ORTHO Flashcards
Severe pain, disproportionate to the injury, which is not readily improved with initial measures (analgesia, elevation to the level of the heart, and splitting a tight cast). This pain is made worse by passively stretching the muscle bellies of the muscles traversing the affected fascial compartment.
Often occurs following recent surgery.
What is the most likely diagnosis, and what are the investigations & treatment required?
COMPARTMENT SYNDROME
Often diagnosed clinically
If uncertain intra-compartmental pressure monitor, and CK can be elevated/rising.
Immediate surgical treatment via urgent fasciotomies
- keep limb at neutral level, high flow oxygen, fluids to lower BP, remove dressings/splints/casts, IV analgesia
What is a complication from emergency open fasciotomy that should be closely monitored for?
Rhabdomyolysis and reperfusion injury
- therefore monitor renal function closely
What should be done when a patient arrives at A+E with an open fracture?
Check neurovascular status and examine overlying skin for tissue loss
Plastics + Ortho input
Basic bloods, group + save, clotting screen
Plain film xray of affected area(s)
Management: stabilise pt prior to any op, urgent realignment and splinting of the limb is warranted
- broad spec abx cover required, tetanus vaccine if not up to date, photograph wound and remove any large debris (washout done in theatre)
- Definitive surgical management requires debridement of the wound and the fracture site, removing all devitalised tissue present. This should happen either immediately if contaminated with marine, agricultural, or sewage material, or <12-24 hours in all other cases
What is the pathophysiology of osteoarthritis?
Breakdown of cartilage and remodelling of bone due to an active response of chondrocytes in the articular cartilage and the inflammatory cells in the surrounding tissues. Enzymes released from these cells break down collagen and proteoglycans, destroying the articular cartilage. The exposure of the underlying subchondral bone results in sclerosis, followed by reactive remodelling changes that lead to the formation of osteophytes and subchondral bone cysts. The joint space is progressively lost over time.
What are some of the risk factors for OA?
Obesity, advancing age, female gender, and manual labour occupations.
What are some characteristic findings found on examination in patients with OA?
Bouchard nodes (swelling of PIPJs) or Heberden nodes (swelling of DIPJs) in the hands, and fixed flexion deformity or varus malalignment in the knees.
- movement of joint is generally reduced and painful
How is OA diagnosed?
Primarily clinically
- Investigations can be used to exclude differential diagnosis; routine blood tests can be useful to exclude inflammatory or infective causes
- Xray can rule out fracture and also show characteristic features = loss of joint space, subchondral sclerosis, subchondral cysts, osteophytes
What is the most common bacterial cause of osteomyelitis? How does this differ in IVDU and those with sickle cell?
S. aureus is most common
- P. aeruginosa in IVDU
- salmonella spp in sickle cell disease
What are the main 4 risk factors for developing osteomyelitis?
- Diabetes mellitus
- Immunosuppression (such as long term steroid treatment or AIDS)
- Alcohol excess
- Intravenous drug use.
What investigations are required in a pt with suspected osteomyelitis?
Routine bloods, including FBC, CRP, and ESR.
Blood cultures should be performed (positive in around 60% cases)
Xray - though poor diagnostic tool, Definitive diagnosis can achieved through MRI imaging.
Gold standard diagnosis is from culture from bone biopsy at debridement
What is the management for patients with osteomyelitis?
Long-term intravenous antibiotic therapy (>4 weeks) tailored to any cultures available
- surgical intervention is usually not required UNLESS pt deteriorates, or limb is worsen then curettage of the area is required to prevent chronic osteomyelitis
What are the 3 principles of fracture management?
Reduce – Hold – Rehabilitate
What are the 6 main risk factors for developing septic arthritis?
Age >80yrs Any pre-existing joint disease (e.g. rheumatoid arthritis) Diabetes mellitus or immunosuppression Chronic renal failure Hip or knee joint prosthesis Intravenous drug use
What investigations are performed in pts with suspected septic arthritis?
Routine bloods - FBC, CRP, ESR, urate
Blood cultures
Joint aspirate BEFORE starting Abx
Plain Xray
What is the management of pts with septic arthritis?
Empirical antibiotic treatment should be started as soon as possible, after any planned cultures and aspirates have been performed. As a guide, antibiotics are typically administered for long term (often 4-6 weeks), initially intravenously (usually 2 weeks).
- Infected native joints require surgical irrigation and debridement (‘washout’) in theatre to aid in source control. This is sometimes needed a number of times before the infection has cleared. If the infection is within a prosthetic joint, washout is still required, but revision surgery (either acutely or staged) is typically needed.
What are the main complications of septic arthritis?
osteoarthritis and osteomyelitis
- Early intervention and management will reduce the risk of developing these complications
What is the most likely diagnosis in a patient presenting with a deep + constant pain in shoulder that often disturbs sleep. They have a limited range of motion, principally affecting external rotation and flexion of the shoulder.
Adhesive Capsulitis (Frozen Shoulder) Differentials include: - Acromioclavicular pathology - Subacromial impingement syndrome - Muscular Tear - Autoimmune disease e.g. PMR, rheumatoid arthritis, SLE
How is adhesive capsulitis diagnosed + managed?
Often diagnosed clinically
- x-ray generally unremarkable but important to rule out other DDx
- MRI can show thickening of the glenohumeral joint capsule
- HbA1c and glucose may be useful in terms of diagnosing any underlying diabetes/glucose intolerance
Self-limiting condition but recurrence is not uncommon
- patients should keep active, receive physio and analgesic relief (paracetamol +NSAID 1st line)
- if no improvement after 3 months, surgery is considered
What are the most common complications in adhesive capsulitis?
Some patients will never regain a full range of motion but will regain movement beyond that required to perform ADLs
In some patients the progression of symptoms may persist beyond 2 years and it may recur in the contralateral shoulder.
Who is biceps tendinopathy likely to affect?
younger individuals who are active (e.g. sports with repetitive flexion movements, such as tennis or cricket) and in older individuals with more of a degenerative tendinopathy.
What are the 2 special tests that can be performed for biceps tendinopathy?
- SPEED TEST (proximal biceps tendon) – The patient stands with their elbows extended and their forearms supinated. They then forward flex their shoulders against the examiners resistance
- YERGASON’S TEST (distal biceps tendon) – The patients stands with their elbows flexed to 90 degrees and their forearm pronated. They actively supinate against the examiners resistance
How is biceps tendinopathy treated?
Majority are treated conservatively
- analgesia (specifically NSAIDs, if tolerated) and ice therapy as first line. Physiotherapy also plays an important role.
- Ultrasound-guided steroid injections can be useful in cases unresponsive to initial conservative management.
- surgical options available in severe refractory cases
What type of fracture tends to occur from a fall directly onto the outstretched limb or falling laterally onto an adducted limb?
Humeral shaft fracture
How is a humeral shaft fracture diagnosed? And what should you always check for in suspected cases?
Diagnosed on plain film radiographs, with lateral and antero-posterior views
- check for radial nerve damage
