ortho 2 Flashcards
where does the quadricep insert?
the superior pol of the patella
what are the risk factors for quadricep rupture?
increasing age CKD DM RA medications - coricosteroids and fluoroquinolones
what are the clinical features of a quadricep rupture?
hearing a pop or feeling a tearing sensation
pain in anterior knee or thigh
difficulty weight bearing
localised swelling
tender palpable defect above the superior pole of the patella
if complete tear - inability to straight leg raise
differential for quadricep rupture?
patella tendon rupture
patella fracture
femoral shaft fracture
investigations for quadricep rupture?
XR
USS - will help to measure the degree f rupture
how is quadricep rupture managed?
treatment depends on degree of rupture
partial tears - managed non-operatively - immobilisation of joint in a brace in tandem with intensive physio
complete tendon tears - surgical intervention.
what are distal femur fractures?
fractures extending from the distal metaphyseal-diaphyseal junction of the femur to the articular surface of the femoral condyles.
what is the classification of distal femur fractures?
The classification is commonly used to classify distal femur fractures into extra-articular (type A), partial articular (type B), and complete articular (type C).
Partial articular fractures can be further classified into sagittal fractures of lateral condyle, sagittal fractures of medial condyle, and coronal fractures.
what is a hoffa fracture?
A Hoffa fracture is a specific type of type B articular distal femoral fracture in which there is a fracture of the posterior aspect of the femoral condyles in the coronal plane. Hoffa fragments are more commonly unicondylar affecting the lateral femoral condyle.
what are the clinical features of a distal femur fracture?
severe pain in the distal thigh
inability to weight bear
obvious deformity on examination
swelling and ecchymosis of the distal thigh
If it is intra-articular then a knee effusion may be present
*make sure to do a full neurovascular exam
what are the differentials for distal femure fracture?
tibial plataeu fractures
haemarthrosis
tibial shaft fracture
what investigation for distal femur fracture?
bloods
serum calcium and a myeloma screen may be warranted
AP and lateral XR of entire femur
if there is intra articular extension then CT imaging is helpful
how do you manage a distal femur fracture?
if there is significant realignment - then initial realignment in A&E
majority are managed surgically
with either retrograde nailing or open reduction internal fixation
how does a pelvic fracture present?
significant pain and swelling
obvious deformity
** full neurovascular assessment is needed
investigations for pelvic fracture?
XR
CT
how are pelvic fractures classified?
Two classification systems are commonly used to describe pelvic ring injuries:
Young and Burgess classification – groups based on the vector of the disrupting force and the resulting degree of displacement (see Appendix) Antero-posterior compression (APC 1-3) Lateral compression (LC 1-3) Vertical shear (VS 1-2) Tile classification – fractures grouped based on the stability of the pelvic ring A-type fractures = rotationally and vertically stable B-type fractures = horizontally unstable but vertically stable C-type fractures = both horizontally and vertically unstable The Denis classification can be used to classify fractures of the sacrum; it describes the line of the fracture in relation to the sacral foramina, with type 1 = lateral to the foramina, type 2 = transforaminal, type 3 = medial to the foramina. In addition, a transverse component may result in an H-shaped or U-shaped fracture pattern.
how are pelvic fractures managed?
definitive management can be conservative or operative
Indications for operative management include life threatening haemorrhage, unstable fractures, open fractures, and associated fractures with an associated urological injury. The approach and method of stabilisation can be guided by the Young and Burgess classification* and involves a combination of anterior and posterior stabilisation.
what is the acetabulum?
a cup-like depression located on the inferolateral aspect of the pelvis, formed by the ilium, ischium and pubic bones.
It articulates with the head of the femur to for the hip joint
what are the clinical features of acetabular fracture?
usually following high energy injury
significant pain and swelling
inability to weight bear
there are often associated pelvic fractures
when examining someone with suspected acetabular fracture what should you do?
**you should check the neurovascular status of both limbs during the assessment
Check for any evidence of open fracture and assess the condition of the overlying skin for any Morel-Lavallée lesions.
what investigations for acetabular fracture?
plain film XR - AP view and judet view (obtained by tilting the patient 45o laterally in both directions)
CT
how are acetabular fractures classified?
using the Judet and Letournel classification:
Elementary = posterior wall, posterior column, anterior wall, anterior column, transverse Associated = posterior wall + posterior column, transverse + posterior wall, T-type, anterior column + posterior hemitransverse, both columns
how are acetabular fractures managed?
Undisplaced or minimally displaced acetabular fractures can be managed conservatively with protected weight bearing for 6-8 weeks.
surgical management - in young patients with displaced fractures surgery is usually performed to restore the anatomy
what are the two distinct areas of the neck of femur?
