ORTHO bro Flashcards
Ac joint degenerative disease
a very common occurance, by 3rd decade of life usually.
pain particularly on overhead or cross body activities.
occurs due to large axial loads on a small surface area.
Ix: imaging with x-rays, or palpation
Rx: activity modification, nsaids.
steroid injection
surgery- remove only 8-10 mm as any more risks loosing ligamentous stability.
AC joint seperation
quite common, 9% of all shoulder injuries.- a fall onto adducted arm.
Rf: male, athletes.
S+S: pain, noticable seperation, history consistent, pain on adduction
Ix: imaging- x-ray Ap B/L.
+ axuillary lateral view + zanca view.
Classification:
1- no instability- reducable Rx with sling
2- AC torn, CC sprained, horizonal instability-inc CC distance <25% of contralateral– RX with sling.
3- AC + CC torn. inc CC dist 25-100% contralateral. - controversial management.
3A has only vertical instability
3B has both horiz and vert.
4- AC + CC Torn- skin tenting, posterior fullness. - lateral clav dinsplaced into trap posteriorly on axillary XR. – surgery.
5- Ac +CC torn- shoulder droop, not imp with shrug. CC dist > 100% contralat. – surg
6- inferior dislocation- surg
achilles tendon rupture
sudden dorsiflexion of a plantarflexed foot- I.e stepping backwards
clinical diagnosis- dangle angle, thompsons test, weakness.
MRI can confirm + plan surgical management.
Rf: male, 30-40, weekend warrior, steroid injections, fluroquinolones.
S+S: pop, weakness, difficulty walking.
Rx: mix of casting + bracing or surgery to re-approximate the ends.- similar outcomes.
if ends done approximate- hen ? surgical management.
role of nsaids and corticosteroids in achilles tendinopathy
nsaids in acute phase only, not for long term use
no corticosteroids
ACL tear
half of all knee injuries
Rf: female, previous concussion, landing in risky position.
non contact pivoting injury, assoc with lateral meniscus tears (54% of time) medial in chroinc cases.
2 bundles- AM- ightest in flexion,
PL- tightest in extension
S+S: pop, immediate swelling,
Ix: lachmans most sensitive, pivot shift,
confirm with MRI scan
Rx: can be conservative
or
reconstruction-
repair - in younger/ avulsion patients.
adhesive capsulitis
painful, restrictive shoulder condition. fibrosing pathology. usually lasts 18-24 months.
Rf: women, 40-70. recent trauma to shoulder. DM, Thyroid
S+S: pain, worse in bed and disturbs sleep.
stiffness- capsular pattern
Ix: diagnosis of exclusion- X-rays +/- ultrasound may help.
Rx:
heat pack, physio, analgesia.
2’ -steroid early if no progress with physio.
3’ - MUA, Hydrodilatation, arthroscopic release.
pain and stiffness for 3 months–> refferal.
ankle fracture
generally following trauma.
most commonly lat mal.
but can be medial +/- posterior also.
inability to wt bear/ ottowa ankle rules helpful
Ix: plain x-ray.
Rx: non-displaced, anatomically reduced- conservative- cast 6/52
if open- debride wound, saline irrigation
internal fixation once wound clean.
if talar shift, irreducable, webber C, - ORIF.
distal biceps tendon rupture
excessive eccentric contraction- avulses bicep off its radial tuberosity.
occurs in dominant hand in men in their 40s.
Rf: steds (both types) smoking,
S+S: acute, pop sound, weakness + pain in supination. reverse popeye sign,
Ix: Hook test, MRI- will help beetween partial/ full.
Rx: low demand + willing to ccept functional loss- non-op
op otherwise- done within a few weeks of injury.
biceps tendinopathy
painful, swollen, and structurally weaker tendon that is at risk of rupture
Rf: young, active,
S+S: pain worse on stressing tendon, tenderness on palp,
Ix: speeds test
clinical diagnosis- aided by uss.
Rx: analgesia, physio
uss guided injections
3’- arthroscopic tenodesis, tenectomy.
clavicle fracture
fall onto lateral shoulder +/- adducted arm.
most common fracture of childhood- 10% of all fractures.
middle 1/3 # in 70% of cases, lateral in 28%, v rare medial.
Rf: male, sports, young, cycling, older + falling.
S+S: pain, trauma, setp, tenderness on palp,
Ix: perform a complete neurovasc exam.
