Ortho Flashcards
Mx of snuffbox pain but no obvs fracture
Futura splint and review in fracture clinic
Features of neck of femur fracture
Non union
External rotation
Shortening
Osteomalacia biochem profil
Low Ca
Low P
High ALP
Bennets fracture
Intra-articular fracture of the first carpometacarpal joint
Impact on flexed metacarpal, caused by fist fights
X-ray: triangular fragment at ulnar base of metacarpal
Potts fracture
Bimalleolar ankle fracture
Forced foot eversion
Barton fracture
This is an intra-articular fracture of the distal radius with associated dislocation of the radio-carpal joint.
A Barton fracture can be described as volar (more common) or dorsal (less common
Extracapsular mx of NOF
Intertrochanteric- DHS
Subtrochanteric- IMN
Intracapsular mx of NOF
Young- IF
Non displaced- IF
Mobile older- Full arthro
Not mobile/cog impaired- Hemiarthro
When does out of hours surgery occur for open fractures
there is marine/ sewage contamination, vascular compromise or it is a polytrauma.
Gustillo-Anderson classification
Used to classify open wound fractures
1 Low energy, clean wound <1cm
2 Greater than 1cm wound with moderate soft tissue damage
3 High energy wound > 10cm with extensive soft tissue damage
3 A (sub group of 3) Adequate soft tissue coverage
3 B (sub group of 3) Inadequate soft tissue coverage- require plastics
3 C (sub group of 3) Associated arterial injury- require vascular
Mx of open fractures
Remove obvious contaminants from very contaminated wounds in the ED
Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injury
Early wound photography should be performed
Consider transfer of complex cases to centres that provide orthoplastic care
All wounds should be managed within 24 hours and high velocity ones within 12 hours, those with vascular compromise should be managed immediately
CT angiography is useful in delineating the extent of concommitant vascular injury
Depostition in pseudo gout
Calcium pyrophosphate
weakly-positively birefringent rhomboid shaped crystals
RF for pseudogout
hyperparathyroidism
hypothyroidism
haemochromatosis
acromegaly
low magnesium, low phosphate
Wilson’s disease
Features of pseudogout
knee, wrist and shoulders most commonly affected
joint aspiration: weakly-positively birefringent rhomboid shaped crystals
x-ray: chondrocalcinosis
Mx of Grade 3c open fracture
Vascular shunting
Temporary skeletal fixation
Vascular reconstruction
Wishing 3-4 hours
Anatomical neck of humerus fracture mx
Hemiarthroplasty
Anatomical neck fractures which are displaced by >1cm carry a risk of avascular necrosis to the humeral head.
Mx of ankle fractures
Weber A- mobilised fully weight bearing in an ankle boot.
B- treating undisplaced ankle fractures in a below knee plaster, non-weight bearing for six weeks is still widely practised, and a safe approach.
If trimalleolar- fixation
C-require operative fixation.
Rotator cuff tear presentation
Weakness in active movement
Passive movement fine
Associated injuries with glenohumeral dislocation
Bankart lesion - avulsion of the anterior glenoid labrum with an anterior shoulder dislocation (reverse Bankart if poster labrum in posterior dislocation).
Hill Sachs defect - chondral impaction on posteriosuperior humeral head from contact with gleonoid rim. Can be large enough to lock shoulder, requiring open reduction.
Osgood schlauer syndrome
Multiple micro fractures at the point of insertion of the tendon into the tibial tuberosity. Most cases settle with physiotherapy and rest.
Avascular necrosis causes
P ancreatitis
L upus
A lcohol
S teroids
T rauma
I diopathic, infection
C aisson disease, collagen vascular disease
R adiation, rheumatoid arthritis
A myloid
G aucher disease
S ickle cell disease
Spiral fracture of the mid shaft of the tibia. Attempts to achieve satisfactory position in plaster have failed. Overlying tissues are healthy
Mx?
IM nail
Mx of Colles fracture
High velocity- surgical reduction
Osteoporotic- reduction and fixation
Osteoporosis tx
Calcium, Vit D,
Bisphosphonates
Treatment is indicated following osteoporotic fragility fractures in postmenopausal women who are confirmed to have osteoporosis
Or if DEXA not required
Immediate mx of displaced ankle fracture
Reduction and back slab
Which salter Harris look similar on x ray
1 and 5
Brown squared syndrome
It results in ipsilateral paralysis (pyramidal tract) , and also loss of proprioception and fine discrimination (dorsal columns). Pain and temperature sensation are lost on the contra-lateral side.