Intra-capsular – from the subcapital region of the femoral head to basocervical region of the femoral neck, immediately proximal to the trochanters
Extra-capsular – outside the capsule, subdivided into:
>Inter-trochanteric, which are between the greater trochanter and the lesser trochanter
>Sub-tronchanteric, which are from the lesser trochanter to 5cm distal to this point
what classification is used for intracapsular hip fracture?
the garden classification
what are the clinical features of NOF fracture?
pain - in the groin, thigh or referred to the knee
inability to weight bear
o/e - shortened and externally rotated with pain on pin-rolling the leg and axial loading
although neurovascular deficits are rare a full neurovascular exam should be performed
what are the differentials for neck of femur fracture?
pelvis - pubis ramus fractures
acetabulum fractures
femoral head and femoral diaphysis fractures
if no history of trauma - pathological fractures should be considered
what are the investigations for neck of femur fracture?
XR - AP and lateral views of the affected hip as well as an AP pelvis
Full length femoral XR
Basic bloods
Urine dip and CXR - especially in older patients
how is neck of femur fracture managed?
initial management - A-E approach to stabilise the patient
adequate analgesia - such as opioid analgesia or a regional block such as fascia-iliaca block
definitive management is surgery:
Displaced subcapital - hip hemiarthroplasty
Inter-trochanteric and basocervixal - dynamic hip screw
Non-displaced intra-capsular - cannulated hip screws
Sub-trochanteric - intramedullary femoral nail
post operative complications of NOF fracture management?
Immediate post-operative complications include pain, bleeding, leg-length discrepancies, and potential neurovascular damage, all of which should be consented for pre-operatively.
how does hip osteoarthritis present?
pain in the groin or over lateral hip or deep buttock
pain aggravated by weight bearing and improved with rest
stiffness
grinding or crunching sensation
antalgic gait
passive movement is painful
n severe OA, the range of motion is reduced. In end stage disease, the patient may have a fixed flexion deformity and walk with a Trendelenburg gait.
differentials for hip OA?
Trochanteric bursitis – presents with lateral hip pain radiating down the lateral leg, with associated point tenderness over the greater trochanter
Gluteus medius tendinopathy – lateral hip pain with point tenderness over the muscle insertion at the greater trochanter
Sciatica – low back pain and buttock pain, but often radiates down the posterior leg to below the knee. Diagnosis is made with the straight leg raise to produce Lasègue’s sign
Femoral neck fracture – most commonly there will be a history of trauma or known severe osteoporosis (if it is a stress fracture); the patient will be unable to weight bear due to pain and the limb will appear shortened and externally rotated
how is hip OA managed?
pain control with analgesic ladder
lifestyle modifications - weight loss, regular exercise, smoking cessation
phsiotherapy
hip replacement is the definitive treatment
who are femoral shaft fractures commonly seen in ?
High-energy trauma
Fragility fractures in the elderly (low-energy trauma)
Pathological fractures (e.g. metastatic deposits, osteomalacia)
Bisphosphonate-related fractures
what are the clinical features of femoral shaft fracture?
pain in the thigh and or hip or knee pain
unable to weight bear
if severe there may be an obvious deformity
assess skin and do a full neurovascular examination
what classification is used for femoral shaft fractures?
The Winquist and Hansen Classification can be used to classify the degree of comminution to femoral shaft fractures:
Type 0 – No comminution
Type I – Insignificant amount of comminution
Type II – Greater than 50% cortical contact
Type III – Less than 50% cortical contact
Type IV – Segmental fracture with no contact between proximal and distal fragment
investigations for femoral shat fracture?
Plain XR AP and lateral of the entire femur, including the hip and knee
CT may be warranted is polytrauma is suspected
how is femoral shaft fracture managaed?
A-E stabalise patient
pain relief with opioid or regional block
immediate reduction and immobilisation
traction splinting used in isolated fractures of the mid-shaft femur
most femoral shaft fractures will require surgery within 24-48 hours
antegrade intramedullary nail
External fixation may be used in polytrauma or open fractures
what are distal radius fractures caused by?
fall on an outstretched hand
how are radius fractures classified?
Colles fracture - extra-articular fracture of the distal radius with dorsal angulation and dorsal displacement, within 2cm of the articular surface. This type of fracture typically occurs as a “fragility fracture” in osteoporotic bone.
Smiths fracture - volar angulation of the distal fragment of an extra-articular fracture of the distal radius (the reverse of a Colles fracture), with or without volar displacement.
Bartons 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), depending on whether the volar or dorsal rim of the radius is involved.
risk factors for distal radius fracture?
increasing age female gender early menopause smoking alcohol prolonged steroid use
