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BMSc > Orthopaedic Medicine > Flashcards

Orthopaedic Medicine Flashcards

1
Q

The literal translation of Orthopaedics?

A

“straight children”

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2
Q

Define “acute disease”?

A

strikes the patient suddenly

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3
Q

Immune response to an acute disease?

A

production of polymorphs (many nuclei)

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4
Q

Define “chronic disease”?

A

takes a long time to develop, and may last a long time

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5
Q

Immune response to a chronic disease?

A

production of lymphocytes in the bone marrow and spleen

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6
Q

Two principal symptoms in Orthopaedics?

A

Pain and stiffness

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7
Q

Overall treatment objectives in Orthopaedics?

A 
Pain relief 
(in most cases cure cannot be achieved)
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8
Q

what is a “self-limiting” condition

A

a temporary condition that will get better

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9
Q

list the types of orthopaedic problems in terms of aetiology

A 
Congenital abnormalities 
Inflammatory abnormalties 
Metabolic disorders 
Degenerative disorders 
Trauma
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10
Q

List the types of orthopaedic problems in terms of frequency

A 
Arthritis + other joint conditions 
Back pain 
Conditions of Childhood 
Common adult disorders 
Common fractures
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11
Q

the definition for osteoarthritis

A

excessive wear of articular cartilage, resulting from a breakdown in the balance between wear and repair processes in the joint

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12
Q

classify the causes of osteoarthritis?

A

PRIMARY OA

  • unknown cause (majority)
  • problem with repair of cartilage

SECONDARY OA

  • known cause
  • problem with wear of cartilage
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13
Q

causes of secondary osteoarthritis?

A

1) Congenital (CDOH)
2) Childhood (Perthe’s disease, infection)
3) Trauma (fracture into a joint)
4) Metabolic (gout, crystal arthropathy)
5) Infection (TB)
6) Chronic inflammatory (rheumatoid)

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14
Q

symptoms of osteoarthritis

A
  • pain during activity
  • loss of function of affected joint and limb
  • stiffness (secondary to the pain!!)
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15
Q

when is help usually sought by a patient from their GP when they have OA?

A

when simple pain relief doesn’t control the pain

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16
Q

when is help usually sought by a GP from specialist help when a patient has OA?

A

when the patient’s sleep is disturbed

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17
Q

usual examination findings of an OA patient?

A
  • pain

- limitation of movement

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18
Q

what is the management of OA aimed at?

A

PAIN RELIEF, which then leads to return of function

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19
Q

list the conservative treatment options for OA

A
  1. Weight loss
  2. Use of a stick
  3. Physiotherapy

Analgesia can be used subsequently, or in parallel to these measures.

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20
Q

How does weight loss act as a conservative Tx for OA and explain

A

Reduces load on the joint

  • loads of joints can be up to several times of body weight. modest weight reduction results in a significant difference to loads on joints. also helps with general well being.
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21
Q

How does the use of a walking stick act as a conservative Tx for OA and explain

A

Use in the opposite hand allows the shoulder girdle to tilt the pelvis.

  • when we weight bear on a leg, the gluteal muscles are contracting on the same side in order to tilt the opposite side of the pelvis upwards to allow leg swing to take place. this action is essential for efficient walking. the use of a stick reduces the work required by the abductor muscles, so reduces the muscle induced load on the hip.
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22
Q

How does physiotherapy act as a conservative Tx for OA and explain

A

It is a controversial method, and balance is needed. Helps to maintain the natural tone of the muscles.

  • exercises relieve stiffness and muscle spasm and therefore pain.
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23
Q

list the surgical treatment options for OA

A
  1. Nothing
  2. Arthrodesis
  3. Osteotomy
  4. Arthroplasty
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24
Q

Why is doing nothing considered a surgical treatment option for OA?

A

The patient has to be aware that the benefits of surgery must outweigh the risks. If the patient is very old and disabled, it surgery might not be the best option

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25
Q

What is arthrodesis?

A

Surgical stiffening of a joint in a position of function. Joint is cut out and bone ends are held together by external splint or screws until they heal with a bony bridge.

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26
Q

What type of patient is arthrodesis best used for?

A

Young person with a painful and limited range of movement in the affected joint

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27
Q

describe arthrodesis procedure in the hip joint

A

more acceptable in males as in females it will affect sexual activity.

fusion in 30 degrees of flexion and some abduction allows pain-free functional gait, whilst allowing sitting. prolonged recovery (6 months in plaster splint)

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28
Q

what type of joints is arthrodesis better for

A

smaller joints, like ankle and wrist

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29
Q

the long-term disadvantage of arthrodesis

A

puts stress on adjacent joints

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30
Q

What is osteotomy?

A

Surgical realignment of a joint. Redirects forces across a joint by removing a wedge of bone so that loads are more evenly distributed.

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31
Q

What type of patient is osteotomy best used for?

A

Young person who has maintained good range of movement despite the pain (typical in early stages).

If ROM is very limited, then realignment isn’t going to help because function can’t be restored.

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32
Q

what type of joints is osteotomy good for

A

hip and knee

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33
Q

the long-term disadvantage of an osteotomy

A

will only last 2-10 years. although correction can be achieved to a certain extent, the underlying abnormality hasn’t been dealt with.

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34
Q

What is arthroplasty?

A

Replacement of one or both surfaces of a joint.

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35
Q

What are the main limitations of arthroplasty?

A

1) Relieves pain and restriction of movement that pain brings, but does not help with the stiffness that is caused directly by the disease within the joint. This is because soft tissue distortion persists after replacement.
2) Joint replacement is not the same as a transplant. As soon as the joint is inserted, it begins to wear.