Parsonage Turner syndrome
Neuropathy post viral infection usually affecting the shoulder
3a vs 3b open fracture management
3a-may not requries plastics
3b- plastic involvement
Perthes disease features
Idiopathic avascular necrosis of the femoral epiphysis of the femoral head
Male
>2w
Limp; Hip pain
* Decreased Abduction& internal Rotation
AS features
Sacro-ilitis is a usually visible in plain films
Up to 20% of those who are HLA B27 positive will develop the condition
Affected articulations develop bony or fibrous changes
Typical spinal features include loss of the lumbar lordosis and progressive kyphosis of the cervico-thoracic spine
Related to UC
Adhesive capabilities sx
Frozen shoulder passes through an initial painful stage followed by a period of joint stiffness.
With physiotherapy the problem will usually resolve although it may take up to 2 years to do so.
Associated with prolonged immobilization, previous surgery, thyroid disorders (AI) and diabetes
The loss of ROM usually follows a specific pattern starting with external rotation, followed by abduction, internal rotation, and forward flexion
Avascular necrosis presentation and imaging
Pain and stiffness proceed radiological changes
Often despite apparent fracture union.
Plain film- earliest evidence on plain films is the affected area appearing as being more radio-opaque due to hyperaemia and resorption of the neighboring area
Late evidence- radiolucency and subchondral changes
MRI scanning will show changes earlier than plain films.
Non weight bearing may help to facilitate vascular regeneration.
Joint replacement may be necessary- drilling may be an appropriate alternative
Compartment syndrome RF and sx
Delayed fracture management
Two main fractures carrying this complication include supracondylar fractures and tibial shaft injuries
Pain, especially on movement (even passive)
Parasthesia early
Absent pulse late
Pes anserinus bursitis sx
Athletes
Medial proximal tibia pain
Eacerbated by particular activities such as ascending and descending stairs
McMurray test is negative
Impacted fractures of the surgical neck of humerus mx
Collar and cuff for 3 weeks
Then physio
Pt unable to weight bare and pain on internal rotation of hip- x ray normal what next
MRI or CT
Chondromalacia patella
Teenage girls, following an injury to knee e.g. Dislocation patella
Pain walking down stairs
Pseudolocking
Tenderness, quadriceps wasting
Sx of radial head fracture
It is usually caused by a fall on the outstretched hand.
On examination, there is marked local tenderness over the head of the radius, impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination).
Spondylolisthesis symptoms and management
May occur as a result of stress fracture or spondylolysis
Traumatic cases may show the classic ‘Scotty Dog’ appearance on plain films
Treatment depends upon the extent of deformity and associated neurological symptoms, minor cases may be actively monitored.
Individuals with radicular symptoms or signs will usually require spinal decompression and stabilisation
Maisonneuve fracture
Combination of a fracture of the proximal fibula together with an unstable ankle injury (widening of the ankle mortise on x-ray
Types of spina bifida
spina bifida occulta- 10% of the population may have spina bifida occulta- bone doesn’t develop there properly
meningocele- swelling of CSF in a sac that forms where the vertebrae do not form properly
myelomeningocele - ost severe type with associated neurological defects that may persist in spite of anatomical closure of the defect
Holstein Lewis Fracture and what nerve is at risk
Fracture of the distal third of the humerus resulting in entrapment of the radial nerve.
