Orthopaedic Conditions Flashcards
Ankle - Weber classification, management
Weber classification
- A = below syndesmosis
- B = level of syndesmosis
- C - above level of syndesmosis
Management
- A = cam boot, WBAT
- B = short-leg back slab, NWB
Non-displaced - Ortho follow up 7-10 days
Displaced - ED follow up 1-2 days
- C = short leg back slab, ortho follow up STAT
** Refer to page 167 of GP Study Notes
Clavicle
Key point
● Nondisplaced or minimally displaced middle third fractures = broad arm sling, analgesia and regular elbow range of motion exercises.
● Complete displacement, shortening or comminuted = orthopaedic referral.
10M presenting with a painful left shoulder after falling off the scooter. O/E: unable to move left shoulder due to pain, L) upper limb is neurovascularly intact, skin intact. XR: minimally displaced midclavicular fracture.
- What is the next most appropriate management?
What is the next most appropriate management?
● Broad arm sling for 2-3 weeks
Note: Reduction of the middle third is almost never required. Manipulation can lead to neurovascular injury.
Humeral (surgical neck, proximal, shaft)
Surgical neck of humerus #
- No displacement or impaction = triangular sling, pendulum exercise when pain settles, full activity in 8-12 weeks.
- Pitfalls = overzealous early mobilisation can cause non-union, prolonged immobilisation can increase rehabilitation time.
Proximal humeral
- Humeral neck involvement, neurovascular complications, concomitant shoulder dislocation = ortho referral.
- One-part # = collar and cuff sling, ice, analgesia.
Shaft of humerus
- Undisplaced # = collar and cuff with elbow flexed to 110-120. U-shaped hanging cast
assists.
- If no experience with hanging cast then patients should be referred to ortho for review.
Hand/wrist - Boxer, Colles, Buckle
● Boxer #
○ Transverse fracture of the 5th metacarpal neck
○ No amount of rotational deformity is acceptable
○ Can be managed conservatively but often requires K-wire for better cosmetic outcomes
● Colles fracture (dinner fork deformity)
○ Minimal displacement - below elbow plaster for 4 weeks and then crepe bandage
○ Displacement
■ Set in flexion 10 degrees, ulnar deviation 10 degrees and pronation
■ Below elbow plaster for 4-6 weeks
■ Check XR in 14 days
● Buckle fracture
○ Management: removable back slab
Elbow - supracondylar
Supracondylar #
○ Common in children
○ XR finding: raised posterior +/- anterior fat pad
○ Urgent ortho review: no radial pulse, ischaemia of hand, severe swelling of forearm or elbow, skin puckering or anterior bruising, open injury, neurological injury.
Femur
** subcapital have high risk of vascular necrosis
** Refer to page 170 of GP Study Notes
Patella
Key point
● Lateral view most helpful for assessment of displacement
● Need to refer to ortho if: >2mm of articular step-off, >3mm of separation, comminuted fracture with displacement, disruption of extensor mechanism
Treatment:
● Immobilisation of knee in extension with knee in extension for 4-6 weeks (cast ankle to groin)
Metatarsal shaft
Presentation: several weeks after abrupt increase in activity
Complaint: poorly localised in the forefoot or focal over a particular metatarsal
Imaging: nuclear bone scan (can pick up early signs)
Management: activity reduction and basic analgesia for 4-8 weeks
Osteoid osteoma (definition, features, presentation)
Definition: benign bone-forming tumour with small radiolucent nidus (<1cm to 1.5 cm in diameter).
Clinical features: presents during second decade, lower extremity (proximal femur most common).
