ORTEM Flashcards
Ruptured anterior cruciate ligament summary
Sports injury
Mechanism: High twisting force applied tto bent knee
Typical presentation: Loud crack, pain ane RAPID joint swelling (haemoarthrosis)
Poor healing
Manage: Intense Physio or surgery
Ruptured posterior cruciate ligament
Mefh: Hyperextension injuries
Tibia lies back om femur
Paradoxical anterior draw test
Rupture of medial collateral ligament
Mech: Leg forced into valgus via force outside the leg
Knee unstable when put into valgus position
Meniscal tear
Rotational sporting injury
Delayed knee swelling
Joint locking (patient may develop skills to inlock)
Recurrent episodes of pain and effusions are common, often following minor trauma
Chondromalacia patellae
Teenage girls following an injury to knee eg dislocation of patella
Typically history of pain on going downstairs or at rest
Tenderness, quadriceps wasting
Dislocation of the patella
Most commonly as traumatic primary event, either through direct traume or severe contraction of quads with knee stretched in valgus and external rotation
Genu valgum, tibial torsion and high riding patella are risk factors
Skyline xrays of patella may be obvious
Osteochondral fracture present in 5%
Recurrence rate: 20%
Fractured patella types
Direct blow to patella cuasing undisplaced fragments
Avulsion fracture
Tibial plateau fractures
Occur in elderly (or signif trauma in yougn)
Mech: Knee locked into valgus or varus, but knee fractures before the ligament ruptures
Varus injury affects medial plateau, valgus injury then lateral plateau depressed fracture
Classify using Schtzker system
Adhesive capsulitis also known as…
Frozen shoulder
Adhesive capsulitis associated with
Diabetes mellitus. 20% of diabetics may have an episode
Features of adhesive capsulotis
Tend to develop over days
External rotation affected more than internal or abduction
Passive and active movement affected
Typically painful freezing phase, an adhesive phase and recovery phase
Bilateral in up to 20% patients
Episode lasts 6 months. To 2 years
Management of adhesive capsulitis
diagnose clinically
NSAIDs, Physio, oral corticosteroids, intra articular corticosteroids
No single intervention has been shown to I,prove outcome in long term
What is an iliopsoas abscess
collection of pus in iliopsoas compartment
Either from haematogenous spread of bacteria (commonly staph aureus), or secondary to:
Crohns, dicerticulitis, UTI, Gu Cancer, vertebral osteomyelitis, femoral catheter, endocarditis IVDU
Features of iliopsoas abscess
fever
Back/flank pain
Limp
Weight loss
with patient supine with knee flexed and hip slightly externally rotated, ask to lift thing against hand ->pain, or huperextend affected hip with parient on their side
Management of iliopsoas abscess
antibiotics
Percutaneois drainage
Surgery if failed to drain or other need for intra ah’dominal
Paeds complete fracture
Both sides of cortex are breached
Toddlers fracture
oblique tibial fracture in infanrs
Ttpically from falling off sofa onto straight leg
Not NAI concern particularly
Paeds plastic deformity
stress on bone resulting in deformity without cortical disruption
Paeds greenstick fractire
unilateral cortical breach only
Paeds buckle ‘torus’ fracture
incomplete cortical disruption resulting in periosteal hematoma only
Salter Harris system
Classification of paeds fractures with involvement of the growth plate.