fell on chin, reduced mouth opening, jaw not aligned, pre auricular tenderness which part fractured
Coronoid
Mx of Gustillo type 3A
Debrided and lavage within 6hrs and external fixation
Best to avoid metal workout in open fractures
IV Abx
Mx of gustily types 3B and 3C
Debrife lavage, external fixation, IV abx
Free tissue flaps
3C- vacaular repair
Drugs affecting bone healing
NSAIDs
Periosteum and bone healing
Aids if in tact
Contains osteoblasts
Most common fractures causing compartment syndrome
Tibial or supracondylar
What should you measure with fasciotomy
CK in blood and myoglobin levels- in urine
Assess risks of renal failure
Organism for osteomyelitis
Staph
Salmonella- sickle cell
Developmental dysplasia of hip sx
Acetabulum not well developed with head and dislocated easy
Breech delivery
Antalgic gait
Destruction of femoral head and narrow acetabulum
Test for DDH and management
Barlow - hip started reduced- test will dislocate- posterior and adduct force
Ortholani- started dislocated- will reduce - anterior and abduct force
USS
Harness
If years later- osteotomy and realignment
Pain in hip for 8w, X ray normal what next
MRI
Movements limited by perches
Abduction and internal rotation
Gage sign
V-shaped lucent defect at the lateral portion of the epiphysis and/or adjacent metaphysis. It is pathognomonic for Perthes disease
X ray of perches disease
Flat femoral head
o Sub-chondral crecent shaped radiolucent line
o Calcification lateral to epiphysis
Increased joint space
Gage sign
Staging of Perthes disease
Stage 1- clinical and histology only
2- sclerosis with preservation of articular surface
3- loss of integrity of femoral head
4- loss of acetabulum integrity
Mx of Perthes
- To keep the femoral head within the acetabulum: cast, braces
- If < 6 years: observation and symptomatic Rx
- 6-8 yrs: Brace or surgical management with moderate results
- > 8yrs: Surgical containment: (femoral / pelvic )osteotomy
Osgood schlatter Features
Micro fracture in tibial tuberosity
Athletics boys
Settles with rest and physio
Greenstick vs buckle fracture
Greenstick - unlateral cortisol breech only
Buckle- Incomplete cortical disruption resulting in periosteal haematoma onl
Ricketts features
Start at 1 yrs
Small for age, FTT
Bowing of tibia
Large head
Dental hypoplasia
Pectus carinatum
Widening and cupping of epiphysis
Osteomalacia features
Bone pain
Fractures
Muscle tenderness
Proximal myopathy
NAI features
Delayed presentation
Spiral fractures
Multiple fractures
retinal haemorrhage
torn frenulum
Rib fractures
Metaphyseal fracture- bucket handle
Non parietal skull fracture
Kocher criteria fo septic arthritis
WIFE
W >12
Inability to weight bear
Fever
ESR >40
Osteogenesis imperfecta features
Type 1 collagen defect
Hypermobile
Blue sclera
Multiple fractures
Extra bone in skull- workman bone
Types of spina bifida
Occulta -10% population- brith mark, patch of hair
Meningocele - meninges form sac
Myelomeningocele - spinal cord- neuro defects
PCL rupture features
Hyperextension injury
Tibia posterior
Posterior draw test +
Meniscal injury features
Delayed onset knee swelling
Rotational injury
Locked knee
Recurrent effusions and pain
Terrible triad
Rupture of MCL, ACL and medial meniscus
MCL and LCL injury forces
Valgus- MCL
Pain on valgus force
Varus- LCL
Pain on varus force
Patella dislocation features, x ray
Direct trauma
Knee in valgus, external rotation and quad contraction
Skyline x ray- sublux- partial
Extracapsular hip fracture mx
Intertrochanteric- DHS
Subtrochanteric- IM device
Intracapsular hip fracture mx
Undispaced- IF
Displaced- <70- ORIF
>70 - total hip (mobile and not cognitively impaired)
Unmobile- hemi
Gardner classification
Hip
1- undiscpalced, incomplete
2- complete but undisplaced
3- partially displaced (one end in contact)
4- completely displaced
Pauwel Hip fracture classification
degree of inclination of the fracture line measured from the horizontal on an AP radiograph
1- <30
2-30-50
3- >50
Angel
Weber fracture mx
A- mobilised fully weight bearing in an ankle boot.
B- if trimalleolar (affecting post malleolus) require fixation
Uni- ankle boot
C- fixation
Maisonneuvre facture
Spiral fracture of proximal third of fibula
Tear of syndemosis
Widening on x ray
requires fixing
Stress fracture
2nd metatarsal frequent
Repetitive injury
Freiberg disease
Osteonecrosis of the metatarsal heads, prominently the second metatarsal
Patients present with pain and swelling localized to the involved metatarsal head region of the forefoot. They describe the sensation of walking on something hard, such as a stone. Symptom onset is typically gradual, with no specific acute even
Spondylolithesis features
Young female athletes
On vertebrae displaced over another
Occurs as a results of a stress fracture of spondylosis
Radical symptoms- neuro- spinal decompression
Ankylosing spondylitis test and allele
Schober
2 points 15cm apart- if doesn’t increase by 5cm
HLA B27- associated with UC
Anterior cord injury mechanism and symptoms
Flexion injury
Loss of motor and pain/temp below
Central cord
Hyperextension
Sensory and motor deficit
Upper>lower-since cervical motor are located more medially than others
Crystals in gout and pseudo gout
Calcium- pseduogout
Rhomboid- positive birefringent- blue when parallel
Monosodium urate- gout
Needele- negative- yellow when parallel
RF for psuedogout
Hyperparathyroid
Hyperthyroid
Haemachromatosis
Acromegaly
Wilsons
Low Mg or Phosp
X ray of pseudo gout
Chondrocalcinosis
Gout vs pseudogout
Gout
>40
Small joints
Severe pain
Urate acid- yellow when parallel to polirizer
Pseudo
large joint
Elderly
Calcium
Chondrocalicnosis
Osteoporosis tx
Treatment is indicated following osteoporotic fragility fractures in postmenopausal women who are confirmed to have osteoporosis (a T-score of - 2.5 SD or below).