Presentation: progressive pain, worse at night, relieved by NSAIDs within 20-25 mins. *** If not relieved by NSAIDs then consider something else
Osteoarthritis (radiological findings, principles of management, examination, management)
Radiological findings: loss of joint space, subchondral sclerosis, osteophytes
Key principles of management: ● Individualise goals of management ● Educate patient on condition ● Optimise management of comorbidities ● Provide advice on exercise and nonpharmacological interventions ● Organise regular clinical review
Examination: Heberden’s node, Bouchard’s node
Management:
● Topical
○ Topical NSAID up to 4 times a day
○ Capsaicin 0.025% 3-4 times a day
● Oral (only prescribe NSAID if not contraindicated)
○ Chronic pain:
■ Duloxetine 30mg PO daily
■ Opioids (reserve for severe persistent pain)
○ Complementary: low evidence
■ Glucosamine
● Intra-articular injections
○ Corticosteroid - good for relief, does not alter disease progression
○ Hyaluronan - more expensive, may worsen initially
○ Platelet-rich plasma
Ottawa ankle rules
Ankle
- Point tenderness at posterior edge (of distal 6 cm) or tip lateral malleolus
- Point tenderness at posterior edge (of distal 6 cm) or tip medial malleolus
- Inability to weight bear (four steps) immediately after the injury and in emergency department
Mid-foot
- Point tenderness at the base of the fifth metatarsal
- Point tenderness at the navicular
- Inability to weight bear (four steps) immediately after the injury and in emergency department
Monteggia fracture-dislocation (key points, management, complications)
Key point
● Reduction is always required
● Delayed or missed diagnosis in the most common complication
● If an ulna fracture is present, always look for radial head dislocation
Definition: anterior dislocation of the radial head with fracture of the ulna shaft (diaphysis)
Management: Referral for urgent orthopaedic assessment
Complications:
● Delayed diagnosis with poorer healing outcome
● Nerve injury (radial nerve most commonly injured)
Buckle fracture (definition, management, follow up)
Definition: Incomplete fractures of the shaft of the long bone with bulging of the cortex.
Management: below-elbow fibreglass/plaster backslab or removable wrist splint for 3 weeks
Follow up: none required
Note: Minimally displaced complete metaphyseal fractures can be mistaken for buckle fractures (different management).
PCL rupture (mechanism, features, management)
Mechanism: hyperextension injury.
Clinical features: minimal swelling, minimal disability, pain running downhill, posterior sag or draw.
Management: conservative with immobilisation and protection for 6 weeks. Then graduated weight-bearing and exercises.
Radial fracture
Key point
● Most common type of fracture
Malunion
Key point
● Most common complication of distal radial fracture
Significance: risk of ongoing disability
Presentation: wrist weakness, pain, decreased motion, numbness or tingling, irritability, cosmetic concerns
Investigation: imaging is gold standard (PA, lateral, oblique)
● Consider CT for rotational deformity
Rib fracture (key points)
Key points
● CXR misses 50% of rib fractures but is useful to rule out other pathology
● Rib fractures do not always require CT chest (i.e. younger group with no comorbidities)
● Elderly patients are at higher risk of secondary infection from missed rib fractures
● Aim of management is to optimise pain relief to decrease risk of infection
Scaphoid fracture (key point, examination, management)
Key point
● Suspect in anyone who has had FOOSH with wrist in dorsiflexion
● Risk of nonunion or osteonecrosis with fractures of the proximal pole
Examination: Pain in anatomical snuff box
Management:
● Plain XR immediately after injury (even though may not be evident)
● Immobilisation with repeat imaging (MRI ASAP, bone scan 3-5 days, plain XR 7 to 10 days)
Scheuermann disease (definition, features, diagnosis, radiological findings, treatment)
Definition: structural sagittal plane deformity (unknown cause) affecting T7-9 or T11-12 regions.
Clinical features: age 11-17, males > females, increased thoracic kyphosis over 1-2 months, short hamstrings, cannot
touch toes.
Diagnosis: lateral standing XR.
Radiological findings: Schmorl node and anterior vertebral body wedging.
Treatment:
● Avoidance of sports involving lifting and bending, extension exercises.
● If early: Milwaukee brace.
● If serious deformity: surgery.
Stress fracture of lower leg (common site, RF, timeframe, Ix, Tx, when to refer)
Common site: tibia, fibula and foot (navicular, calcaneus, metatarsals).
Risk factor: runners, jumpers.
Timeframe: pain over weeks.
Investigation:
● XR finding of tibia: ‘dreaded anterior black line’, thickened cortex around the fracture line. ** Findings can be normal for the first few weeks.
Treatment: cessation of inciting activity, rehabilitation and graded exercise.
When to refer:
● Stress fracture of the anterior tibial cortex
● Severe fractures
● Intra-articular stress fractures
Trimalleolar fracture (involves, significance, management)
Involves: medial malleolus, posterior aspect of tibial plafond, lateral malleolus.
Significance: unstable fracture, likely associated with ligamentous injury.
Management: orthopaedic referral for ORIF.
