Ortho/MSk PACES Flashcards
What is the most basic management of an trauma injury
Reduce
Restrict
Rehabilitate
What are the clinical signs of a fracture?
Pain
Swelling
Crepitus
Deformity
Adjacent structural injury to nerves/vessels/ligament/tendons
What should always be mentioned in your management plan of any traumatic presentation?
Pain relief
How can you control swelling
Ice
What structures run in the limb
Nerves
Vessels
Ligaments
Tendons
What are the three functions of nerves (thinking about orthopaedic conditions causing neuro compromise)
Sensory
Motor
Autonomic
How may a vessel injury present in a traumatic injury
Think about the 6 Ps
What is ‘displacement’
loss of bone alignment along its long axis
What is ‘angulation’
a specific type of displacement where the distal portion of the bone points off in a different direction
What does a bone technetium-99 scan tell you
technetium is taken up by metabolically active tissues
what are the three options for activity on a bone tecnetium-99 scan?
metabolically active tissues:
osteoblasts trying to heal a fracture
white cells
tumour
How do you describe a fracture radiograph
Clinical history
Fracture type
Fracture location
Fracture displacement
Anything else
what is an avulsion injury?
where the joint capsule, ligament, tendon or muscle attachment site is pulled off from the bone
what are the rough definitions of displacement
over 1cm = definitely displaced
at a joint surface, anything over 2-4mm is displaced
what is the difference between translation and angulation
translation = a line drawn down the centre of the bone is not continuous
angulation = a line drawn down the centre of the bone is angled at the fracture
What are the three main types of fracture?
Complete (all the way through the bone)
Incomplete (the whole cortex is not broken)
Salter-Harris (involves the growth plate)
what does transverse fracture look like on x-ray
straight through
oblique fracture x-ray
straight through, but on a slope
spiral fracture appearance
cork screw
commisurated fracture appearance
in several pieces
bowing fracture appearance
incomplete, with the long bone bent
buckle fracture appearance
incomplete fracture, with the fracture on the concave surface
greenstick fracture appearance
incomplete fracture, with the fracture on the convex surface
what are the three parts of the bone
diaphysis
metaphysis
epiphysis
label the parts of a bone
what is the general rule when describing angulation?
You are comparing the distal component displacement relative to the proximal component for the distally broken bit
what are the final ‘other things’ to talk about when describing a fracture x-ray?
joint involvement (requires different treatment)
other fractures
underlying bone lesion
what is the orientation of most x-rays in orthopaedics
AP
is the tibia (big bone) lateral or medial usually
tibia is medial usually
what is the name given to lateral displacement
valgus (away from the midline)
what is the name given to medial displacement
varus (towards the midline)
how do you tell if a fracture is translated or not
is there still contact between the fracture location bit
Go through the management algorithm for reducing a fracture
What are the two different ways you can reduce a fracture
either closed (manipulation or traction) or open (make a cut in the skin and push the bones back into position)
What are the potential ways of reducing a fracture through a closed method
manipulation (used in most cases nowadays)
traction (either through skin or pins into the bone) -> not used too much as patient is in bed for too long
What are the ways in which you can restrict a fracture after reducing it?
Most of the time:
plaster (closed method)
fixation (sticking metal in)
What’s the difference between internal or external fixation?
Internal = fixation by sticking metal under the skin and then closing it
external = sticking metal into the bone through the skin and part of it sticks out still
What are the two broad types of internal fixation?
either intramedullary (through the bone) - pins or nails
or extra medullary (around the bone) - plates/screws or pins
What are the two main intramedullary devices
pins and nails
What are the main types of extra medullary devices
plates/screws
pins
What are the two main types of external fixation?
monoplanar (in a straight line)
multiplanar (in circular)
What are the principles of orthopaedic rehabilitation
use -> pain relief + retrain
move
strengthen
weight bear
What type of fixation is this
external fixation -> on the surface of the wrist
(not internal fixation as doesn’t go through the medulla of the bone)
Why is external fixation used?
