissue damage
What are the 3 sub levels of GA classification 3?
a) Adequate soft tissue coverage
b) Inadequate soft tissue coverage
c) Associated arterial injury
What is a valgus displacement of a fracture?
Distal partion lateral
What is a varus displacement of a fracture?
Distal portion medial
What are the 3 main aetiologies of fracture?
- Acute
- Stress
- Pathological
What are the 3 most common types of fracture in children?
- Greenstick
- Buckle
- Salter-Harris
What is a greenstick fracture?
Unilateral cortical breach only
What is a buckle fracture?
Incomplete cortical disruption resulting in periosteal haematoma only
What are the 5 levels of the Salter-Harris classification?
I) Fracture through the physis (growth plate) only (X-ray often normal)
II) Fracture through the physis and metaphysis
III) Fracture through the physis and epiphysis to include the joint
IV) Fracture involving the physis, metaphysis and epiphysis
V) Crush fracture through the physis (X-ray may resemble type I) (these are rare)
What are causes of pathological fracture in children?
- Osteogenesis imperfect
- Osteopetrosis
What are some features of osteogenesis imperfecta?
- Collagen problem leading to brittle bones
- Autosomal dominant
- Blue sclera, hearing and teeth problems
- Normal blood results
What are some features of osteopetrosis?
- Autosomal recessive
- Mable bone from lack of corticomedullary differentiation
What are the 4 components of fracture management?
1) Resus (if required)
2) Reduction
3) Restriction
4) Rehab
What are the components of fracture resus?
- Haemodynamically stabilise and ALS
- 4A’s
- Open fractures need 6L saline irrigation
What are the 4 A’s of fracture resus?
- Analgesia
- Assess N&V
- Alignment
- Antibiotic (antiseptic and anti-tetanus)
What is used to reduce a closed fracture?
Bone manipulation
What are some methods for fracture restriction and when might they be used
- Slings
- Plaster of Paris cast
- External fixation (open fracture or significant soft tissue damage)
- Internal fixation
What are 2 important side-effects/considerations of PoP casting?
- Compartment syndrome
- Staph skin infection risk
What is an important side-effect/consideration of external fixation?
Pin infection risk
What is an absolute and relative contraindication to internal fixation?
- Absolute = active infection
- Relative = compound fracture
What are the 3 stages of bone healing?
Reactive, reparative, and remodelling
What are some early complications of fractures?
- Compartment syndrome
- Nerve damage
- Vascular injury
- Infection
- Rhabdomyolysis
- Haematoma
- Fat embolism
Wha are some features of compartment syndrome?
- Pressure buildup >30mmHg
- Pain on passive movement and using more breakthrough analgesia
- Raised creatinine kinase
- 6P’s: pain, pallor, pulselessness, perishingly cold, parasthesis, paralysis
What are some chronic complications of fractures?
- Non-union
- Malunion
- Post-trauma osteoarthritis
- Myositis ossificans
What are some causes of bone malunion?
- Infection
- Ischaemia
- Intercurrent disease (cancer)
- Increased strain
- Increased tissue
What are some risk factors for bone malunion?
- Smoking
- Alcohol
- DM
- Steroids
- Old age
- CKD
When can post trauma OA occur?
Following an intra-articular fracture
What is myositis ossificans and how does it present?
- Muscle ossification at site of fracture
- Restricted, painful movement
Where is myositis ossificans most common?
The elbows and quads
What is the mechanism for clavicular fracture?
FOOSH or fall onto shoulder
What are the most common sites of clavicular fracture
1) Middle (80%)
2) Lateral (15%)
3) Medial (5%)
What are the signs of a clavicular fracture and why?
- Medial clavicle raised more than lateral clavicle
- Medial portion pulled up by SCM, lateral portion pulled down by weight of arm
What is the management of clavicular fracture?
- Good prognosis
- Endochondral ossification in 3 weeks
- Broad or figure 8 sling if severe
What structures are at risk in clavicular fracture?
- Brachial plexus
- Subclavian artery
- Lung (pneumothorax)
- All these are rare
What is the MoA of humeral neck fracture?
FOOSH or direct blow
What are the features of a humeral neck fracture?
- Upper arm and chest bruising
- Pain and reduced range of movement
- X-ray diagnosis
What is at risk in humeral neck fracture and what will happen?