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36
Q

Ideal strategy of joint replacement?

A

the joint should outlive the patient

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37
Q

Why is joint replacement of the upper limbs not as common as the lower limb?

A

Arthroplasty does not really help with intrinsic stiffness, so is no use in the upper limb where a large range of motion is required.

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38
Q

list the main requirements of an artificial joint

A
  1. provide a functional and pain-free range of motion
  2. withstand the forces placed upon it
  3. doesn’t wear or come loose
  4. same stability as a natural joint
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39
Q

why is arthroplasty of the hip successful?

A

The hip joint is stable due to the deep ball and socket joint, as well as range of motion being fairly limited

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40
Q

What is involved in knee arthroplasty?

A

Balance of the collateral ligaments by cutting tight parts of the ligaments and then putting in artificial surface replacements to ensure the medial and lateral collateral ligaments are under equal tension.

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41
Q

List the general complications of joint arthroplasty

A

chest infection
UTI
pressure sores
DVT

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42
Q

List the specific early complications of joint arthroplasty?

A

dislocation
DVT
infection

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43
Q

why is dislocation a specific early complication of joint arthroplasty?

A

the prosthesis isn’t fully supported by surrounding tissues, scar tissue hasn’t formed yet, and muscles and their proprioceptors may be out of action due to the trauma of surgery.

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44
Q

why is deep vein thrombosis a specific early complication of joint arthroplasty and how is it prevented?

A

due to the inactivity after surgery etc. Prophylaxis should be given, but the best method is not agreed universally.

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45
Q

Why is infection an early complication of joint arthroplasty?

A

the presence of foreign material inhibits the body’s ability to kill bacteria

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46
Q

What bacteria commonly cause early infection in joint arthroplasty?

A
  • recognised hospital bacteria (S. aureus)

- skin commensals (S. albus)

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47
Q

List the specific late complications of joint arthroplasty?

A
  • late infection (blood borne - contamination of bloodstream - bacteraemia)
  • loosening and wear (inevitable)
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48
Q

What is rheumatoid arthritis?

A

A chronic systemic inflammatory disease that is thought to be due to abnormal reactions to bacteria. It is characteries by symmetrical deformity.

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49
Q

Clinical presentation of rheumatoid arthritis?

A

Severe pain, swelling and deformity of the joints - especially the small joints of the hands and feet. (MCPs and PIPs, not DIPs)

Stiffness that is worse in the morning and improving throughout the day

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50
Q

what is the role of surgery in RA?

A

ensuring the patient is comfortable, whilst retaining as much function as possible. (mostly salvage - not correction of deformity!)

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51
Q

types of surgery carried out for RA?

A

1) Soft tissue surgery
- synovectomy
- limits damage to tendon sheaths and tendons themselves
- can be useful in early disease

2) Joint surgery
- excision arthroplasty
- usually done in combination with synovectomy

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52
Q

define avascular necrosis

A

bone tissue death through loss of blood supply

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53
Q

general causes of AVN

A
  • spontaneoulsy/idiopathic

- trauma

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54
Q

what sites are most at risk of AVN after a trauma

A
  • femoral head
  • proximal scaphoid in the wrist
  • proximal talus of the foot
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55
Q

what sites are prone to spontaneous AVN

A
  • lunate bone in the wrist

- femoral head

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56
Q

list common situations when idiopathic AVN of the femoral head is seen

A
  • chronic alcohol abuse
  • high dose steroid therapy
  • deep seas divers (Caisson’s disease)
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57
Q

X-ray appearance of AVN

A

Early - no changes

Later - dense bone, due to no blood vessels

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58
Q

When is it possible to reverse AVN?

A

If the blood supply can be re-established NATURALLY

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59
Q

Mx of AVN

A

Non-specific Tx. Often salvage with joint replacement needed.

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60
Q

define ‘crystal arthropathies’

A

deposition of crystals of the by-products of metabolism onto the surface of articular cartilage and within synovial fluid

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61
Q

how do crystal arthropathies arise?

A
  • abnormality of metabolism resulting in excess production

- kidneys failing to eliminate them

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62
Q

the deposition of which crystal causes gout?

A

urate crystals

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63
Q

what is urate?

A

a waste product of cell metabolism

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64
Q

causes of gout?

A
  1. overuse of diuretics (most common)
  2. dehydration
  3. post chemotherapy
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65
Q

joints where gout is normally found

A

knee and first metatarsophalangeal joint

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66
Q

presentation of gout, and what condition must you rule out first

A

hot, swollen and tender joint.

must rule out infection, as this can cause a lot of damage to articular cartilage

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67
Q

Dx of gout

A

GS - fluid extraction of infected joint for presence of urate crystals

Also, high uric acid level in the blood

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68
Q

Mx of gout

A

NSAIDs

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69
Q

the deposition of which crystal causes pseudogout?

A

pyrophosphate crystals

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70
Q

the consequence of long-term pseudogout?