Enables you to see and treat infection very quickly
-> hence you use in extensive soft tissue injuries or complex periarticular fracture
How do you classify surgical complications?
Local and General
Immediate, within 24h, early <30d, late >30d
What are the general complications of a fracture/any surgery?
Fat embolus
DVT
Infection
Prolonged immobility -> UTI, chest infections, bedsores
What are the specific complications to a fracture?
Damage to local structures: nerves, vessels and tendons
Non-union / Mal-union (healing in a wonky position)
Infection
What are the causes for a fractured neck of femur?
osteoporosis (older)
trauma (younger)
combination
types of NOF fracture by location
What is the anatomical boundary between extra vs intra-capsular NoF fractures
the trochanteric line is the boundary
what anatomical feature is used to look for NOF fractures?
schenton’s line i.e. the smooth semi circle
What is the usual management of an extra capsular NOF fracture?
if minimal risk to blood supply and AVN, internal fixation with plate and dynamic hip screw
What are the management options for an intracapsular NOF fracture?
if undisplaced: less risk to blood supply - fix with screws
displaced: 25-30% risk AVN, replace in older patients, reduce and fixation with screws if young
What is the difference in uses of hemiarthroplasty vs total hip replacement?
hemiarthroplasty used if patient is less suitable for surgery (i.e. less mobile, more co-morbidities, older etc)
What is the difference between a total hip replacement and a hemiarthroplasty?
THR = femoral head replaced + cup inserted
Hemiarthroplasty = femoral head inserted into native cup
What are the three most important factors for a NOF fracture?
age, activity levels, risk of AVN
What is the definition of osteoarthritis?
chronic condition resulting in wear of the articular cartilage presenting as pain, swelling, stiffness
What is the significance of rest/night pain in osteoarthritis?
could herald infection/tumour
mostly just severe osteoarthritis -> indicates severe pain
How do you measure disability caused by osteoarthritis?
walking distance
stairs
giving way
what does it stop them from doing what they want to do
what do you always need to remember to ask with any Msk/rheum joint history?
are other joints affected?
What is the basic structure of an orthopaedic assessment?
look
feel
move
special tests
Should you do a special test in ortho if you think it may hurt the patient?
No, ask the examiner first
most likely reason for this knee scar?
total knee replacement
what is the angle of flexion in ortho exam?
just make sure you don’t say 180 degrees for a straight leg
what is an antalgic gait?
way of walking to minimise pain
What is the basic structure for investigations in an ortho exam?
weight bearing plain x-ray (AP/lateral views)
if soft tissue, MRI
bloods
What is the conservative management of osteoarthritis
analgesics
physiotherapy
walking aids
avoidance of exacerbating activity
injections (steroid/viscosupplementation) - mostly for wet arthritis / inflammatory arthritis
What is the operative management of osteoarthritis
replace (knee/hip)
realign (knee/big toe)
excise (toe)
fuse (big toe)
synovectomy (rheumatoid)
denervate (wrist)
what type of hip replacement is done for OA?
pretty much always THR
what causes joint effusion
Anything that irritates the synovial lining
- synovitis
- inflammatory conditions
- torn ACL
- torn meniscus
shoulder MSk exam: look
scars
swelling
deformity
muscle wasting (supra/infra)
shoulder MSk exam: feel
clavicle
ACJ
humeral head
shoulder MSk exam: move
flexion + extension
abduction (thumb pointing up)
internal rotation
hand behind head (sun-lounger)
hand behind back
shoulder MSk exam: special tests
resisted external rotation
resisted abduction
belly press
impingement
adduction
instability
how do you test the infra/teres minor
resisted external rotation
how do you test the supraspinatus
resisted abduction
how do you test the subscapularis
belly press
how do you test the ACJ
adduction
what are the shoulder conditions in a 15-45 year old
dislocation / fractures
what are the shoulder conditions in a 45-60 y/o
impingement
dislocation
ACJ OA
Rotator cuff tears
fractures
what are the shoulder conditions in a >60y/o
glenohumeral OA
impingement
cuff tears
fracture
hip examination: look standing
scars
wasting
deformity
muscle wasting (gluteal)
alignment
hip examination: look walking
from front: antalgic / short leg
trendelenberg
from the side: heel strike, toe off, time spent in stance phase
How do you do trendelenberg?