- Axillary nerve (regimental badge loss and deltoid paralysis)
- Posterior humeral circumflex artery (not much effect as not main supply
- Anterior circumflex artery if displacement >1cm (causes avascular necrosis)
Wha is the management of undisplaced humeral neck fracture?
Collar and cuff sling
What are the features of humeral shaft fracture?
- Bruising and swelling of arm
- Radial nerve injury
How common is radial nerve injury in humeral shaft fracture and how will it present?
- Most common complication of humeral shaft fracture (18%)
- Loss of wrist flexion and base of thumb sensory loss
What is the management of humeral neck fracture?
- Closed reduction and gutter splint
What is an important side-effect/consideration on humeral neck fracture splinting?
Requires 12 weeks immobilisation which may cause capsulitis
What is the MoA of a supracondylar humeral fracture?
- FOOSH or blow onto flexed elbox
- Typically transverse or oblique fracture
- Most common in kids
What are the signs of supracondylar fracture?
- Arm held in semi flexed position
- Fat pad and sail sign on X-ray
What is at risk in supracondylar fracture?
- Anterior interosseous branch of the median nerve (weak pincer but normally neuropraxia)
- Brachial artery
What happens in brachial artery damage from supracondylar fracture?
- Volkamns ischemia (fibrotic contracture of long flexors due to ischemia)
- First sign is pain in the fingers and forearm
What is a common side-effect of supracondylar fracture and how do you avoid it?
- Compartment syndrome
- Keep patient in hospital for 24 hours to monitor
What are other common side effects of supracondylar fracture?
- Posterior displacement of distal portion
- Varus deformity from malunion
What are some features of medial epicondylar fracture?
- Avulsion fracture from medial ligament
- Ulnar nerve damage common as it runs dee
What is the MoA for an olecranon fracture?
- High energy fracture in young
- Low energy fracture in the elderly
What are some features of an olecranon fracture?
- Palpable defect on posterior elbow
- Inability to extend arm
- Ulnar damage common
What are some features of a radial head fracture?
- FOOSH
- Localised pain and tenderness and restricted movement
- Sharp pain on pronation and supination
- Mason classification
What are some features of a Monteggia fracture?
- Ulna shaft fracture and dislocation of the proximal radio ulnar joint
- FOOSH onto pronated hand
- Radial nerve injury
What are somme features of a Galeazzi fracture?
- Radial shaft fracture and distal dislocation of the radioulnar joint
- FOOSH + rotational force
- Lower arm tenderness
- Displaced radius and prominent distal ulnar head from the dislocation on X-ray
What are some features of osteochondritis dissecans?
- Joint locking and ‘clunking’
- Pain on exercise
- Repeated exercise
What X-ray finding can differentiate between gout and pseudogout?
Pseudogout shows chondrocalcinosis
What investigation is most appropriate for meniscal tears?
MRI
What is the triad for fat embolus?
- Respiratory symptoms
- Neurological symptoms
- Petechial rash (usually after the first 2 symptoms)
What can be used to remember the difference between Monteggia and Galeazzi fracture?
Monteggia ulna (Manchester United), Galeazzi radius (Galaxy rangers)
What are the blood test results in osteomalacia?
- Low calcium and phosphate
- High alkaline phosphatase
What is the MoA of a Colles fracture?
FOOSH in the elderly
What are the features of a Colles fracture?
- Dinner fork deformity (dorsal angulation)
- Transverse fracture of distal radius
- 1cm proximal to radoiocarpal joint
What are possible complications of Colles fracture?
- Median nerve damage
- Carpal tunnel syndrome from swelling
- Sudeck’s atrophy (complex regional pain syndrome post Colles)
What is the management of minimally displaced Colles’ fracture?
- Reduction in the ER
- Dorsal backslab cast
- Review in 2 weeks to check for malunion
What is the management of displaced or malunion of Colle’s fracture?
Open surgical reduction and internal fixation
What is a Smith’s fracture?
- Essentially a reverse Colles fracture
- Garden spade deformity (volar angulation)
- Result of backwards FOOSH onto flexed wrist
- Treated with open reduction and internal fixation
What is a Barton’s fracture and how do they occur?
- Any distal radial fracture (inc Colles and Smiths) with dislocation
- Caused by FOOSH onto extended and pronated wrist
What is the mechanism of scaphoid fracture and what are a couple of examples oaf when one may occur?