In women aged 75 years or older, a DEXA scan may not be required if the responsible clinician considers it to be clinically inappropriate or unfeasible
Vitamin D and calcium supplementation should be offered to all women unless the clinician is confident they have adequate calcium intake and are vitamin D replete
Alendronate is first-line
Around 25% of patients cannot tolerate alendronate, usually due to upper gastrointestinal problems. These patients should be offered risedronate or etidronate
SERM and stratum increase thromboembolic events
Osteopetrosis features
AR adults
Anaemia, thrombocytopaenia, leucocytopaenia -infections
Decreased marrow space
X ray- lack of differentiation between medulla and cortex
Marble bone
Osteocondroma features
Metaphysis
Cartilage
Mushroom appearance on X ray
Usually asymtpomatic
Tibial plateu fracture types
Type 1- split
2- split decompression- untreated valves may form
3- central depression
4- split, medial plateau
5- bicondylar
6- dissociation of metaphysic and diaphysis
Disclocation of hip presentation
Posterior- adducted, IR
Anterior- abducted, ER
Tx of Pagets
Indications for treatment include bone pain, skull or long bone deformity, fracture, periarticular Paget’s
bisphosphonate (either oral risedronate or IV zoledronate)
Common cancers that cause bone mets
Breast
Lung
Prostate
Thyroid
Renal
Bone mets biochem
All raised
PTH normal or low
Syringomyelia features
Cystic cavity in spinal cord
Arnold chiari malformation
Acquired- prev meningitis or surgery
Spinothalamic- loss of pain and temp in UL
Subacromial impingement presentation
Insidious onset
Exacerbated by overhead activities
Night pain- poor indicator
Painful arc- 60-120
Tests for subacromial impingement
Neer impingement sign - flexion >90 causes pain
Neer impingement test- subacromial injection relieves pain with forward flexion
Hawkin - internal rotation and passive forward flexion causes pain
Jobe- resisted pronation and forward flexion to 90 causes pain
Arc
X ray of subacromial impingement
Proximal migration of humerus- tear arthropathy
Calcification
Tx of subacromial impingement
Physio, NSAIDs
Injections
Ops- after failure of 4-6m
SA decompression or acromioplasty
Classification of rotator cuff tears
Anatomical
SIT- associated with subacromial impingement - often degenerative tear
Subscapularis- subcoracoid impingement
Tear size
Small 0-1
Medium- 1-3
Large- 3-5
Massive- >5cm- involves 2 or more tendons
Examination findings of rotator cuff
Supraspinatus- drop arm, pain with Jobe
Infra- ER weakness at 0 abduction p external rotational lag
Teres- ER weakness at 90 abduction - Hornblower
Subscapularis- IR weakness at 0 abduction- Geber lift off, internal lag
Ix for rotator cuff tear
X ray
MRI- diagnostic
Rotator cuff tear treatment
Non op- physio NSAIDs, injection
Avoid overhead activities
Op- decompression, debridement
Repair- arthroscopic
Frozen shoulder hx
Start of with pain
Then freezing
Then resolve
ER first effected
Radial nerve damage location presentation
Axilla- loss of elbow extension and reflex and wrist extensnon
Spiral- preservation of elbow extension and reflex
Humeral fractures- type and damage to which structures
Surgical neck- axillary and circumflex arteries
Spiral groove- radial and profunda brachii
Posterior medial epicondyle- ulnar
Proximal humerus fracture mx
Collar and cuff or broad arm sling for 4-5w
Mobilise at 3w
Mx of diphyseal humeral fracture
Undiscpalced or minmal- collar and cuff
Displaced <30 or shortening <2cm- collar and cuff
Displaced >30 or shortening >2cm or neurovascular or compound- reg - potential surgical
Tennis vs golfer elbow
Tennis- lateral epicondyle
Golf- medial epicondyle
Frommet test
Weakness of adductor pollicis
Use flexor policies
Sign od ulnar weakness
Cause of cubital tunnel syndrome