From I: Through physis only
To IV: Involving physis, metaphysis and epiphysis
V: Crush injury
NAI red flafs
Delayed presentation
Delay in attaining milestones
Lack of concordance between proposed and actual mechanism of injury
Multiple injuries
Injury at site not normally exposed to trauma
Children on at risk register
Pathological fractures caused by…
underlying bone issues eg osteogenesis imperfecta
Or osteoporosis
acetabular labral tear
may occur following trauma in Young, or as result of degenerative change in older
Feat: Hip/groin pain
Snapping sensation around hip
Occasional sensation of locking
Leriche syndrome
atheromatous disease involving the iliac vessels
Blood flow to pelvic viscera is compromised
Classic triad of symtpoms:
1. Claudication of buttocks and thighs
2, atrophy of the musculature of legs
3. Impotence (due to paralysis of L1)
Diagnose with angiography, and if poss treat with endovascular angioplasty and stent insertion
Fearures of discitis
=an infection in intervertebral disc space
Back pain
Pyrexia + rigors + sepsis
Neuro fearures: Changing lower limb neurology if epidural abscess develops (=basically Progressing to cauda equina)
Diagnosis and treatment of discitis
MRI has highest sensitivty, CT guided biopsy may be useful for guiding antimicrobuals
Treatment: 6-8 weeks IV abx. Choice dependent on organism cultured
Assess for endocarditis
What is avascular necrosis of the hip
death of bone tissue secondary to loss of the blood supply
Leads to bone destruction and loss of joint function
Commonly epiphysis of long bones eg the femur
Causes of avascular necrosis
long term steroid use
Chemotherapy
Alcohol excess
Trauma
Diagnosing avascular necrosis
initially asymptomatic but then pain in affected joint and stiffness. In the hip, pain is typically in the anterior groin region
Xray may see osteopenia and microfractures early on, MRI is investigation of choice
Injury resulting in a scaphoid fracture
typically following fall onto outstretched hand causing axial compression of scaphoid with wrist hyperextended and radially deviated
In contact sports but also RTA the person holding the wheel
Importance of recognizing a scaphoid fracture
80% of blood supply is from dorsal carpal branch of the radial artery in a retrograde manner. Interruption of blood supply -> poss avascular necrosis. Often initially inconclusive radiography, so need further imaging 7-10 days later.
Symptoms and signs of a scaphoid fracture
Pain along radial aspect of wrist and at base of thumb
Loss of grip/pinch strength
Point of max tenderness over the anatomical snuff box
wrist joint effusion
Pain elicited by telescoping of the thumb
Tenderness of the scaphoid tubercle
Pain on ulnar deviation of the wrist
Management of scaphoid fracture
immobilize with futuro splint or below elbow backslab
Refer to orthopaedics
- if undisplaced to cast for 6-8 weeks, should unite well
- displaced scaphoid fractures require surgical fixation
- proximal scaphoid pole fractures also need surgery
What is lumbar spinal stenosis
condition in which central canal is narrowed by a tumour, a disc prolapse or other degenerative change
Degenerative disease in most common underlying cause
Lumbar spinal stenosis presentation
back pain
Neuropathic pain
Symptoms mimicking claudication (severe low extremity pain, or weakness with ambulation- due to incr metabolic demands of compressed nerve roots)
Sitting better than standing, may be easier to walk uphill than downhill
Absence of pain when spine is in flexed position
Differentiating lumbar spinal stenosis from peripheral arterial disease
pain improving on sitting down or croucdhing
Weakness of leg
Lack of smoking history
Lack of cardiovascular history
Features of L3 nerve root compression
sensory loss over anterior thigh
Weak hip flexion, knee extension and hip addiction
Reduced knee reflex
Positive femoral stretch test
Features of L4 nerve root compression
sensory loss anterior aspect of knee and medial malleolus
Weak knee extension and hip addiction
Reduced knee reflex
Positive femoral stretch test
L5 nerve root compression features
sensory loss dorsum of food
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
S1 nerve root compression features
sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test
Intracapsular hip fractures locations
subcapital (below femoral head)