A

calcification of joint surfaces and menisci in the knee. long-term degeneration is likely, even with Tx

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71
Q

Mx of pseudogout

A

NSAIDs

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72
Q

define acute septic arthritis

A

an infection of the joint caused by bacteria that has spread through the bloodstream from a trivial site of infection

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73
Q

presentation of septic arthritis in children

A

the child is very unwell with an acute illness and high temp.
joint is very hot, tender and stiff

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74
Q

presentation of septic arthritis in adults

A

presents less acutely than children, and can be mistaken for just minor upset. then presents a few days later with blood poisoning, and may die as a result

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75
Q

most likely cause of a young adult presenting with septic arhtirtis

A

gonococcus, resulting from veneral disease

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76
Q

Mx of septic arthritis

A
  1. surgery - opening and washing of joint

2. IV ABx - first guess is anti-staph agent

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77
Q

what are the risks of inadequate Tx of septic arthritis

A
  1. risk of septicaemia

2. disintegration of articular cartilage, leading to bony fusion

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78
Q

what bacterial infection causes chronic septic arthritis

A

joint tuberculosis (TB) - spreads to the joints via the blood

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79
Q

presentation of chronic septic arthritis

A
  • chronic ill health
  • weight loss
  • muscle wasting around infected joint
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80
Q

Mx of chronic septic arthritis

A
  • TB drugs (RIPE)

- Surgery rarely necessary

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81
Q

presentation of meniscal tears

A
  • pain
  • fluid in the joint (effusion)
  • locking
  • giving way
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82
Q

examination findings of a meniscal tear

A
  • poorly localised on examination

- discomfort is elicited by gently but forcibly extending the knee joint

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83
Q

most common mechanism of meniscal tear injury

A
  • twisting injury

- foot gets stuck on the ground and the femur twists over the stationary tibia

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84
Q

which meniscus is more commonly torn and why?

A

medial more so than lateral

- medial meniscus is firmly attached to the medial collateral ligament

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85
Q

what type of meniscal lesion is very common in old age, and explain pathology

A
  • cleavage lesion
  • this is a horizontal split of the meniscus, which can act like a flap valve and allow build-up of synovial fluid within the meniscus forming a cyst
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86
Q

list the common types of meniscal tear patterns and give short explanation

A
  • Bucket handle tear (vertical split, anchored at both ends)

- Parrot beak tear (a split off one end of the lateral meniscus)

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87
Q

why is extending the knee joint prevented in a meniscal tear?

A

the torn prt becomes jammed in the joint

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88
Q

Mx of meniscal lesions

A 
Clinical suspicion - arthroscopy 
then 
Peripheral tears - suturing 
or 
Tear within substance - arthroscopic menisectomy
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89
Q

what are loose bodies in a joint also known as, and how do they arise?

A
  • Osteochondral fragments

- fragments of cartilage and bone that are sheared off in injury

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90
Q

what is the consequence of the presence of loose bodies in a joint?

A

knee swells due to associated bleeding into the joint (haemarthrosis).
the loose body floats free in the synovial fluid

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91
Q

presentation of osteochondral fragments?

A

can present years later after the first incident with locking, pain, giving way, effusion

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92
Q

what is osteochondritis dissecans

A

osteochondral fragments that arise spontaneously

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93
Q

Mx osteochondral fragments

A

removal via arthroscope

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94
Q

compare the healing capacity of the collateral ligamentsand the cruciate ligaments

A

collateral ligament injuries can heal spontaneously because they have an excellent blood supply. cruciate ligaments do not heal spontaneously because once they are torn the blood supply is lost

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95
Q

mechanism of cruciate ligament lesions

A

hyperextension or twisting injuries

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96
Q

presentation of cruciate ligament injury

A
  • “pop” sound
  • swelling from haemarthrosis from bleeding of the artery in the cruciate ligament
  • loss of anter-posterior stability
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97
Q

Mx of cruciate ligament injury

A
  • leave ligament for a while and rehabilitate muscles

- synthetic ligament replacement

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98
Q

what causes dislocation of the patella

A

malformation of the patella or the femoral condyle, leading to the patella moving abrasively over the femur

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99
Q

presentation of dislocation of the patella

A
  • spontaneous dislocation of the patella

- quadriceps extensor failure, therefore fall to the ground

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100
Q

Mx dislocation of the patella

A

Minor - surgical splitting of the vastus lateralis

Major - medial tightening (plication) of vastus medialis

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101
Q

why are prosthetic knee ligaments liable to fail?

A

there are no sensory receptors to let the brain know if the ligament is being over-stretched

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102
Q

most backache is self-limiting - T/F?

A

True!

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103
Q

A minor backache is easy to distinguish from a serious problem - T/F?

A

False! - difficult without extensive investigation

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104
Q

What is the collective name for non-nervous tissue in the spine?

A

spondylitides

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105
Q

What are the non-nervous tissues in the spine?

A

bones (vertebrae), muscles and ligaments

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106
Q

Abnormalities in spondylitides are known as?

A

Spondylitis

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107
Q

What is a possible consequence of a structural abnormality in the spondylitides?

A

Compression of the spinal cord, or nerve roots

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108
Q

What are the 3 types of pain experienced in spinal disorders?

A
  • locally
  • in another part of the body (referred pain)
  • along the length of the nerve arising from an affected nerve root
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109
Q

How does ‘local pain’ in the back tend to present?

A

tends to be related to a whole region e.g. dorsal region. difficult to pinpoint the exact area

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110
Q

where can pain in the back be referred to?

A

from the back > buttock, thigh and leg (RARELY below the calf!)

from the neck > shoulder and upper arm

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111
Q

where do nerve roots emerge from the vertebrae?

A

intervertebral foramina

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112
Q

what are the intervertebral foramina surrounded by?

A

facet joints behind

IV discs in front

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113
Q

how does the brain interpret a pressure on a particular nerve root?

A

the brain interprets this as pain in the length of the spinal nerve which is originating from that particular nerve root

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114
Q

give the name of the disease where there is pressure on a nerve root in the lower lumbar region of the spine, and explain

A

Sciatica

the pressure on a nerve root in the lower lumbar region means pain is perceived in the sciatic nerve.

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115
Q

symptoms of sciatica?

A

pain in the leg, mainly the back of the leg. almost always down into the foot.

pain can be exacerbated by coughing

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116
Q

what are the ‘localising signs’ of nerve root pain?