Post supracondylar fracture
Valgus or varus
Tumour
Colles fracture features
- Transverse fracture of the radius
- 1 inch (2.5 cm) proximal to the radio-carpal joint 3. Dorsal displacement and angulation
Mx of Colles fracture
Reduction under block or GA
Plaster
may need surgery down the line
Barton fracture
Distal radius fracture
That is intra-articular
Radiocarpal disclocation
* Fall onto extended and pronated wrist
What is a proximal scaphoid fracutre at risk of
Atrophic Non union
AVN
RF for non union
Age
Smoking
DM
NSAIDs, steroids
Open fracture
Extensive soft tissue injury
Infection
Neurovascular injury
Pathalogical fracture
Radial nerve damage at level of humerus vs wrist
Humerus- Wrist drop
Inability to sense over snuff box
Wrist- finger extension
Ulnar nerve palsy at wrist presentation
Adductor polices
Abduction and adduction of fingers
Positive Formment sign
Hypothenar wasting
Carpal tunnel borders
Scaphoid tubercle and trapezium radially
Hook of hamate and pisiform ulnarly
Transverse carpal ligament roof
Proximal carpal row dorsally
Carpal tunnel mx
Non op
Steroids -80% improvement
Op- decompression
De Quervain tenosynoviitis
Sheath inflammation of 1st extensor compartment
EPB, APL
Age 30-50
Pain and tenderness
Finkelstein test
Fist over thumb- deviate in ulnar direction
Tx of de Quevain tenosynovitis
Non surgical
Steroids
Surgical release of first dorsal wrist compartment
Trigger finger features and mx
Fibrotic thickening of tendon sheath- stenosis
Flexor tendon gets caught- A1 pulley
Use other hand to open
Feel pop
Flexor tenosynovectomy
Dupuyntens contracture
Progressive nodules in palm that forms cord- my-fibroblast- contract
Changes of collagen from 1 to 3
Fixed flexion
Ring finger
Mx of dupuytrens contracture
Fasciectomy
Extensor tendon injury level
1- distal to or at DIP
2- middle phalanx or proximal phalnx of thumb
3- PIPIJ
4- proximal or thumb
5- MCPJ
6- metacarpal - neuromuscular injury
7- wrist joint
8- forearm
Boutonnière deformity extensor zone damage
Zone 3
How extensor injury present
Zone 1- inability to extend at DIP - mallet finger
Forced flexion of
Zone 3- Elson
Central slip intact- DIP supple
Distrupted- rigid
Zone 5- extensor lag and flexion loss
Extensor tendon anatomy
Central slip attaches to medial phalanges proximally
Lateral bands attach to distal phalanges
SO if damage to central slip- Boutonniere- since lateral remain in tact
Mx of extensors tendon injuries
Splinting
Full time- 6w
DIP- zone 1
PIP- 3
MCP- 5
Surgical- fight bite (knuckle hits tooth) - washout
>50% tendon- repair
Mallet finger features
Direct blow
Rupture of distal extensor tendon slip
Causing flexion of DIP
Findings in hands with OA
Bouchards- PIJ
Herberdens nodes- DIJ- skew finger sideways
If patient has anatomical snuffbox tenderness no findings on x ray, then comes back 2 weeks later asymptomatic what do you do
Discharge with reassurance
Features of ganglion
Associated with tendon sheath
Fluid filled
Not usually excised unless troublesome
Mx of proximal pole scaphoid fracture
Surgical fixation
Patient has a 75% lytic lesion in femur mx
IM nail
Femur lytic lesion, hyper vascular, malignancy location
Renal- tend to be hyper vascular
Mirel Scoring system for bone mets and tx
1- upper extremity, blastic, less than 1/3 width, mild pain
2- lower, mixed, 1/3-2.3, mod pain
3- peritronchanteric, lytic, >2/3, aggravate by function
> 9/=- impending fracture- prophylactic fixation
8- borderline consider
7 or less- non operative
Most common cause of osteolytic bone in children
Neuroblastoma
First sign of Perthes on X ray
Scleoris of femoral head
Indication for tx of Perthes
Indication for treatment (aide memoire):Half a dozen, half a head
Those aged greater than 6 years with >50% involvement of the femoral head should almost always be treated.