X-rays- AP + 45 deg cephalic tilt.
Rx
- non displaced- sling with less than 90 deg motion
displaced- fix-
absolut indications for surg- neurvasc compromise, open, tenting, angulation/ displacement.
shortening of 1.5cm or more, or 15% of contralateral side. floating shoulder, poly trauma, seziure disorder.
compartment syndrome
where the ossiofascial compartment of the leg reaches pressure that causes occlusion of the vessels. – causing hypoaemia and damage
S+S: severe foot ankle and leg pain, worsens with time and movement of the foot.
- pain out of proportion with current sitch
common following trauma/ crush injuries.
common in the young.
Ix: compartment pressure measurement- within 5cm of #.
Rx: generally emergency fasciotomy of all 4 compartments. - anterior lateral and posteriomedial incisions- 15-18 in length.
distal radius fracture
most common orthopaedic injury- nearly 20% of all fractures.
FOOSH
50% intra-articular
RF: osteoperosis- DEXA reccomended for all women with one.
S+S: swelling, pain, deformity.
Ix: X-rays, AP, lateral, oblique.
Rx: non-op if- less than 5mm radial shortening
dorsal angulation of less than 5’
ORIF- if intra articular step >2mm.
dupuytrens contracture
benign proliferative disorder
painless nodule progressing to diseased cords.
2:1 male- female ratio. 5-7th decades of life.
northern europeans most at risk.
autosomal dominant with variable penetrance.
ring > small> middle > index.
cytokine-mediated transformation of normal fibroblasts into abnormal myofibroblasts, turning normal fascial bands into pathological cords
generally painless, restricts ROM.
Ix: clinical diagnosis
Rx: watch + wait
hand therapy + injection
needle aponeurotomy
partial/ full palmary fasciectomy if severe
elbow dislocation
most often posteriorlateral dislocations.
10-20 year old active people.
axial load, supination force + valgus posteriolateral.
progression of lig injury lateral to medial.
simple- if no assoc #.
complex- if # e.g terrible triad (coronoid + radial head)
Ix: x-ray.
Rx: simple- closed reduction and immobilisation splint at least 90’ for 10 days.
complex- ORIF- LCL repair, fix #s.
flexor tendon injury zones
1- fdp
2fdp and fds
3- palm
4 - carpal tunnel
5- after wrist
extensor tendon injury zones
odd is on a joint
1- dip or later
2- middle phalanx
3- pip
4- prox phalanx
5- mcp
6- back of hand
7- wrist.
hip fracture- discuss frequency, classification, subclassificaiton of the classification and some treatment (but most covered next card)
65000 each year in the uk
30% one year mortality.
intra capsular- up to just proximal of the trochanters
extra-capsular. - 2 types
sub troch- lesser trochanter to 5cm more distal
inter-troch- as it says.
predominant blood supply- medial circumflex.-
displaced intracapsular fractures disrupt the blood supply- even if fixed. ——- need arthroplasty.
garden classification 1-4
1-2 non displaced (1 not fully through)
3-4 displaced- 3 partial 4 fully.
hip fracture S+S, Ix, Rx.
S+S: trauma, shortened + externally rotated.
pain in the groin thigh or knee
Ix: plain film x-ray
if long lie- CK.
Rx: - displaced subcapital- him hemi/ full if they are good craic
intertroch- DHS
non displaced intra-capsular- cannulated hip screws. (or consider THR if good craic)
sub troch- IM fem nail.
humeral fracture- shaft
bimodal- in young due to trauma
in old due to frailty.
sig risk of radial nerve damage.
S+S: pain and deformity after trauma.
reduced sensation over dorsal 1st webspace. , weakness in wrist extension
Ix: check neurovasc status
X-ray - AP and Lateral.
Rx: realign limb + brace. (<20 angulation, <30 deg var/val, <3cm shortening)
ORIF if big deformity
IM if pathological
humeral head/ neck fracture
FOOSH injury, fragility fracture.
due to close relation to axillary nerve and circumflex art - need neurovas status of arm assessed.
Ix: plain film X-ray
classification-
greater tuberosity
lesser tuberosity
anatomical neck (articular segment)
humeral shaft (surgical neck)
Rx: nearly always non surg- immobilisation in collar + cuff 2-4 weeks.
surg if displaced, open or neurovasc comprimise.
liz franc injury
severe injury to the tarsometatarsal joint
medial cuneiform and base of 2nd metatarsal.
can be ligamentous or bony also.
severe torsional or teanslational force through plantarflexed foot.
piano key sign- bones go down and back up with pressure.