A

loss of sensation or muscle weakness

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117
Q

how is referred pain distinguished from nerve root pain in the lower limb?

A

Referred pain involves the buttock, thigh, and leg, but generally never descends below the calf. This differs from nerve root pain, where the pain almost always extends down the back of the leg and into the foot.

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118
Q

what are the 2 general classifications of backache and neckache?

A
  • Backache + Neckache related to the spondylitides

- Backache + Neckache related to the nervous tissue

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119
Q

3 backache conditions in the unit related to the spondylitides

A
  1. Aches and sprains
  2. Mechanical backache
  3. Spondylolisthesis
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120
Q

what is the cause of most back sprains

A

awkward twisting or poor lifting, cause muscle or ligament injuries

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121
Q

what is a good recommended lifting technique to minimise back sprains

A

reducing the distance between the back and the weight results in less leverage and reduced spinal loading

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122
Q

how are back sprains distinguished from neurological causes of backache?

A

the absence of signs of nerve compression (e.g. tingling, loss of sensation)

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123
Q

Mx of back sprains

A

a brief rest period

analgesia (if insufficient, give anti-inflammatories)

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124
Q

define ‘mechanical backache’?

A

it is an ill-defined condition, but can be thought of as recurrent back sprains

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125
Q

what are some possible causes of mechanical backache?

A
  1. spondylosis
    • degeneration of the IV disc
    • leads to increased loading on the facet joints, leading to the development of secondary OA
  2. primary OA
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126
Q

presentation and Mx of mechanical backache?

A

recurrent

no known cure - rest, analgesia and physio during a bad episode

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127
Q

define ‘spondylolisthesis’

A

slippage of one vertebrae relative to the one below

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128
Q

causes of spondylolisthesis?

A
  • a bony abnormality which interferes with the stability of the facet joints
  • can also occur due to either acute or fatigue fracture of the pars interarticularis
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129
Q

what is the pars interarticularis

A

joins the facet joints in the posterior spine

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130
Q

a fracture in the pars interarticularis with no forward slippage of vertebrae is known as?

A

spondylolysis

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131
Q

how can spondylolysis differ from spondylolisthesis?

A

doesn’t always cause pain!

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132
Q

presentation of spondylolisthesis

A

low back pain

very similar to mechanical backache presentation

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133
Q

Dx of spondylolisthesis

A

X-ray

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134
Q

Mx of spondylolisthesis?

A

spinal corset to relieve pain
similar Mx to mechanical backache
severe pain > surgical fusion

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135
Q

2 backache conditions in the unit related to nervous tissue

A
  1. prolapsed intervertebral disc

2. bony root entrapment

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136
Q

are “slipped disc” and “prolapsed disc” interchangeable terms?

A

No! the IV disc doesn’t “slip”, it is the disc contents which prolapse

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137
Q

the typical presentation of a prolapsed IV disc

A

men, < 40 years old

backache and legache passing down the back of thigh and leg into the foot

can arise after single episode of lifting, or can arise spontaneously

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138
Q

describe the pathology of a prolapsed disc

A

an abnormality in the IV disc leads to extrusion of the nucleus pulposus through the annulus fibrosis

if the prolapse extends backwards and laterally it impinges on a nerve root

if the prolapse extrudes posteriorly, it will impinge on the spinal cord, or more commonly the cauda equina

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139
Q

Mx of a prolapsed disc

A
  1. ensure nerves supplying bowel and bladder are not affected
  2. rest, and progressive gentle mobilisation
  3. analgesia and anti-inflammatories
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140
Q

if the pain of a prolapsed disc persists despite initial intervention, what is the Mx

A

do a myelogram to confirm location of prolapse (radio-opaque dye and x-ray)

removal of prolapsed material by surgery

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141
Q

what is the typical presentation of bony root entrapment?

A
  • M or F
  • > 40
  • previous Hx of mechanical backache
  • development of new leg pain radiating to the foot that is made worse by exercise
  • episodes are acute and recurrent against chronic Hx of back pain
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142
Q

what is spinal claudication

A

the name given to leg pain radiating to the foot that is made worse by exercise

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143
Q

what is the cause of bony root entrapment

A

bony overgrowth around the intervertebral foramina where the nerve roots emerge

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144
Q

what is the bony overgrowth in bony root entrapment due to?

A

secondary to degenerative changes in the adjacent facet joints

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145
Q

Mx bony root entrapment

A

removal of bone overgrowth - can result in disturbance of spinal stability, so decision to operate is based on the severity

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146
Q

define cervical spondylosis

A

degeneration of the IV discs in the cervical spine

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147
Q

describe the appearance of a vertebrae with cervical spondylosis

A
  • bony overgrowth causing narrowing of the disc space,
  • narrow foramen
  • presence of osteophytes
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148
Q

typical presentation of cervical spondylosis

A
  • F > M
  • > 40 years old
  • dull neck ache, referred to shoulders and upper arms
  • +/- entrapment of nerve roots, so tingling in the arms
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149
Q

Mx of cervical spondylosis

A
  • no nerve root entrapment: analgesia, NSAIDs, soft collar, physio
  • nerve root entrapment: surgical fusion of the vertebrae and decompression of the nerve root
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150
Q

what is the presentation of cervical disc disease

A

difficult to distinguish from cervical spondylosis, but sufferers tend to have no history of neck trouble

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151
Q

average age for a child to sit independently

A

9 months

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152
Q

average age for a child to stand

A

12 months

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153
Q

average age for a child to walk

A

20 months

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154
Q

what is the normal alignment of a child’s knees < 7 years old

A

slightly valgus, with the feet around 4cm apart

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155
Q

by what age is a child’s knees normally aligned?