tell patient : ‘I’m going to put my hands on your pelvis’
place middle 3 fingers on ASIS and ask patient to put their hands on your arms
stand on one leg, pelvis drops on the side opposite to the stance leg (weak hip abductors) -> SOUND SIDE SAGS
hip examination: feel
femoral pulse
assess temperature evenly down both legs
greater trochanter
leg length discrepancy (true or false)
hip examination: move
Thomas’s test (fixed flexion)
flexion
abduction
adduction
internal and external rotation
hip examination: special tests
leg length discrepancy
Thomas’ test
where do you expose the patient to in a hip examination
ask to expose to the groin (I.e. lift shorts up)
how do you measure leg length discrepancy
measure apparent leg length on both
start by put measuring tape on xiphisternum and measuring down to the medial malleolus
how do you do Thomas’ test?
place palm of hand under the small of the back
ask patient to initially flex both knees up and hold them there
then them to lower one leg down to the bed
look at the angle between the couch and the long axis of the femur
what would a positive Thomas’ test look like?
femur makes an angle to the bed
when you try to extend the hip down, you’d lose the small of the back gap (lumbar lordosis)
how do you assess hip flexion
lying flat on bed, bend hip up with patient holding their knee, place your hand in small of the back again, see what the max degree of flexion is whilst maintaining lordosis
can do both sides of hip from the right of the patient
how do you assess hip abduction / adduction?
take leg at the ankle whilst other hand is on contralateral ASIS, watch the patients face, test abduction then adduction second
in what position do you assess hip internal/external rotation
1: legs straight, cup the heels with your hand, internally rotate both sides simultaneously
switch thumb side then externally rotate
2: bend hip and knee to 90 degrees, move ankle out and in (internal rotation of the hip = moving ankle away laterally)
what do you look for first in a knee examination
look for overall posture, any varus or valgus alignment
look at feet, are the arches present
what are you looking for on the back view of a knee exam
bakers cyst (popliteal fossa)
muscle wasting of the calves or hamstring
what is the first thing you feel for in a knee exam
feeling for quadricep muscles
ask patient to pull toes towards their head on both sides and push knee down into your hand
feel for vastus medialis, lateralis and then intermedialis (in the middle superiorly)
how do you test for knee effusions?
sweep test: milk the fluid by moving your hand superiorly on the medial aspect of the knee, then from laterally above the kneecap, then back down inferiorly
patellar tap test: tap the patellar with right index finger whilst you’ve stabilised the knee joint
cross-fluctuance test: pinch the kneecap with fingers then move from side to side
what position do you use for assessing knee flexion?
ask patient to bring their toes towards their head, push knee down into hand,
lift leg up straight (approx 20 degrees), then bend knee as far as it will go
what position do you assess anterior draw in
80 degrees flexion
what is the first thing to do before doing anterior draw
look from the side for a posterior sag
positioning for anterior draw
sit on edge of the foot gently
ensure the hamstrings are relaxed
feel for the joint line, thumbs beneath the joint line
what positioning do you use for Lachman’s test
left thigh under patient’s right thigh just above popliteal fossa
left hand over the femur in supracondylar region
other hand on the tibial tuberosity with hand wrapped around the leg
what is the preferred method for assessing the collateral ligaments of the knee
control the lower tibia using your own armpit
thumbs on the joint lines
what movements do you do when assessing the collateral ligaments of the knee
leg fully extended move the knee varus then valgus
then do the same at 30 degrees of flexion
how do you assess for patellar maltracking
ask patient to straighten the knee then move it back down again
do this whilst your feeling the patella with your thumb and index finger
what is the sergeant’s patch?
