Ortho Flashcards
What are the five unstable C-spine fractures?
atlantoaxial dislocation
Jeffersons fracture (C1 burst)
Hangmans fracture (bilateral pedicle C2)
Type 2 or 3 odontoid process
Tear drop fracture
Bilateral facet joint dislocation
What is Spinal shock and what are the features?
neurological injury to spinal cord and period of confusion where overestimates injury
Features:
Areflexia
Flacid paralysis
What is neurogenic shock and what are the features
distributive shock due to lack of sympathetic tone
Features:
Bradycardia
Hypotension
Warm skin
Poikilothermia
Above what level does neurogenic shock occur?
T6
What is the management of neurogenic shock?
Supportive care - analgesia, immobilise injuries, anti emetics
MAP 85-90 with hartmans when norad
normoxia, normothermia, normoglycaemia
IDC, pressure areas, VTE prophylaxis
What are findings and diagnosis
bilateral facet joint dislocation
anterior displacement of c4/c5 with no fracture
narrowing of vertebral foramen
What are the three lines to follow when looking at c spine x ray?
What other sign is important
The anterior longitudinal line runs along the anterior surface of the vertebral bodies.
The posterior longitudinal line runs along the posterior surface of the vertebral bodies.
The spinolaminar line runs along the anterior edge of the spinous processes (at the junction of the spinous process and the laminae).
NB - prevertebral soft tissue swelling
name the contraindications to biers block
allergy to anaesthetic
BP <200
cuff wont fit eg obese
methaglobulinaemia
uncooperative patient
raynaud/PVD/lymphoedema
What are the indications for closed reduction of distal radial fracture?
neurovascualr compromise
extra articular
less than 5mm radial shortening
dorsal angulation under 5 degress or within 20 degress of contralateral distal radius
less than 2mm articualar step off
describe fracture
Extraarticular distal radius #
25% posterior displacement
45o dorsal angulation
Minimally displaced ulna styloid
What is a normal retropharyngeal space
describe abnormality
comminuted fracture Rt femur
Intertrochanteric fracture
Spiral fracture of proximal femoral shaft with shortening and displacement
(one mark for description – displacement/angulation
what are the indications for ankle X ray as per OTTAWA guidelines
- inability to weight bear and immediately and in WR for 4 steps
- bone tenderness along distal 6cm of posterior edge of tibia or tip of medial malleolus
- OR bone tenderness along distal 6cm of posterior edge of fibula or tip of lateral malleolus
what are the indications for a foot x ray as per the OTTAWA guidelines
- bone tenderness at base of 5th
- bone tenderness at navicular
- inability to weight bear and immediately and in WR for 4 steps
abnormality
minimally displaced fracture distal tibia with intra articular involvement
what injuries are associated with fall from height?
- calcaneous fracture
- vertical shear pelvic fracture
- T spine fracture
- retroperitoneal injuries
- intracranial injuries
list abnormalities
diagnosis
management?
- medial mallolar fracture
- posterior tibial fracture
- fibula fracture
- lateral talar displacement
*
unstable tri malleolar fracture*
management
* analgesia - state
* sedation
* below knee backslaab
* elevation
* ortho admit for ORIF
what are the red flags for back pain?
- under 20 and over 55
- constant progressive and not relieved by rest
- IVDU
- fevers
- weight loss
- underlying malignancy
- immunosupression
- recent spinal surgery
yellow flags for back pain recovery
- inappropriate attitude of belief about back pain eg activity is harmful
- recurring back pain
- workers comp related
- poor social support
- poor coping skills
- stress related illness
sources of spinal epidural abscess
- skin or soft tissue
- IVDU
- pneumonia
- UTI
- bacterial endocarditis
- iatrogenic eg LP
- spinal stimulator
- penetrating injury
*
with localised central back pain what are key components of exam and why?
- assess for spinal cord compression - motor and sensory
- cauda equina eg no anal tone
- systemic - fever, chills
what tests may you do in epidural abscess and why
what is the treatment?