Ix: plain film AP, Oblique, lateral foot.
Rx: non displaced- cast/immobilisation + NWB mvt.
displacement- op- ex fix if big swelling going on
screw fixation if not too much swelling. #
arthritis is significant risk, midfoot compartment syndrome also frequent.
MCL injury
most commonly injured knee lig.
Pop with slower swelling over hours. pain common.
inc laxity on valgus test.
grade 3 is lax in both extension and 30 deg flex,
grade 2 only lax in 30 deg.
Ix: gold standard MRI
Rx: gd 2-3 - brace
surgery if distal avulsion alongside.
meniscal tears
injury occurs through trauma or degeneration.
S+S: tearing feeling in knee, slow swelling. can lock.
joint tenderness
Ix: MRI gold standard
Rx: large or persistantly symptomatic - surg
in outer 1/3 suture repair
inner 1/3- trim (poor vasc)
sig risk for 2’ osteoarthritis.
metacarpal/ phalangeal fractures- types of + ix rx etc.
boxers- classic
bennets - thumb displacement - intra articular
rolando- intra atricular 1st metacarpal - in Y or T shape (similar to bennets)
Ix: X-ray then build up to CT.
Rx: REMOVE jewlery
if simple- buddy strap for 3-4 weeks. re-xray at 1 weeks to asssess for displacement.
if rotational deformity, intraarticular involvement, angulation, shortening or unstable—– fix.
K wire or ORIF 2 choices.
metatarsal stress fractures
most commonly 2nd or 3rd
sudden inc in duration or intensity of activity.
generally low risk stress fractures.
Ix: x-ray, MRI gold standard
Rx: analgesia and rest mostly
high risk of non union in neck of 2nd #s, but in stress its ok.
mortons neuroma
compression neuropathy of common digital plantar nerve
mostly in 3rd intermetatarsal space.
occ in 2nd
rarely elsewhere
benign fibrotic thickening of the nerve due to constant irritation
RF: high arch feet, tight/ ill fitting shoes, heavy impact on feet.
avg age 50-55. 4:1 women : men
S+S: pain in forefoot, lump feeling, tingle, pain on squeezing.
Ix: clinical with x-ray and bloods to rule out # or gout etc.
olecranon bursitis
either septic or aseptic
commonly found in young/ middle aged men.
people with repetitive trauma
generally only painful if infected- or in full flexion of elbow when the bursa is compressed.
Ix: clinically- if not infectious don’t aspirate
aspirate if concern about septic.
Rx: RICE, activity modification. can aspirate for symptoms relief. refer after 2 months if still bothering
if septic- aspirate- treat empirically
fluclox (500 mg four times daily)
2’-
Clarithromycin (500 mg twice daily) may be used if the person is allergic to penicillin. Erythromycin (500 mg four times daily) is the preferred macrolide in pregnancy and breastfeeding.
olecranon fracture
common
often causes disruption of the extensor mechanism
mean age- 57 years.
direct blow- cominuted #
FOOSH- transverse / oblique #.
many classification systems.
Ix: plain film
Rx: non displaced with intact extensor mechs- immobilise 45-90 degrees - 1 week. early rom.
surgery if above criteria not met. many options.
pathological fracture
500x more likely to be as a result of a met than a primary sarcoma.
lung, breast, thyroid, renal, and prostate- most frequently met to bone.
Ix: when detected- comprehensive work up if primary unkwown.
PSA CEA etc
x-ray - high aggression indicated by lesion diameter > 5 cm, cortical interruption, periosteal reaction, and associated pathologic fracture.
Rx: there are criteria to meet for prophylactic fixation (50% of diameter, 2.5cm in size, lesser trochanter, pain after radiotherapy)
healing rates for metastasis from multiple myeloma, renal, breast, and lung carcinoma are 67%, 44%, 37%, and 0%, respectively
if renal met- excise widely where possible.
plantar fasciitis- one good fact but not the whole thing
assoc with seronegative arthritidies
pubic ramus fracture
needs at least 3 x - rays to assess whole ring
AP
inlet view
outlet view
generally don’t operate
fragility fracture
6-8 weeks to solidify but FWB through the rehab, manage pain as needed.
radial head fracture
most common elbow fracture
mean age 45. 85% occur before 60.
