Orthopaedic Conditions

Question 1

Ankle - Weber classification, management

Answer 1

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

Question 2

Clavicle

Answer 2

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.

Question 3

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.

1. What is the next most appropriate management?

Answer 3

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.

Question 4

Humeral (surgical neck, proximal, shaft)

Answer 4

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.

Question 5

Hand/wrist - Boxer, Colles, Buckle

Answer 5

● 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

Question 6

Elbow - supracondylar

Answer 6

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.

Question 7

Femur

Answer 7

** subcapital have high risk of vascular necrosis

** Refer to page 170 of GP Study Notes

Question 8

Patella

Answer 8

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)

Question 9

Metatarsal shaft

Answer 9

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

Question 10

Osteoid osteoma (definition, features, presentation)

Answer 10

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

Question 11

Osteoarthritis (radiological findings, principles of management, examination, management)

Answer 11

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

Question 12

Ottawa ankle rules

Answer 12

Ankle

1. Point tenderness at posterior edge (of distal 6 cm) or tip lateral malleolus
2. Point tenderness at posterior edge (of distal 6 cm) or tip medial malleolus
3. Inability to weight bear (four steps) immediately after the injury and in emergency department

Mid-foot

1. Point tenderness at the base of the fifth metatarsal
2. Point tenderness at the navicular
3. Inability to weight bear (four steps) immediately after the injury and in emergency department

Question 13

Monteggia fracture-dislocation (key points, management, complications)

Answer 13

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)

Question 14

Buckle fracture (definition, management, follow up)

Answer 14

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).

Question 15

PCL rupture (mechanism, features, management)

Answer 15

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.

Question 16

Radial fracture

Answer 16

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

Question 17

Rib fracture (key points)

Answer 17

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

Question 18

Scaphoid fracture (key point, examination, management)

Answer 18

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)

Question 19

Scheuermann disease (definition, features, diagnosis, radiological findings, treatment)

Answer 19

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.

Question 20

Stress fracture of lower leg (common site, RF, timeframe, Ix, Tx, when to refer)

Answer 20

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

Question 21

Trimalleolar fracture (involves, significance, management)

Answer 21

Involves: medial malleolus, posterior aspect of tibial plafond, lateral malleolus.
Significance: unstable fracture, likely associated with ligamentous injury.
Management: orthopaedic referral for ORIF.