Management of open patella fracture
Abx
Debridement
Fracture control with encircle wires and rpaimary closure
Klumpkes vs ulnar
Klumpkes affects arm sensation too
Causes clawing in the whole hand
Compartment syndrome urine
Red cells +
As myoglobin
What is at greater risk the longer a hip is dislocated
Avascular necrosis
Lytic lesion in iliac crest with cytokeratin positive cells
Bone mets
Lytic vs plastic lesion mets
Lytics- thyroid, intestinal, renal, lung
Breast- mixed
Blastic- prostate, lymphoma
Fellow bone in tact next to fracture causes
Delayed healing as causes distraction
Osteoid osteoma features
Benign tumours
Radiolucent zone surrounded by sclerotic zone
Main muscle supporting medial plantar arch
TP
Muscular and ligament support of medial arch
Muscular support: Tibialis anterior and posterior, fibularis longus, flexor digitorum longus, flexor hallucis, and the intrinsic foot muscles
Ligamentous support: Plantar ligaments (in particular the long plantar, short plantar and plantar calcaneonavicular ligaments), medial ligament of the ankle joint.
Muscular and ligament support of lateral arch
Muscular support: Fibularis longus, flexor digitorum longus, and the intrinsic foot muscles.
Ligamentous support: Plantar ligaments (in particular the long plantar, short plantar and plantar calcaneonavicular ligaments).
Giant cell tumour features
Epiphyses
Bening
Lytic lesion
20s-30s
Nerves in cauda equina
L2-S5
All lower motor nerves
Hyporeflexia
Ewing sarcoma histology
Small blue cells
Most common complication of hip replacement
Asymptomatic DVT
Mx of septic shock and rapid progressing cellulitis
Wide excision fo skin and necrotic fasciae
Cause of avulsion fracture
Muscle contractions
Atrophic non union OP fracture management
Plating and bone graft
Most common benign bone tumour <21 yrs
Osteochondroma
Ortho condition that trisomy 18 is associated with
Congenital talipes equinovarus
Pes cavus features
High medial longitudinal arch
High stress on hind foot
Clawing of toes as using extensors
What nerve is damaged in tarsal tunnel
Tibial
Mx of pelvic fractures
Pelvic binder
Where bleeding occurs with AP pelvic fracture
Superior gluteal
First X ray feature to appear for OP
Narrowing of joint space
Greatest flexor of elbow
Brachialis
Loss of bicep- biggest movement loss
Supination
Minimum time for callus to appear on x ray
2-3 weeks
Tibial spine fracture test
Anterior draw test +
As ACL inserts on spine
Koher disease
Avascular necrosis of navicular
Ix highest diagnostic value of osteomyelitis
MRI
Imaging for ankle
AP
Lateral
Mortise -20degree IR
What indicates syndesmotic injury on Ix
Decreased tibiofibular overlap
medial joint clear space
lateral talar shift
There is suspicion of syndesmosis involvement in the absence of radiographic evidence
Stress radiograph
How complex ankle fracture and posterior malleolar fracture are best imaged
CT
Time taken for ankle fractures to heal
6W
Return to activities at 3m
Scheuermann’s disease presentation and management
Epiphysitis of the vertebral joints is the main pathological process
Predominantly affects adolescents
Symptoms include back pain and stiffness
X-ray changes include epiphyseal plate disturbance and anterior wedging
Clinical features include progressive kyphosis (at least 3 vertebrae must be involved)
Minor cases may be managed with physiotherapy and analgesia, more severe cases may require bracing or surgical stabilisation
structural and non structural scoliosis
Non-structural scoliosis refers to lateral curvatures of the spine caused by reversible changes to posture and function
Structural scoliosis affects > 1 vertebral body and is divisible into idiopathic, congential and neuromuscular in origin. It is not correctable by alterations in posture
Mx of severe or progressive scoliosis
managed surgically with bilateral rod stabilisation of the spine
Spondylosis cause
Congenital or acquired deficiency of the pars interarticularis of the neural arch of a particular vertebral body, usually affects L4/ L5
Radial fractures needing surgical fixation
Dorsal tilt of more than 20 degrees,
comminuted fracture,
injury to the ulnar styloid,
intra articular disruption
How distal radial fractures are reduced
under either a haematoma or Biers block and immobilisation in a cast
Ix for hip fracture
AP and cross table lateral
If the fracture extends below the level of the lesser trochanter, or there is any possibility of pathological fracture, full length femur views are essential to plan surgery.