FOOSH- elbow extension and forearm pronation
Type I
Nondisplaced or minimally displaced (<2mm), no mechanical block to rotation
Type II
Displaced >2mm or angulated, possible mechanical block to forearm rotation
Type III
Comminuted and displaced, mechanical block to motion
Type IV
Radial head fracture with associated elbow dislocation
S+S: pain, possible blocks to elbow ROM (inc pro/sup)
Ix: x-ray
ct for surg workup
RX: type 1-2 with no block.
immobilise for 3-7 days then light rom
2 with block-3-4 ORIF if feasible.
if more than 3 bits- replace radial head, or if continued non union.
scaphoid fracture
blood supply by dorsal carpal branch of radial artery
80% is supplied by retrograde flow.
snuffbox tenderness / tubercle tenderness is important
scaphoid compression (axial thumb) is pretty sensitive and specific.
Ix: 5 view scaphoid imaging
repeat in 14-21 days if no # seen but high suspicion.
or mri
Rx: cast immobilisation 21 at least- non displaced- if <1mm pretty high union rate
perc screw fixation - pole #, displacement >1mm, waist #.
ORIF if pretty mad looking x-rays.
scoliosis
most common is adolescent idiopathic
affects 10-18 year old girls most commonly
(10-1 female-male for big curves >30’) equal ratio for smol ones.
multifactoral causes predominantly unknown.
Rf: FH
Ix: standing PA, lateral. Cobb angle (>10’ is scolisosis)
Rx: Cobb angle <25 deg. - nonop
Cobb angle 25-45- bracing.
cobb angle 45+ - surgery- posterior spinal fusion.
septic arthritis
inflammation 2’ to infection
monoarticular usually.
staph aureus is common causitive organism.
more common in kids than adults.
Rf: kid or over 80, DM, RA, recet surg, prosthesis, prev injection, skin infections, hiv, sex,
S+S: acute monoarticular joint pain, fever, sepsis, swelling, inflammation.
Ix: synovial culture
Rx: antimicrobial therapy- Fluclox 4-6/52.
clincamycin if allergic.
if large collection- drainage and washout.
shoulder dislocation
contact sports in young, falls in the old.
associated with bankart lesion
hill-sachs lesion
axillary nerve injury
mostly are anterior dislications, 2-4% are posterior
S+S: arm often abducted and externally rotated.
Ix: X-ray AP and axillary lateral/ Y views
Rx: reduce and sling
if recurrent - bankeart repair –> laterjet
spondylosis/ spondylolisthesis
due to pars fracture insificciency- one vertebra slips foreward relative to the other one
causes: degenerative, isthmic, traumatic, dysplastic, or pathologic.
Ix: AP/ lateral flexion and extension.
graded: based on quaters of slippage.
Rx: grade 1- nothing
grade 2- probably nothing
after that no real defined terms for how to do the operations.
spinal chord injury- types, how are they graded + treatment.
primary- irreversable arising from direct damage
2’- as a result of changes prod by primary.
most common cause- car crash.
Graded using ASIA score- A worse, E best.
Image with MRI
Rx:
maintain BP above 90 systolic,
consider need for intubation
catheterise if retaining
trigger finger
A1 pulley mechanical impingement
progressive pain, clicking, triggering, tenderness
Rf: diabetic, female, over 50,
increaced type 3 collagen
associated with carpal tunnel 60% of the time.
Grading
1- pain
2- some locking but goes away on onw
3- locking requing manual release
4- locked
Ix: clinical diagnosis
Rx: splinting, activity modification, nsaids
steroid treatment
Operative- perc release of A1 tendon.
ulner nerve entrapment
gen occurs in cubital tunner in elbow or in guyons canal
ulnar is medial chord of brachial plexus.
men 2:1 women at elbow.
Ix: x-rays to rule out any ossious/ ossification cause.
Rx: NSAIDs, pad the nerve, splints at night.
atrophy + weakness = release of ligaments, medial epicondylectomy.
ganglion cysts
mucin filled synovial cysts
can occur spont or at site of injury.
most common hand mass
dorsal 70%.
volar carpal 20%
volar retinacular 10%
usually asymptomatic.
Ix: firm well circumscribed transilluminating mass- clinical
Rx: usually leave alone
closed rupture (bible) - high reocurrence
aspiration- 2’ line usually. avoid on volar due to radial artery.
operative- resection- recurrent