A

7 years

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156
Q

what is genu valgum

A

knock knees

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157
Q

what is genu varum

A

bow legs

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158
Q

what is in-toeing

A

when a child’s feet point inwards and is exaggerated when they run

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159
Q

causes of in-toeing

A

femoral neck anteversion
tibial torsion
abnormal forefeet

160
Q

describe the pathology of femoral neck anteversion

A

during development, the leg rotates on the pelvis so that the acetabulum points nearly backwards and the femoral head is pointing forwards.

if this rotatory process isn’t completed by birth then the femoral neck will be more anterior (anteverted) than normal.

161
Q

what types of movements will a child with femoral neck anteversion be able to do?

A

internally rotate their femur a lot, but not externally rotate

162
Q

Tx of femoral neck anteversion

A

no Tx! Will usually correct itself by age 10, but some are left with a little residual deformity

163
Q

what is tibial torsion

A

the tibia is warped along its vertical axis

164
Q

Tx of tibial torsion

A

No Tx! it is a normal variation and should be ignored

165
Q

Tx of abnormal forefeet

A

no Tx - most cases correct themselves by age 7.

do not consider surgery before then

166
Q

special shoes make a difference in abnormal forefeet - T/F?

A

False!

167
Q

flat foot is a normal variation - T/F?

A

True!

168
Q

what are the 2 types of flat feet and explain them

A

Mobile
- normal variation. the arch may not form until 7 years

Rigid
- implies underlying bony abnormality

169
Q

rigid flat foot can be a sign of which disease?

A

rheumatoid arthritis

170
Q

which toe is most likely to be curly?

A

5th toe

171
Q

Tx of curly toes

A

Most resolve spontaneously so should be left alone

If fixed - requires surgical correction (only the 5th toe!)

172
Q

what is Osgood Schlatter’s disease

A

inflammation of the attachment of the patellar tendon to the growing tibial epiphysis

173
Q

cause of Osgood Schlatter’s disease

A

overuse injury, meaning excess traction by the quadriceps

174
Q

Tx of Osgood Schlatter’s disease

A

Rest!

Symptoms will cease in mid-adolescence when the epiphysis fuses

175
Q

who is more likely to experience adolescent knee pain - M/F?

A

Females

176
Q

Tx of adolescent knee pain

A

just watch briefly - most girls grow out of the condition

?arthroscopy if symptoms persist

177
Q

what is chondromalacia patellae

A

erosion of an area of the patella cartilage

178
Q

what is the incidence of CDOH

A

1 or 2 live births per thousand

179
Q

define CDOH

A

there is an underlying abnormality of the acetabulum, the femoral head or both, meaning that the hip joint is abnormal and likely to dislocate

180
Q

CDOH is more common in boys than girls - T/F?

A

False! More common in girls

181
Q

CDOH has a familial and racial tendency - T/F?

A

True

182
Q

CDOH is more commonly unilateral - T/F?

A

False - more commonly bilateral

183
Q

at what ages is a child screened for CDOH

A

birth, 3, 6 and 9 months

184
Q

what are the tests for CDOH

A

Ortolani test - attempt to dislocate the hip by abduction of the thigh and external rotation

Barlow test - attempt to relocate the hip by adduction and depression of the femur

185
Q

what results of the tests for CDOH would make you suspect something

A

a slight ‘click’ is a suspicious sign

a definite ‘clunk’ if diagnosis is positive

186
Q

clinical signs of CDOH if the Dx was missed at birth

A
  • shortening of the limb
  • asymmetrical skin creases
  • limited abduction
  • limp
187
Q

if the CDOH tests produce a ‘click’ what should be done

A

re-examine and radiograph in specialist clinic at 3 months

188
Q

if the CDOH tests produce a ‘clunk’ what should be done

A

treat from birth

relocate femoral head in acetablum and maintain with splintage

189
Q

Mx if CDOH is discovered late, but before weight bearing (ie sitting)

A
  • period of gentle traction, then open or closed manipulation
  • plaster splint for 3 months
190
Q

Mx if CDOH is discovered late and weight bearing has commenced (ie walking)

A

surgery to deepen acetabulum and re-angulate the femoral neck
- results are only adequate and secondary arthritis is likely

191
Q

what is club foot

A

deformity of the foot which makes it look like a gold club

192
Q

what is club foot also known as

A

talipes equino varus

193
Q

forms of club foot and explain them

A
  1. mild, postural form
    - seen after breech birth due to position in the womb
    - can be bilateral
  2. fixed form
    - due to developmental abnormalities of the leg nerves and muscles
    - can be bilateral
194
Q

Tx of club foot

A

Both forms:

  • 2 phases of gentle stretching
  • 1st phase corrects hindfoot
  • 2nd phase corrects midfoot and forefoot

Mild form:
- the above for 6 weeks is all that’s needed

fixed form:
- surgery

195
Q

for how long should a child with club foot be followed up?

A

until their feet stop growing (around 14 years)

late relapses not uncommon!

196
Q

what is spina bifida occulta?

A

a neural tube defect, where one or more vertebrae don’t form properly and there is a small gap in the spine

197
Q

what are the symptoms of spina bifida occulta?

A
  • many have no symptoms
  • mechanical backache
  • tethering of the spinal cord to higher lumbar vertebrae during growth (diastamatomyelia)
198
Q

what is spina bifida cystica?

A

a neural tube defect where the neural plate tissues are open with little or no bony cover

199
Q

what is the difference between a menigocele and a myelomeningocele?

A

A meningocele is a cyst covering the open neural tissue in spina bifida cystica.

