Ortho & Rheum Flashcards
Types of fracture (8)
Fissure Impaction Greenstick Transverse Avulsion Comminuted Oblique Spiral
Displacement of bones (3)
Translation (sideways movement, as % of bone diameter)
Angulation (bend in degrees)
Shortening (collapse, in cm)
Fractures causing avascular necrosis
Scaphoid fracture
Femoral head
Wrist fratures
Colles’ (distal radius with dorsal displacement fragments) - Forward fall. Dinner fork on lateral X ray
Smith’s (distal radius with volar displacement) - Backward fall. Garden spade on lateral x ray.
Scaphoid (*vulnerable blood supply)
NOF fracture
Types & Management (3)
Presentation
Complications
Intracapsular - Femoral neck between edge of femoral head and insertion to capsule
50% damage medial/lateral circumflex artery
May disrupt blood supply to femoral head - avascular necrosis - Surgery within 36 hours (Undisplaced - Internal fixation with screws. Displaced - hemiarthroplasty)
Extracapsular trochanteric # distal to insertion, involving or between trochanters - Nail/screw fixation
Extracapsular subtrochanteric # below lesser trochanter to 5cm distal - Nail/screw fixation
Pain in outer upper thigh or groin, radiate to knee, no wt bearing
Affected leg shortened, adducted and externally rotated
Pressure sores, DVT, bedbound, avascualr necrosis.
Total hip replacements dislocate more than hemis
Fracture healing time
Simple fractures take 3 weeks - Metaphyseal, closed, paediatric, upper limb.
Any complicating fracture doubles healing - Adult, diaphyseal, lower limb, open.
Stages of fracture healing
Haematoma formation *hours
MP and inflamm leukocytes move to area and begin secreting pro-inflammatory agents
Fibrocartilaginous callus formation (soft callus) *days
Inflammation leads to angiogenesis and increased number of chondrocytes. Secrete collagen and proteoglycans - fibrocartilage
Bony callus formation *weeks
Endochondral ossification and direct bone formation. Soft callus replaced by woven bone
Bone remodelling *months
Woven bone replaced by organised cortical bone. Continually remodelled therefore no scarring
NOF fracture grading
Gardens
- Incomplete #
- Complete but not dispisplaced
- Comp displaced <50%
- Comp, displaced > 50%
Femoral shaft fractures
High-velocity, and high-energy e.g. RTA
Joints in the ankle and pres of #
2 joints: ankle (tibia and fibula meet talus), syndesmosis joint (tibia to fib)
Similar to severe sprain: immediate severe pain, swelling (localised or along leg), bruising, tenderness - consider the mechanism
Ottawa ankle rules
When to X ray
>55
Inability to wt bear (4 steps) now and at time of injury
Bone tenderness at posterior edge or tip of lateral malleolus (6cm)
Bone tenderness at posterior edge or inf tip medial malleolus
(+ XR midfoot) bone tenderness at base of 5th metatarsal, cuboid or navicular
Preventing NOF#
Prevent falls - Good lighting, less sedation
Exercise and balance training - Tai Chi
Prevent osteoporosis - Bisphosphonates & Exercise
Vitamin D supplements
Management of ankle breaks
If neurovascular compromise or dislocation (obvious deformity) then reduce immediately
Reduce
Stabilise (4-6 weeks) moulded cast
Analgesia
Elevation
Re-assess neurovascular status
XR at reduction, 48 hours, 7 days, then 2 weekly
Ankle # Classifcation
Danis-Weber - Relative to the tibofibular syndesmosis
Below
At the level of
Above
Main complication of #
Compartment syndrome
6Ps - Pain out of proportion, parasthesia, pallor, paralysis, perishingly cold
When - Post fracture or reperfusion
Reduce risk by prompt fracture reduction and loose dressings
Treatment - Prompt fasciotomy
Post complications - Rhabdomyolysis -> renal failure (So give fluids)
Frozen shoulder
Thickening and contraction of glenohumeral joint capsule ± formation of adhesions - pain and loss of function either spont or post rotator cuff injury
40-65, Diabetes, thyroid
Loss of external rotation
Analgesia (paracetamol, NSAID), tens, activity, physio
Bone remodelling process
Osteocytes send signal to osteoclasts and osteoblasts
Osteoclasts resorb bone matrix: resorption pit - increases serum Ca
Osteoclasts undergo apoptosis and send signals to osteoblasts
Osteoblasts synthesise bone matrix
Bone matrix undergoes mineralisation
Hormones involved in bone remodeling (4)
PTH, 1,25-dihydroxyvitamin D, calcitonin, oestrogen
Osteoporosis
Definition
Location of #
Symptoms
T-score < -2.5 (s.d. below young healthy adult mean)
-2.5 < T
Risk factors for Osteoporosis
SHATTERED + FRAX (parental fracture) + SEDENTARY (decreased loading)
S - steroids + Cushing’s (>7.5mg for 3 months) - Decrease Ca absorption from gut, Increase osteoclast activity & Decrease muscle mass
H - hyperTh, hyperPTh, hypercalciuria
A - alcohol and tobacco
T - thin (BMI<19) or AN
T - testosterone decreased - primary hypogonadism, or anti-androgens @ PrCa
E - early menopause (<45)
R - renal/liver function - renal osteodystrophy in CKD, chronic liver disease
E - erosive/inflammatory disease: RA, multiple myeloma, metastasis
D - dietary Ca/T1DM - malabsorption, malnutrition
Osteoporosis managament
Lifestyle: smoking, alcohol, wt bearing exercise, balance (fall risk), calcium + vit D rich diet, fall prevention
Meds: Bisphosphonates + Ca + vit D supplements - AdCal D3, Accrete D3
Fall prevention: avoid polypharmacy
If low testosterone add testosterone
If intolerant bisphosphonates use denosumab (monoclonal aB to RANKL)
Raloxifene can be used for women (selective oestrogen receptor modulator)
Bisphosphonates
Egs
Mechanism
Side effects
Alendronic acid, risedronate, zoledronic acid
Inhibit osteoclastic bone resorption
Upper GI therefore take sitting upright with plenty of water first thing before food - crap absorption (1 hour before food)
Difficulty swallowing, oesophagitis, gastric ulcers
Osteonecrosis of the jaw
Osteoporosis blood tests
Ca, PO4, ALP, PTH all normal
Osteomalacia
Presentation
Blood test results
Widespread bone pain + tenderness (low back pain and hips)
Proximal muscle weakness - waddling gait (if severe)
Fatigue
Symptoms of underlying disease
Costochondral swelling, spinal curvature, hypocalcaemia (tetany, carpopedal spasm)
Ca - Decreased
PO4 - Decreased
ALP - Increased
PTH - Increased