When should NOF surgery occur
Within 36 hrs >48 hrs increases morbidity and mortality
How reverse oblique NOF is treated
IM nail
(Pertronchanteric fracture- reverse of intertrochanteric)
Which structures do MCL and LCL attach to
MCL- medial epicondyle to adductor magnus tendon and medial meniscus
LCL- lateral epicondyle- splits biceps femoris to fibula
Popliteal inbertween it and capsule
RF for discloation of patella
Genu valgum, tibial torsion and high riding patella are risk factors
X ray of osteomalacia vs rickets
x-ray: children - cupped, ragged metaphyseal surfaces; adults - translucent bands (Looser’s zones or pseudofractures)
Description of anatomical and surgical neck of humerus
Anatomical- between head and tuberosities
Surgical- between tuberosities and metaphysis
Attachment of Rotator cuffs
Supra, infra, TM- greater
Subscapularis - Lesser
Mx of humeral fractures
ORIF- complex fractures
IM nail- Suitable for extra-articular configuration, predominantly surgical neck +/- GT fractures.
Hemi- Used for un-reconstructable fractures in the older patient who has good glenoid quality.
Total - Unconstructable fractures where high functioning shoulder is required (hemiarthroplasty will cause glenoid erosion)
Reverse- Total shoulder arthroplasty that provides better functional outcome than conventional total shoulder replacement.
Mx of scapula fracture
The vast majority of scapula fractures are amenable to conservative management, consisting of sling immobilisation for two weeks followed by early rehabilitation.
Floating shoulder (clavicle and scapula) will usually require fixation, and consideration of surgery should also be given to intra-articular and displaced/angulated glenoid fracture
Mx of shoulder dislocation
Anterior
Hippocratic.
Milch.
Stimson.
Posterior
Gentle lateral traction to adducted arm.
50% missed in A&E
Tx of glenohumeral arthritis
Hemiarthroplasty can sometimes be considered if glenoid is in excellent condition or if patient has large comorbidity.
Total shoulder replacement is shown to produce superior outcome when compared to hemiarthroplasty in terms of pain relief, function and implant survival.
Anatomical TSR requires an in tact rotator cuff, so often reverse is preferable when the cuff if questionable in integrity.
Central cord lesion
Flaccid paralysis
Upper >lower limb
Dermatomes
C2 to C4 The C2 dermatome covers the occiput and the top part of the neck. C3 covers the lower part of the neck to the clavicle. C4 covers the area just below the clavicle.
C5 to T1 Situated in the arms.
C5 covers the lateral arm at and above the elbow.
C6 covers the forearm and the radial (thumb) side of the hand.
C7 is the middle finger,
C8 is the medial aspect of the hand,
and T1 covers the medial side of the forearm.
T2 to T12 The thoracic covers the axillary and chest region. T3 to T12 covers the chest and back to the hip girdle. The nipples are situated in the middle of T4.
T10 is situated at the umbilicus. T12 ends just above the hip girdle.
L1 to L5 The cutaneous dermatome representing the hip girdle and groin area is innervated by L1 spinal cord.
L2 and 3 cover the front part of the thighs.
L4 and L5 cover medial and lateral aspects of the lower leg.
S1 to S5 S1 covers the heel and the middle back of the leg.
S2 covers the back of the thighs.
S3 cover the medial side of the buttocks and S4-5 covers the perineal region.
S5 is of course the lowest dermatome and represents the skin immediately at and adjacent to the anus.
Upper limb myotomes
Flexor- C5
Wrist extensors- C6
Elbow extensors- C7
Long finger flexor- C8
Finger abductors- T1
Lower limb myotomes
Hip flex- L1+2
Knee extensors- L3
Ankle dorsiflexors- L4,5
Toe extensors- L5
Ankle plantar- S1
Ix for scaphoid fracture
Ulnar deviation AP needed for visualization of scaphoid
Position of foot in talipes
Inversion, adduction relative to hindfoot and plantarflexion
Flexor tendon zones
Zone 1- end to middle of middle
2- middle to distal palmar crease
3- distal palmar crease to carpal tunnel
4- carpal tunnel
5- beyond
Sign in compartment with poorest prognosis
Anaesthesia