- CRP - more sensitive that WCC in early disease
- blood cultures - identify organism and guide treatment
- MRI - confirms diagnosis and extent
Treatment:
fluclox 2g QDS plus ceftriaxone 2g IV
OR vancomycin 25mg/kg
gent 5mg/kg
what organisms are likely causing epiural abscess
- s.aureus
- s.pyogenes
- group b strep
- h. influenzae
- e.coli
- klebsiella
- pseudomonas
list 5 ways of c spine immobilisation
- hard collar
- soft collar
- foam blocks
- head tape
- towels
- vacuum matress
what are the complications of C-spine immobilisation
- raised ICP
- reduced access to neck
- pain from needing to pass urine
- pressure sores
- aspiration risk
- impaired ventolation
- potential worsening of spinal cord injury
- increased staffing eg log roll
- distracts from other injuries
- poor access in resus
exclusion criteria for canadian C spine
- under 16
- non trauma cases
- GCS under 15
- injured over 48 hour prior
- penetrating injury
- acute paralysis
- ank spon
- pregnant
according to canadian c spine which stable patiens need imaging
- over 65
- dangerous mechanism
- parasthesias in extremities
two significant findings
what are the management priorities?
- grossly deformed swollen left wrist consistent with distal radial +/- ulna fracture
- dorsal angulation distal radius
- skin breech and bleeding
**Management **
- analgesia
- assess for nerve damage
- ‘urgent reducion
- iv abx
- tetanus
- POP and post reducion imaging
- ortho referral
what are the early and late complications of distal radial fracture - displaced
early
* median nerve injury
* compartment syndrome
Late
* non union
* malunion
* chronic pain
* infection
* arthritis
what are the examination findings of traumatic median nerve injury
pain, parasthesia, weakness in median nerve distribution
muscle wasting and fasciculations long term
examination findings of cauda equina
investigation and treatment?
urinary retention
saddle anaesthesia
no anal tone
incontinence
leg weakness
hyporeflexia lower limbs
MRI and surgical decompression
what are the two most common causes of cauda equina?
Others
most common:
large disc prolapse
malignancy
spinal infection
spinal stenosis
spinal trauma
epidural haematoma
differentials and examination findings for limping child
- fracture - eg toddler fracture and tender tibia - hx of fall
- NAI - multiple bruises of different ages
- septic hip - fever, reduced ROM hip
- FB foot - visualised
- transient synovitis - viral illness
investigations and justifications limping child
- x ray hip - Perthes, DDH
- US hup - septic effusion
- CRP/ESR/WCC - signs if infection
causes of hip pain in child
investigations?
- Perthes
- NAI
- transient synovitis
- septic arthritis
- juvenile arthritis
- fracture
Ix
US
Xray
bloods
what organisms cause septic arthritis
Abx treatment?
s.aurues
s.pyogenes
e.coli
h.influenza
IV vanc and clinda
abnormalities
- spiral fracture midshaft ulna
- ulna fracture is displaced and angulated
- dislcation proximal radius
what is a monteggia fracture?
proximal ulna with radial head displacement
complications and clinical features of monteggia
- radial nerve injury - wrist drop and parasthesia
- compartment syndrome - refractory pain, distal parasthesia
- compound - open and bone on view
describe injury
comminuted, displaced, mid shaft clavicle fracture
complications of clavicle fracture
- non union
- malunion
- vascular injury
- infection
- skin tenting
complications of posterior sternoclavicular dislocation
- subclavian vessel injury
- pneumothorax
- mediastinal compression
- oesophageal injury
- brachial plexus injury
3 absolute and relative indications for surgical fixation of midshaft clavicle fracture
Absolute
* open fracture
* skin tenting/compromise
* subclavian vein/artery compromise
* floating shoulder
* neurological damage
Relative
* cosmesis
* poly trauma
* athlete
* shortening/comminuted
complications of ORIF
- anaesthetic complications
- complications of skin incision - scar, infection
- malunion
- non union
- joint infection
- chronic pain
- neurovascular injury
sensory and motor disturbance of common perineal nerve injury
what is the common site of injury
Sensory
* dorsum foot
* lateral leg below knee
Motor
* eversion foot
* dorsiflexion big toe and foot (get foot drop)
injury - fibular head
causes of common perineal nerve injury
- high ankle sprain
- compression from cast
- high knee boots
- fibula fracture
- habitual leg crossing
- knee arthroplasty
- MS
- diabetes
- alcohol
how is common perineal nerve injury differentiated from L5 lesion
decreased reflex in radiculopathy
- proximal tibial fracture minimally displaced
- proximal fibula fracture
- mid shaft tib and fib fracture - comminuted, shortened, laterally angulated
what are the features of compartment syndrome
- increasing/refractory pain
- loss of pulses
- pale limb
- parasthesia distal
- tense muscle compartments
treatment for compartment syndrome
- elevation
- remove external compression
- analgesia
- ortho review for fasciotomy urgently
describe x ray in 9 year old
what are the immediate management priorities?