- FOOSH onto extended radially deviated wrist
- RTA when holding wheel
- Contact sports
What is the most common carpal fracture?
Scaphoid
What is the main risk from scaphoid fracture and why?
- Avascular necrosis
- Disruption of retrograde blood supply from dorsal carpal branch of radial artery
What is the presentation of scaphoid fracture?
- Anatomical snuffbox pain
- Tenderness on scaphoid tubercle (volar side of wrist)
- Telescopic pain of the thumb
- Loss of pincer grip
What is the investigation for scaphoid fracture?
- X-ray at the time, if normal repeat in 2 weeks
- MRI is gold standard
What is the management of scaphoid fracture?
- POP cast until evidence of union (at least 6 weeks)
- If symptomatic malunion then surgery
- If no evidence of fracture on x ray but clinical than splint and re x ray in 10-14 days
What is a Bennet’s fracture?
- Fracture of base of thumb (1st metacarpal) due to impact of flexed metacarpal
- Usually occurs in fist fight
What X-ray sign is seen in Bennet’s fracture?
Triangular fragmentation of 1st metacarpal bone
What is a Boxer’s fracture?
The same as a Bennet’s fracture but in base of little finger (5th metacarpal)
What are the features of a fractured NOF?
- Severe pain
- Shortened and externally rotated leg (from iliopsos pull)
- Internal rotation most commonly affected
What are some features of an intracapsular NOF fracture?
- 30% die in 12 months
- High chance of displacement and AVN
- Treated with hip replacement
- Classified with Gardener’s classification
What are the levels of Gardner’s classification?
1) Stable, impacted valgus
2) Complex but no displacement
3) Displaced but bony contact
4) Complete disruption
What are the 2 types of extra capsular fracture and how are they differentiated?
- Intratrochanteric and subtrochanteric
- If below trochanter horizontal line = substrochanteric
- Trochanteric involvement suggests stability
What is the X-ray finding for a hip fracture?
Disrupted Shenton’s line
What structures are at risk in hip fracture and what will happen?
- Medial circumflex femoral artery from profunda femoris (AVN of femoral head)
- Superior gluteal nerve (trendelenburg gait) (rare)
What is used in extra medullary fixation of the hip and when is it used?
- Dynamic hip screw or intramedullary nail
- Extracapsular fracture
When is an intramedullary nail used in NOF fracture?
Gardener’s 1 and 2 in fit and health patient
When is a hemiarthroplasty used in NOF fracture?
- Gardner 1 and 2 in less healthy patients
- Gardener’ 3 and 4 in unfit patients
When is total hip replacement used in NOF fracture?
Gardner’s 3 and 4 in patients who have good mobility
What are some considerations for total arthroplasty?
- Dislocation is likely
- Patients can’t flex past 90 degrees and can’t flex and adduct at the same time
What are the signs of AVN of femoral head?
Progressive pain and reduced range of movement in recovering NOF fracture or in presence of risk factors (smoking, alcohol, long term steroids, chemo
What X-ray finding is seen in AVN of femoral head?
Crescent sign
What is the gold standard investigation for AVN femoral head?
MRI
What are the risk factors for avasscualr necrosis of the femoral head?
- Long term steroids
- Alcohol
- Smoking
- Chemo
Pubic rami fractures?
- Don’t need surgery
- Heal in 8 weeks
- Keep mobile
- Old ladies with low energy falls
What is the presentation of greater trochanteric pain syndrome?
- Pain over the lateral side of hip/thigh
- Tenderness on palpation of the greater trochanter
Who are particularly at risk of osteosarcoma and how should it be investigated?
- Teenagers
- X-ray within 48 hours
What is the first-line treatment for lower back pain with no red flags?
- NSAIDS
What I the imaging modality of choice for osteomyelitis?
MRI
How does cubital tunnel syndrome occur and is the main feature?
- Caused by compression of the ulnar nerve
- Tingling/numbness of the 4th and 5th finger
What are some features of a femoral shaft fracture?
- Pain, swelling, haemorrhage and significant bleeding
- Need 4 units of blood
- Requires surgical repair
When do femoral shaft fractures occur and what are some examples?
- High energy trauma
- RTA, GSW, fall
What are 3 complications of femoral shaft fracture?
- Sciatic nerve
- superficial femoral artery
- Fat embolism (respiratory signs (SOB), neurological signs (confusion) and subsequent petechial rash)
When do tibial shaft fractures occur and give some examples?