A myelomeningocele is a cyst where the open neural tissue is incorporated into the cyst wall

200
Q

many children also have which severe symptom with spina bifida cystica

A

hydrocephalus -

increase in fluid in the brain, leading to mental retardation

201
Q

what is the prognosis of spina bifida cystica

A
  • many die at birth
  • some have surgery but most are mentally retarded
  • need early foot surgery to maintain shape
  • try to keep the child mobile until adolescence to maintain a good height
202
Q

what is cerebral palsy

A

a term given for delayed or arrested development of the nervous and musculoskeletal systems due to damage to the brain at birth

203
Q

the spinal tissue develops abnormally in cerebral palsy - T/F?

A

False!

The spinal tissue develops normally

204
Q

what is the consequence of the spinal tissue developing normally, but the brain being damaged in cerebral palsy?

A

a child will have uninhibited reflexes but will lack the coordination that is normally controlled by the brain.

results in spastic paralysis - some muscles contract strongly and others are flaccid

leads to abnormal muscle and bone growth, with secondary deformity of joints

205
Q

define ‘hemiparesis’

A

when one arm and leg on the same side are affected

206
Q

define ‘paraparesis’

A

when both legs are affected

207
Q

define ‘quadraparesis’

A

when all limbs are affected

208
Q

how do people with only minor degrees of spasticity in cerebral palsy present?

A

toe-walking in adolescence - calf muscle spasticity

209
Q

General Tx of cerebral palsy

A
  • wide support team
  • physiotherapy
  • splintage (caution - overuse can cause increased muscle spasm)
  • surgery to lengthen tight muscles or denervate them
210
Q

define scoliosis

A

deformity of the spine where there is an abnormal lordosis, leading to buckling and twisting of the vertebral column as a result of the action of muscles and gravity

211
Q

causes of scoliosis

A
  • most cases are idiopathic

- congenital abnormalities of the vertebrae

212
Q

what is the principal effect that scoliosis has on an individual

A

mainly cosmetic, which causes a lot of distress

213
Q

presentation of scoliosis

A
  • twisting of the ribs
  • hump on the shoulder
  • girls - skirt hangs crooked
  • pain - secondary to distress
214
Q

do all curves in scoliosis progress?

A
  • no
215
Q

Mx of scoliosis

A
  • early referral and Tx
  • surgical correction
  • correction of the rotatory element of the deformity, to remove the hump as this is the cause of most distress
216
Q

what are the classic causes of a limp in children from birth?

A
  • CDH

- infection of the hip

217
Q

what are the classic causes of a limp in children between age 4-10 years?

A
  • Perthe’s disease
218
Q

what are the classic causes of a limp in children between 10-15 years?

A
  • SUFE
219
Q

what is Perthe’s disease?

A

osteochondritis (fragmentation of bone and overlying cartilage) of the femoral head epiphysis) - AVN of the growing femoral head

220
Q

is Perthe’s disease more common in boys or girls?

A

Boys

221
Q

is Perthe’s disease more commonly unilateral or bilateral?

A

Unilateral (20% are bilateral)

222
Q

what is the incidence of Perthe’s disease?

A

up to 5 per 1000 children

223
Q

classic presentation of Perthe’s disease

A

a painful limp followed by a slow recovery

224
Q

Ix of perthe’s disease and what do they show

A

X-ray (may be normal at first presentation, but on repeat later will show changes)

Ultrasound - excess fluid at hip joint

225
Q

Mx of Perthe’s disease

A

Minor (< half of femoral head involved) - no Tx needed

Major - maintain femoral head in acetabulum until disease runs natural course (can use splintage)

follow-up with periods of traction

226
Q

What is Slipped Upper Femoral Epiphysis (SUFE)

A

slippage of the epiphysis of the femoral head on the femoral neck so that the head is abnormally tilted

227
Q

what is the classic type of child who will present with SUFE

A

overweight sexually immature boy who has recently undergone a growth spurt

228
Q

presentation of SUFE

A

limp, with pain radiating to the knee (due to sensory distribution of the obturator nerve)

229
Q

Ix of SUFE

A

x-ray - must include a lateral view or slippage can be missed

230
Q

Mx SUFE

A

Surgical

  • Minor: pin hip in new deformed position
  • Major: attempt to manipulate neck back onto head

Remove pins around 18 years old when epiphysis has fused

231
Q

define ‘enthesis’

A

the short, fibrous origin of a muscle

232
Q

define ‘enthesopathy’

A

inflammation of a muscle origin

233
Q

give 2 examples of common enthesopathies

A

golfer’s elbow and tennis elbow

234
Q

what is ‘golfer’s elbow’

A

inflammation of the common origin of the flexor muscles of the forearm (medial epicondyle of the humerus)

235
Q

what is ‘tennis elbow’

A

inflammation of the common origin of the extensor muscles of the forearm (lateral epicondyle of the humerus)

236
Q

causes of enthesopathies

A
  • associated with repetitive movements

- can also arise spontaneously

237
Q

Tx of enthesopathies

A

Encourage patients to wait because it is likely for spontaneous recovery in the long term

  • anti-inflammatory agents
  • local steroid injections into max tenderness site
  • surgery (scrape origin of muscle from bone and permit it to slide distally)
238
Q

why must care be taken when injecting steroid in enthesopathies

A

if there is leakage into the subcutaneous fat or skin, pain will be exacerbated and patient will be left with a dimple

239
Q

define a ‘neuropraxia’

A

compression or stretching injury to a nerve (ie. nerve entrapment)

240
Q

why is early diagnosis of neuropraxia important?

A

if there is continued pressure on the nerve, it will atrophy meaning recovery is long and the atrophy is usually permanent

241
Q

what are the different types of causes of neuropraxia?