complications
- elbow dislocation posterior and laterally
- small bony fragment on epiphysis - relevant as medial and 9 years old
management
analgesia
?neurovascular compromise
any other injuries or NAI
Complications
neurovascular compromise
difficult reduction in bone fragment in the way
malunion,non union, chronic pain
poor function
what does the ulna nerve serve in the hand?
flexor carpi ulnaris
medial two lumbricals
interrosei
half FDP
what does the median nerve serve in the hand?
half LOAF
lateral two lumbricals
opponens pollicis
abductor pollicis brevis
flexor pollicis brevis
what is the course of the ulna nerve at elbow?
- from brachial plexus and medial side of upper arm
- passes posterior to medial epicondyle to enter forarm
- pierces two heads of FCU to travel with artery
what are the elbow ossification centres
important findings
closed supracondylar fracture
fat pad sign, soft tissue swelling
what nerves are damaged with supracondylar fractures?
median and ulna
7 year old girl with pain. key features?
anterior and posterior fat pads visible
cortical disruption of posterior humeral surface at level of olecranon fossa
non displaced supracondylar fracture
complications of supra condylar fracture
Short term:
compartment syndrome
damage to brachial artery
median/ulna nerve damage
Long term
myoisiits officans
pain
indications for surgical fixation of supracondylar fracture
- nerve compromise
- sign of brachial artery damage
- skin compromise
- compartment syndome
- varus/valgus deformity
- rotational deformity
- displacement with over 50% loss of articular contact
4 year old - abnormalities
diagnosis
distended anterior fat pad
posterior fat pad
fracture line across supracondylar part of humerus
supracondylr fracture of humerus
management of supracondylar fracture
- analgesia - give drugs
- sling
- ortho FU
abnormalities
what is this fracture called?
analgesia options
- proximal ulna fracture
- enlarged anterior fat pad
- anterior dislocation of radial head
Monteggia
IN fentanyl 1.5mcg k/k
iv morphone 25-50mcg/kg. if over 40kg 1-2mg per dose
abnormalities
right posterior elbow dislocation
displace fracture radial head
abnormalities
ant fat pad- sail sign
post fat pad
displacement of ant humeral line/ fracture site visible, post displacement with intact post
cortex
abnormalities
- Abnormal / pathological anterior fat pad
- Posterior fat pad
- Transverse fracture of distal humerus
- Dorsal angulation of distal fragment
- Abnormal anterior humeral line
what are the classificairons of supracondylar fractures and their significance
Gartland Classification
1 - sling
2 - plaster and reduction - immobilization at 90 degress
3 - ORIF
abnormalities
Lisfranc
widening of space between first and second metatarsal indicating ligamentous injury
laterally dislocated base of second
transverse first metatarsal
what are the complications of a lisfranc
compartment sydrome
dorsalis pedis damage - vascular injury
what is the management of a lisfranc
- analgesia
- elevation
- short leg plaster
- ortho review
abnormalities
- widened joint first and second metatarsal
- comminuted fracture base of second
- transverse fracture midshafe 2nd
- lateral displacement 2-5
- fracture cuboid
abnormalities
1. galaezzi fracture
2. radial fracture - transverse, displaced medially and dorsally, shortened, volar angulation
3. distal radial ulna dislocation
monteggia v galeazzi
managment for galaezzi fracture
- analgesia eg 2.5mg iv moprhine
- reduction
- above elbow backslab
- elevation
- ortho for orif
what are the risk factors for gout?
renal failure
chemo agents
FH
loop diuretics
high purine food
alcohol
hyperuracemia
what joint aspiraiton findings are consistent with gout?
- negatively bi-refringent crystals
- yellow, turbid fluid
- wbc between 200-50000 u/l
treatment options for acute gout
ibuprofen 400mg TDS
pred 50mg TDS
colchicine 500mcg daily
diagnosis
list imaging and the complication it would search for
right posterior hip dislocation
Imaging;
CT - acetabular fracture, femoral head fracture
MRI - sciatic nerve injury, labral tear
what are the four steps in hip reduction
- sedate
- stabilise pelvis
- hip flexed and adducted
- provide traction
1.
joint aspirate features for gout v septic
what is the treatmnt for septic joint
washout in theatre
abx after
differential categories and example for hot swollen knee
- septic - gonococchal
- crystal - gout
- trauma - fracture
- degenerative - OA
- reactive - IBD/SLE
- inflammatory - SLE
five investigations for painful swollen knee and one pro and con for each
describe abnormalities
- Tibial plateau fracture
- Comminuted
- Both lateral and medial condyles involved
- Lateral displacement of knee
- Head of fibula comminuted fracture
lift associated injuries and examinatiom findings for tibial plateau fractures
abnormalities
comminuted fracture of patella
haemarthrosis
what are the indications for surgical fixation of patella fracture?