Transcervical (across mid femoral neck)
Basocervical (across the base of the femoral neck)
Extracapsular hip fractire lpcations
Intertrochanteric - fracture line between the two trochanters, separation of lesser trochanter
Subtrochanteric - femoral neck remains intact
Garden classification system
traditional way or assessing severity of neck of femur fractures
I incomplete or impacted bone injury with valgus angulation of the distal component
II complete (across whole nexk) undisplacsd
III complete -partially displaced
IV - complete - totally displaced
Posterior hip dislocation
90% of dislocations
Affected leg is shortened, adducted and internally rotated
Anterior hip dislocation
affected lef is usually abducted and externally rotated, no leg shortening
Colles’ fracture
Fall onto extended outstretched hands
Described as dinner fork type deformity
Classically: Transverse fracture of the radius
- 1 inch proximal to radio carpal joint
- dorsal displacement and angulation
Smiths fracture (reverse Colles’ fracture)
volar angulation of distal radius fragment (garden Spade deformity)
Caused by falling backwards onto palm of an outstretched hand or falling with wrists flexed
Bennett’s fracture
intra articular fracture at base of thumb metacarpal
Impact on flexed metacarpal, caused by fist fights
Xray: Triangular fragment at base of metacarpal
Monteggia’s fracture
Dislocation of proximal radioulnar joint in association with an ulnar fracture
Fall on outstretched hand with forced pronation
Needs prompt diagnosis to avoid disabilirt
Galeazzi fracture
radial shaft fracture with associated dislocation of the distal radioulnar joint
Occurs after a fall on hand with a rotational force superimposed on it
OE: Bruising swelling and tenderness over the lower ends of the forearm
XR: Displaced fracture of radius and prominent ulnar head
Peak bone mass dependent on
Calcium intake
Vit D intake
Exercise
Timing of puberty
Smoking
Teen age pregnancy
Exercise amenorrhoea
Anorexia
Fasterbone mass loss of
Low oestrogen/testosterone
Vitamin S deficiency
Corticosteroids (>3mo of any oral dose)
Low weight or muscle mass
2ndary disease
Smoking
Excess alcohol
Septic arthritis history
Red hot swollen joint
Reluctant to move or weight bear
Feeling unwell
Septic arthritis investigations
Kocher criteria: incr WCC, incr ESR, fever, won’t weight bear
Bloods
Aspiration finds pus and cells
X Ray signs in OA
Joint space narrowing
Subchondral sclerosis
Cysts
Osteophytes
Symptoms of OA
Pain worse after activity relieved by rest
Morning stiffness
Creaking/grinding
Abnormal gait
Fixed flex ion deformities
Crepitus
Tennis elbow
= lateral epicondylitis
Inflammation of extensor muscles partic extensor carpi radial is
Typically self limiting and can exercise
Trigger finger
Painful locking of finger during flex on
Often around MCP joint pain
Thickening if flexor tendon as enters its sheath
Steroid injections or can be surgically released
Carpal tunnel associations
Base of thumb OA
F>M
Diabetes
Obesity
RA
hypothyroidism
Pregnancy
Trauma
Acromegaly
Amyloidosis
Shoulder abduction root nerve and muscle
C5
Axillary
Deltoid
Elbow flex ion root reflex nerve muscle
C5/6
Biceps reflex
Musculocutaneous nerve -> Biceps
Radial nerve -> brachioradialis
Elbow extension root reflex nerve muscle
C7
Triceps reflex
Radial nerve
Triceps
Radial wrist extension root nerve muscle
C6
Radial nerve
Extensor carpi radialis longus
Finger extension root nerve muscle
C7
Posterior interosseus nerve
Extensor digitorum communis
Finger flexi on root nerve muscle (2)
C8
Anterior interosseus nerve-> flexor policis longus and flexor digitorum profundity (index)
Ulnar nerve -> flexor digitorum profundus (ring and little finger)
Hip flex ion root and muscle
L1/2
Iliopsoas
Hip adduction root nerve muscle
L2/3
Obturator
Adductors
Hip extension root nerve muscle
L5/S1
Sciatic
Gluteus maximus
Knee flexion root nerve musclr
S1
Sciatic
Hamstrings
Knee extension root reflex nerve muscle
L3/4
Patellar jerk
Femoral
Quadriceps
Ankle dorsiflexion nerve root muscle
L4
Deep peroneal
Tibialis anterior
Ankle eversion root nerve muscle
L5/S1
Superficial peroneal
Peronei
Ankle plantarflexion root reflex nerve muscle
S1/2
Ankle jerk
Tibial nerve
Gastrocnemius, soleus
Big toe extension root nerve musclr
L5
Deep peroneal
Extensor hallucis longus
Cannot prescribe methotrexate with…
trimethoprim or cotrimoxazole.