A

Extrinsic causes:

  • accidents where consciousness is lost and the victim inadvertently presses on a nerve.
  • patients in bed
  • patients in a plaster cast

Intrinsic causes:
- structural local anatomical variations or inflammatory swelling

242
Q

what is the most common site of an extrinsic cause of neuropraxia

A

the common peroneal nerve, where it winds around the head of the fibula

243
Q

what are the most common sites of an intrinsic cause of neuropraxia

A

median nerve at the wrist

ulnar nerve at the wrist

ulnar nerve at the elbow

posterior tibial nerve at the ankle

244
Q

Ix of neuropraxia

A
  • clinical Dx of weakness and real sensory loss

- if doubtful, do nerve conduction studies

245
Q

Mx of neuropraxia

A

remove obvious causes (bandage/cast)

surgical relief of pressure if symptoms persist. cutting of skin and fascia

246
Q

define ‘tenosynovitis’

A

inflammation of a tendon and their associated synovial sheath

247
Q

what condition is tenosynovitis often associated with

A

rheumatoid arthritis

248
Q

causes of tenosynovitis

A
  • idiopathic

- unusual high activity levels or overuse

249
Q

what are bursae?

A

small sac of fibrous tissue lined by synovial membrane and filled with fluid

250
Q

what is the role of bursae?

A

their role is ‘bearing’, for improving muscle and joint function by reducing friction where tendons and ligaments pass over bones

251
Q

what type of activities make bursae likely to become inflamed?

A
  • repetitive movement or strain

- being subject to abnormal loads

252
Q

what are the most common sites for bursitis?

A
  • shoulder
  • knee
  • elbow
  • greater trochanter of the hip
253
Q

what are the symptoms of bursitis

A
  • chronic discomfort over the bursa
  • +/- swelling
  • +/- infection
254
Q

what are the symptoms of an infected bursa?

A
  • tense swelling
  • infection of the skin (cellulitis)
  • general malaise
255
Q

Mx of a chronic bursa with no symptoms

A

No Tx unless patient demands it for convenience or appearance

256
Q

Mx of a tender bursa

A

remove underlying cause

- excise if persistent

257
Q

Mx of an infected bursa

A

incision and drainage

258
Q

causes of a painful flat foot

A
  • infection
  • chronic inflammatory disease
  • acute or impending rupture of the insertion of the tibialis posterior (seen in middle age, with a painful and tender swelling)
259
Q

Tx of a pain-free flat foot

A

no Tx!

260
Q

Tx of a painful flat foot

A

medial heel lift

261
Q

Tx of a persistently painful flat foot

A

fusion of the subtalar joint

- disturbs foot and ankle function

262
Q

what are bunions?

A

fluid filled bursae that are found around bony prominences which for in response to pressure and indicate underlying abnormality

263
Q

what are corns?

A

another way (as well as bunions) that the body reacts to areas of high pressure

264
Q

what does the term ‘hallux’ refer to?

A

the big toe

265
Q

hallux valgus and hallux rigidus are conditions of which joint

A

the first MTP joint

266
Q

define ‘hallux valgus’

A

the turning away of the phalanges of the big toe from the mid-line

267
Q

define ‘hallux rigidus’

A

OA of the first MTP joint

268
Q

hallux rigidus and hallux valgus always occur separately - T/F?

A

False - they can occur separately or together

Tx depends on whether one or both are present, and the age of the patient

269
Q

what age group does hallux rigidus occur in

A

adolescents and adults (rarely seen without hallux valgus in the elderly)

270
Q

what is the main probable cause of hallux rigidus in adolescents

A

osteochondral fracture (not always easy to prove)

271
Q

Mx of hallux rigidus in adolescents

A

Metatarsal bar

  • a rocker at the front of the foot so the toes don’t bend during walking
  • usually fails due to cosmetic compliance issues

Surgery

  • removal of osteophytes with osteotomy
  • fusion in a neutral position
  • interposition arthroplasty with a silastic spacer - alternative with mixed results
272
Q

Mx of hallux rigidus in adults

A

Surgery

  • removal of osteophytes with osteotomy
  • fusion in a neutral position
  • interposition arthroplasty with a silastic spacer - alternative with mixed results
273
Q

what age group does hallux valgus occur in

A

it can occur at any age

274
Q

what is the cause of hallux valgus

A

the cause is unknown!

275
Q

Mx of hallux valgus

A

Dependent on age

Any age
- realignment of the 1st metatarsal to a more lateral position and excision of bony prominence

Only in adults, avoid in young
- Keller’s procedure: excision of the MTP joint

276
Q

why is hallux valgus usually found with hallux rigidus in the elderly?

A

joint degeneration (rigidus) usually develops secondary to the valgus deformity

277
Q

Mx of hallux valgus with rigidus

A

1) well-fitting extra depth shoes

2) Keller’s arthroplasty

278
Q

define ‘claw foot’

A

wasting of small muscles of the feet make the bones and toenails more prominent - like a dogs foot

279
Q

what condition is claw foot often associated with

A

spina bifida occulta

280
Q

what is the cause of ‘hammer toes’

A

occur secondary to the disruption (prolapse) of the MTP joints - primary cause of this is unknown

281
Q

how do people with hammer toes often present

A

generally sore forefeet - metatarsalgia

282
Q

Tx of hammer toes

A

1) good pair of comfortable shoes is often all that’s required
2) fusion of the interphalangeal joints in a straight position

283
Q

what are neuromas?