- open
- displaced over 2mm
- cant straight let raise
what are the ‘frailty fracture’
- NOF
- pelvic
- forearm
- c-spine
- thoracolumnar
abnormalities
- anterior and inferior dislocation of humeral head
- hill sachs
- greater tubicle displace laterally
technques for shoulder reduction
modifed kocher
stimson
cunningham
hippocratic
milch
how do you confirm anterior shoulder dislocation?
clinically - humeral head palpable in deltopectoral groove
Radiologically - axillary view - head anterior to glenoid
dianosis and why?
posterior dislocation - lightbulb sign
management
* analgesia, closed reduction attempt under procedural sedation
* Axial traction in line with humerus, gentle pressure on the posteriorly displaced head and slow
* external rotation.
* If reduction fails then OT for reduction under GA
how do you relocate posterior shoulder dislocation?
how do you stabilise after
- Analgesia, closed reduction attempt under procedural sedation
- Axial traction in line with humerus, gentle pressure on the posteriorly displaced head and slow
- external rotation.
- If reduction fails then OT for reduction under GA
external rotation and abduction
complications of shoulder dislocation
hill sachs
glenoid
axillary nerve damage
recurrent dislocations
neurovascular damage
sunscapularis avulsion
describe three methods of shoulder relocation
**Kocher’s; **arm flexed and ad-ducted, gentle traction, external rotation until
resistance, then extend to saggital plane, then internal rotation to opposite
shoulder.
Spaso; Extend arm in saggital plan, gentle traction, external +/- internal
rotation.
Cunningham’s; support patient’s arm flexed 90 degrees & ad-ducted, gentle
traction, massage Trapezius/Deltoid/Biceps sequentially.
abnormalities
how does this usually occur?
Complications
left inferior glenohumeral joint dislocation** LUXATIO ERECTA**
left greaster tuberosity fracture
Method
1. sudden forceful hyper abduction
2. direct force on fully abducted arm with extended elbow and pronated forearm
complications
brachial plexus injury
rotator cuff injury
axillary artery injury
glenoid fracture
how do you fix luxatio erecta
- anagelsia (dose
- Pre/post neurovascular assessment
- Informed consent
- Reduction under PS and will require pre-sedation risk assessment,
- Mention one technique
○ -Axial (in-line) traction OR
○ -Two step manouvre - Convert to Anterior reduction and reduce with Anterior
methods
significant findings
- fractured right glenoid
- fracture through neck of scapula
- fracture clavicle with skin tenting
- evidence of previous clavicular surgery
- fracture rib
- no obvious pneunothorax
- humeral head enlocated
findings and diagnosis
what would give patient a poor prognosis?
extensive soft tissue gas in plantar and dorsal aspect
nec fasc
poor prognosis
delay to presentation
delay to debridement
immunocopmromised
age
what are the radiographic features of supracondylar fracture
anterior sail sign
posterior fat pad
supracondylar lucency suggestive of fracture
cortical break on anterior surface of lower humueus on lateral view
anterior humeral line that does not bisect capitellum
wrist pain - what are the relevant findings?
short and long term complications of this injury?
peri lunate dislocation
scaphoid fracture
short term complications:
* median nerve injury
* pressure necrosis of skin
* compartment syndrome
* pain
* loss of function
Long term complications
* avascular necrosis scaphoid
* carpal instability
* chronic pain
* OA
9 year old FOOSH
describe abnormalitis
salter harris 1 distal radius
dorsal angulation
dorsal displacement epiphysis
abnormalities
terry thomas sign - scapholunate dislocation
radial and ulna styloid fracture
what is this?
what are the complications?
Segond fracture - avulsion of lateral proximal tibia
Complications:
high chance ACL tear and medial or lateral meniscal tear
diagnosis?
indication for MRI in this injury?
fracture throigh anterior and posterior arches of c1 with lateral displacement
Jefferson fracture
suspected ligamentous injury
complete or incomplete neuro deficits
evolving neuro changes