Incr risk of marrow aplasia
Conceiving a child with methotrexate
Men and women should avoid pregnancy for a least six months after treatment has stopped
Felty’s syndrome
an uncommon complication of rheumatoid arthritis
RA + splenomegaly + low white cell count
Adhesive capsulitis patient population
females in 5th decade
Idiopathic or secondary to injury/trayma
Assoc with diabetes, thyroid disease and cervical spondylosis
Symptoms of adhesive capsulitis
Active and passive movement affected, worse at night
Defined stages of pain for 6 months to 1 year, then frozen for another 6 months and then resolve over 1-3 years
Rotator cuff sybdrome presentation and diagnosis
inflammation of subacromial bursa and rotator cuff tendon
Insidious onset pain elevation and abduction of arm between 60 and 120 degrees
Passive movement only painful when acromion is pressed
Common in middle age
Hawkins Kennedy test is diagnostic, or local anaesthetic injection into subacromial region
What is the Hawkins Kennedy test
test for rotator cuff syndrome
Elbow and shoulder in 90 degrees of flexion, internal rotation leads to pain
Painful arc exacerbated by thumb pointing down and better with thumb pointing up
rotator cuff syndrome management
usually conservative: Rest, NSAIDs, physio, dteroid injection into subacromial bursa ip to 3x per year
Surgery then subacromial decompression if persisting symptoms
Supraspinatus responsible for
abduction
Subscapularis responsible for
internal rotation
Infraspinatus’ responsible for
external rotation
Teres minor responsible for
external rotation and extension
Rotator cuff tears
Patients over 40 actually very common and due to degeneration
If younger maybe trauma
Partial tear: Conservative for 6 weeks
Complete tear: Prompt assessment for arthroscopic repair
Methotrexate scary SE
Myelosuppression
Hepatitis
Pneumonitis
Sulphalazine nasty SE
myelosuppression
Hepatitis
Rash
Leflunamide nasty SE
Myelosuppression
Hepatitis
Diarrhoea
Whats causing a reactive arthritis
previous GI infection - diarrhoea caused by shigella, salmonella, campylobacter
STI (gonorrhoea, chlamydia) causing discharge from genitals, discharge dyspareunia
Most specific antibody for RA
Anti CCP
ANA for lupus
sensitive (90%) but not specific
Polymyositis, Sjogren’s etc also ANA positive
Ro and La antibodies associated with
SLE and Sjogrens
DAS28 scoring includes which joints
PIPs, MCPs, wrists, elbows, shoulders knees
Used to monitor treatment for rheumatoid
Indications for antiTNF therapy in RA
DAS-28 high on 2 occasions with 2 failed DMARDs
Red papules over MCPs, linear erythema over fingers, periorbital rash and oedema
cutaneous signs of dermatomyositis
Tight skin over pulps of fingers with infarcts, Raynaud’s syndrome, tight opening of mouth
= scleroderma
Limited vs diffuse scleroderma
Limited = sskin distal to knees and elbows. Diffuse is more proximal
Linited: Anticentromere antibodies
Diffuse; anti Scl 70
lifethreatening things in major trauma
ATOMFCC
Airway obstruction
Tension pneumothorax
Open pneumothorax
Massive haemothorax
Flail chest
Cardiac tamponade
Trauma analgesia
IV morphine 1st line
If no IV access consider intranasal diamorphine or ketamine
Tension pneumothorax management
thoracostomy with needle: 14-18 gauge needle above rib in 2nd intercostal space in midclavicular line
Finger thoracostomy: 5th intercostal space, mid axillary line (triangle of safety)
Cerebral perfusion pressure =
mean arterial pressure - intracranial pressure
ACS protocol
ABCDE
MONA (morphine oxygen, nitrates, aspirin 300mg
PPCI/thrombolysis
ALS protocol I needed
Reversible causes of pulseless collapse
4Hs and 4Ts
Hypoxia, hypovolaemia, hypoK, hypothermia
Tension pneumothorax, tamponade, toxins, thrombosis
Ventricular fibrillatiom
shockable wave type
Bizarre irregular waveform, no recognizable QRS complexes, random frequenct/amplitude
Bradycardia protocol
If adverse fearures (shock, syncope myocardial ischameia, heart failure)
atropine 500mg, blocks vague so increases SA node automaticity and conduction
Transvenous pacing
Definitive: Pacemaker
Protocol for tachycardia with adverse fearures
adverse fearures: Shock, syncope, myocardial ischaemia, heart failure
-> synchronized DC shock up to 3x
If no response, amiodarone 300mg IV over 10-20 min and repeat shock, then amiodarone 900mg over 24hr
Protocol for tachycardia with no adverse fearures
Establish whether broad or narrow QRS
If broad and regular: VT-> amiodarone
If narrow and regular: SVT (most commonly AVNRT)-> vagal manouevres and then adenosine
If narrow and irregular -> poss AF -> control rate w beta blocker, consider digoxin or amiodarone if evidence of heart failure
Anaphylaxis management
ABCDE
Looking for lifethreatening ABC problems and skin changes for diagnosis
Call for help (and lie flat and raise patients legs)
IM adrenaline 500mcg 1:1000
High flow O2, IV fluid challenge(500-100ml crystalloid). Monitor pulse oximetry,. ECG, BP.