- Hight energy trauma (similar to femoral shaft)
- RTA, GSW, falls
What are some features of a tibial shaft fracture?
- Most common long bone fracture
- Common to have co-morbid fibula fracture
- Require 2 units of blood
What are 2 complications of tibial shaft fracture?
- Common perineal nerve injury
- Compartment syndrome
Who do stress fractures most commonly occur in?
- Runners
- Athletes
- Military
In which bones are stress fractures most common?
- Metatarsal bone (2nd metatarsal most common)
- Leg bones
Imaging in stress fractures?
- X-ray may be normal at the time and show change 2 weeks later
- Bone isotope or MRI scan gold standard
Treatment of stress fractures?
Rest and immobilise
When are tibial plateau fractures common?
- Valgus or varus knees before the collateral ligament
- Valgus causes lateral plateau fracture
- Varus causes medial plateau fracture
What classification is used for tibial plateau fracture?
Schatzker classification
What are the 2 type of patella fracture?
- Comminuted/direct
- Avulsion/indirect
What are some features of a comminuted/direct patella fracture?
- From direct knee blow
- Extensor function of knee intact
- Requires 6 week knee hinge
What are some features of an avulsion/indirect patella fracture?
- Violent quadricep extension against force
- Transverse fracture through patella
- Lose extensor function of leg
- Requires surgical repair and 6 week knee brace
Which its more commonly fractured, the medial or lateral malleolus?
Lateral malleolus
What is talar shift?
- Occurs in medial fracture or deltoid ligament rupture
- Talus not under tibia causing an unstable joint
What is a feature of ankle fracture?
Pain on passive movement
What classification is used for lateral malleolus fracture?
Weber classification
What are the level of Weber classification?
A) Below syndesmosis
B) At level of Syndesmosis
C) Above syndesmosis
What are the Ottawa ankle rules?
Pain in malleolus joint + one of the following:
- Tender lateral malleolus
- Tender medial malleolus
- Can’t weight bear for 4 steps
What is a Pott’s fracture and when is it seen?
- Trimalleolar fracture
- Forced eversion injuries with big toe on the floor
What is the specific MoA of a Pott’s fracture?
- Avulsion fracture of medial malleolus
- Talus shifts and breaks lateral malleolus
- Tibia forced forwards creating shearing force of posterior talus
How is a Pott’s fracture treated?
Surgical repair
What is a Maisoneuve fracture and how is it treated?
- Spiral fracture of the proximal fibula that disrupts the syndesmosis and widens the joint space
- Treated surgically
What is the basic management of ankle fractures?
- Rapid reduction required to prevent neuromuscular compromise
- All surgical except: isolated non-displaced fracture, no talar shift, very old
- If not surgical then manage with weight bearing (as tolerated) in CAM boot
What is a Lisfranc fracture?
Fracture and displacement of the metatarsal bone from the tarsal bone
What sports are commonly associated with Lisfranc fractures?
- Snowboarding
- Ballet
- American football
What is the MoA of Lisfranc fractures?
- Direct: RTA or fall
- Indirect: rotational force on planter flexed foot (e.g. fall off horse with foot in stirrup)
What are some side effects of bisphosphpnates?
- Oesaphagitis and ulcer
- Osteonecrosis of jaw
- Increased risk of atypical stress fractures of the proximal femoral shaft
- Acute phase response: fever, myalgia and arthralgia
- Hypocalcaemia
Ewing’s sarcoma?
- Malignant bone tumour mainly affecting children and adolescents
- Most common in pelvis, and long bones
- Often cause severe pain
- X-ray shows lytic lesion with ‘onion skin’ appearance
What needs to be corrected before giving bisphosphonate?
Hypocalcaemia and low vit-D
What is a common complication of posterior hip dislocation?
Sciatic nerve injury
What I the mot common type of hip dislocation and how might they present?
- Posterior hip dislocation (shortened internally rotated limb)
- Anterior dislocation much rarer and presents with externally rotated limb
What nerve is most commonly injured in anterior hip dislocation?
Femoral nerve
What I a particularly late sign of caudal equine?
Urinary incontinence
What is the most common common type of shoulder dislocation?
Anterior shoulder dislocation (95%)
What is the most commonly dislocated joint?
Shoulder
What is the first line treatment for OA?
Paracetamol and topical NSAIDs