area supplied by the axillary nerve on lateral shoulder
what is the first thing you move in a shoulder examination?
ask patient palms out to front, thumbs outwards, bring up towards the side as far as they can go and back down again.
after you’ve got the patient to demonstrate abduction of the shoulder, what do you do?
passive internal / external rotation
ask patient to tuck elbows by side and move hands out then back in again
what movements do you test after active internal rotation / external rotation for shoulder exam?
compound / screening movements
hand behind head with elbow as far back as possible
then hand behind the back, with thumb as high up as they can go
what first passive movement do you assess in the shoulder?
bring arms to 90 degrees, then slowly raise the arm upwards to assess limit
(stabilising the shoulder and watching the patient’s face)
how do you assess for supraspinatus weakness in a shoulder exam?
empty can test
thumbs pointing down, arms straight and downwards
ask patient to push against your hand
after assessing supraspinatus weakness, what do you check for in shoulder exam?
external rotation against resistance
then internal rotation against resistance
after testing internal/external rotation against resistance, what do you do?
scarf test:
palpate greater tubercle, ask about pain, then move straight arm medially, check for pain
what do you do after scarf test in shoulder exam?
Hawkins sign: with elbow bent to 90 degrees, bring wrist parallel to the ground
after testing for subacromial impingement (Hawkins sign), what do you do in shoulder exam
ask patient to push against the wall, without lifting shoulders too high
show patient the hand position first
then check for winging of the scapula
after you’ve asked the patient to push against the wall, what do you do?
do dislocation tests:
sulcus sign - look along proximal humerus then pull down on the arm to see whether there’s inferior laxity and a sulcus appears
what is the positioning for the apprehension test of shoulder?
patient lying on couch
stabilise the shoulder joint with your right hand to make sure it doesn’t inadvertently dislocate
move the wrist backwards
repeat with stabilisation at the elbow afterwards
what is the first thing to do in a spinal examination
inspection: from the back
look for scars, muscle wasting at the bottom of the back
if you suspect scoliosis on inspection of a back examination, what movement can you ask the patient to do to accentuate this?
lean forward, look for a rib hump (where one rib is higher than the other)
what movements do you first do in a back examination
with your hand on their lower back ask the patient to:
lean backwards as much as possible and look up towards the ceiling (extension)
slide their hand to the left and downwards, then to the right side (lateral flexion)
how do you do a straight leg raise?
lift leg straight up until full flexion, or pain is elicited
then dorsiflex the foot passively
do this on both sides
what are the ortho movements you do in a cervical spine exam?
get them to mirror your movements first:
neck flexion to touch chin to chest,
neck extension to look up towards ceiling
right and left rotation
then right and left lateral rotation
what comes after you’ve done the active movements in a neck ortho examination?
test for spurling sign:
passively extend neck then tilt to one side and push down
ask about pain
what are the three parts of the foot?
what position do you ask the patient to take after looking at the ankle joint whilst standing?
ask them to take a seat, then ask them to show you the soles of the feet (support them as they do this)
what position do you do the move aspect of an ankle exam in?
sitting, support the feet
what passive movements do you test in the ankle joint
dorsiflexion (you need to be on your knees, and you hold onto the sole of the foot, pushing it back)
plantar flexion do the opposite
what movements come after passive dorsiflexion/plantarflexion
assess the subtalar joints
how do you assess the subtalar joints?
stabilise the talus (place your fingers over the top of the foot) then passively invert and evert the foot from the heel using your other hand
after assessing the subtalar joints in an ankle exam, what should you do next?
ask the patient to bring the soles of their feet facing each other, then facing away
testing eversion and inversion
what second special test should you do in an ankle exam?
palpate achilles tendon then do Thomson test:
squeeze the calf, and it should cause contraction of the achilles tendon and plantarflexion of foot