If no response repeat IM adrenaline in 5 mins
Chlorephenamine, hydrocortisone
Anaphylaxis characterized by…
Sudden onset and rapid progression of symptoms.
* Airway and/or Breathing and/or Circulation problems.
* Usually, skin and/or mucosal changes (flushing, urticaria, angioedema).
The diagnosis is supported if a patient has been exposed to an allergen known to affect
them. However, in up to 30% of cases there may be no obvious trigger.
Remember:
* Skin or mucosal changes alone are not a sign of anaphylaxis.
* Skin and mucosal changes can be subtle or absent in 10–20% of reactions
(e.g. some patients present initially with only bronchospasm or hypotension).
Status epilepticus management
ABC: High flow O2, IV access, give glucose if blood sugar low
Lorazepam 4mg IV over 2min
If persistent over 10 mins repeat
If still status, phenytpin 15mg per mg IV
If still persistent, consider phenobarbitone, call anesthetics and ICU
Moderate asthma
Increasing symptoms
PEF 50-75% best or predicted
No features of acute severe asthma
Acute severe asthma
any 1 of:
PEF 33-50% best or predicted
Resp rate >25/min
Heart rate >110/min
Inability to complete sentences
LLife threatening asthma
any one of
PEF <33% best or predicted
SpO2 <92%
PaO2 <8kPa
Normal PaCO2 (4.6-6.0kPa - if raised = near fatal)
Silent chest
Cyanosis
Poor respiratory effort
Arrhythmia
Exhaustion, altered GCS
Hypotension
Acute asthma management
sit up
O2 15L/min non rebreathe mask
Neb salbutamol 5mg and ipratropium 0.5mg
rePeat after 15-20mins
Steroids: IV hydrocortisone 100mg or oral pred 50mg
IF LIFE THREATENING
Inform ITU, MgSO4 2g IV over 20mins, continue B2B nebs
Do not give sedatives of any kind
Paracetamol OD
nausea and vomiting at a few hours, RUQ tenderness at 12h
Jaundice/hypoglycaemia/encephalopathy over 1-4 days
Measure levels after 4hrs, N acetylcusteine within 8h
Opioid overdose
resp depression, pinpoint pupils, hypotension
Give naloxone
Benzo OD
potentiste other CNS depressants
Drowsiness, resp depression, mild hypotension
Give flumazenil
Iron overdose
Surprisingly dangerous
Give desferrioxamine
Anticholinergic overdose
eg tricyclic antidepressants
Hot as hades, blind as a bat, dry as a bone, red as a beet, mad as a hatter
= incr HR, incr temp, dilated pupils, decreased bowel sounds, decreased sweat
Antidote: Physostigmine
Cholimergic OD
=organic phosphates or nerve agents
symptoms; SLUDGE
salivation
Lacrimation
Urination
Diarrhoea
Gastro hypermotility
Emesis
Give atropine
PE management
sit up, 100% O2 non rebreathe mask
Morphine +/- metoclopramide if distressed
If critically ill/massive consider thrombolysis: Alteplase 50mg bolus
LMWH
If low systolic BP need fluid and then possibly inotropes if still low