A

irritation of the cutaneous nerves to the toes between the metatarsal heads

284
Q

causes of a neuroma

A

secondary to repetitive trauma

285
Q

Presentation of a neuroma

A
  • dull and throbbing pain with sharp exacerbations
  • tingling of the toes
  • poorly localising
  • sideways compression of the foot produces a palpable click, reproducing the symptoms
286
Q

Tx of a neuroma

A

excision

  • may cause sensory disturbance of the toes
  • recurrence is common
287
Q

what are ingrowing toenails often associated with?

A

poor nail care

288
Q

what are the consequences of ingrowing toenails?

A
  • digging in of the curved nail into the nail fold
  • secondary infection of the nail fold due to trauma
  • secondary blood borne infections
289
Q

Mx of ingrowing toenails

A

Control
- careful nail care and straight cutting

Definitive treatment
- nail removal, and nail bed removal using phenol

290
Q

what is plantar fascia?

A

tough layer of fibrous tissue running from the os calcis to each toe base

291
Q

define ‘plantar fasciitis’

A

a number of vague, but very painful and incapacitating disorders of the plantar fascia, with unknown cause and sudden onset

292
Q

presentation of plantar fasciitis

A
  • sore instep, worse in the morning
  • relieved by walking, but persists as a dull ache
  • pain is exacerbated by a change in direction, or walking on rough ground
293
Q

how often do symptoms of plantar fasciitis usually last

A

a few months, or even years

- most cases settle spontaneously

294
Q

Tx of plantar fasciitis

A

no specific cure - Tx relief

  • insoles hollowed out under the tender area
  • soft shoes
  • local injection of steroids if marked tender point
  • long acting local anaesthetic
295
Q

define the term ‘‘neuropathic feet’

A

loss of sensation in the feet due to disease

296
Q

what are neuropathic feet more prone to?

A

sores - due to inability to perceive trauma

297
Q

what is the insertion point of the achilles tendon

A

the os calcis

298
Q

what 2 groups of people is achilles tendinitis most commonly seen in

A

young athletes

middle aged men

299
Q

cause of achilles tendinitis in young athletes

A

over-use

300
Q

Tx of achilles tendinitis in young athletes

A

1) rest

2) surgical decompression of the tissue surrounding the tendon

301
Q

cause of achilles tendinitis in middle aged men

A

the lower part of the achilles tendon has a poor bloody supply and is a point of weakness in some people who are active into middle age

302
Q

Tx of achilles rupture in middle age

A

1) equinus plaster for 8 weeks minimum
2) suturing of tendon (high complication risk)
3) wear a felt raise inside shoe for as long as possible after treatment to decrease chance of re-rupture

303
Q

what causes a ‘painful arc’ in shoulder movement

A

inflammation of the supraspinatus tendon

304
Q

Tx of a painful arc

A

rest, gentle exercise and anti-inflammatories

305
Q

what is ‘frozen shoulder’

A

a condition where there is little or no glenohumeral movement

306
Q

frozen shoulder can occur rarely after which type of incident

A

specific trauma incident, e.g. epileptic fit or shock

307
Q

outer membrane of bones

A

periosteum

308
Q

main aims of early management of a fracture

A
  1. minimise effects of blood loss

2. reduce pain

309
Q

2 main reasons for taking a history after trauma

A

clinical and medico-legal

310
Q

what 5 main questions must be asked during a trauma history

A
  • what happened
  • how did it happen
  • where and when
  • what was the injured person like before it happened
  • who is the person
311
Q

what are the 7 main signs of a fracture

A
  1. pain
  2. deformity
  3. tenderness
  4. swelling
  5. bruising
  6. loss of function
  7. crepitus
312
Q

what determines the positions of the proximal fragment and the distal fragment in a fracture?

A

proximal fragment - determined by the muscles

distal fragment - determined by gravity

313
Q

what is the most important first aid Tx in fractures

A

elevation of the injured part to reduce the swelling by helping fluid to drain

injured arm - elevate above heart
injured leg - lying down with elevation above chest

314
Q

explain the colouring of bruises as they age?

A

1) dark - deoxygenated blood loss into the soft tissues

2) green to yellow - the haemoglobin in the RBC is broken down and carried to the liver by scavanger cells

315
Q

what tissues, other than bones, are often involved in injuries to the limbs

A 
skin 
fat
muscle 
blood vessels 
nerves
316
Q

what 5 investigative techniques are commonly used to confirm fractures

A

1) x-ray
2) tomograms
3) Computerised axial tomography (CAT scan)
4) USS
5) radioisotope scanning

317
Q

main Ix for fractures

A

x-ray (sagittal and coronal views)

318
Q

what is a tomogram

A

an Ix technique that uses electronic detectors to view a “slice” through a body part

319
Q

when are tomograms useful

A

when there are many overlapping structures and the area is difficult to see

320
Q

what is a CAT scan

A

modern version of a tomogram, where tomograms are generated onto video screen

321
Q

when is USS used in Ix fracture

A

to show the accumulation of fluid (especially blood)

322
Q

when is radioisotope scanning used in Ix a fracture

A

where there is clinical doubt whether a bone is fractured or not, especially in injuries that are not acute

323
Q

explain what is involved in radioisotope scanning

A
  • radioactive substance injected
  • attaches to phosphate molecules that are taken up by bone
  • xray plate is placed under the affected part
  • the more metabolically active the bone is, the faster it takes up the radioactive substance
  • sites of high metabolic activity i.e. at the fracture will be seen on the radiograph
324
Q

what 8 features are necessary to describe a fracture

A
  1. which bone is broken
  2. which side of the bone
  3. is it open or closed
  4. where on the bone is it broken
  5. what shape is the fracture
  6. how many fragments
  7. what is the position of the distal fragment
  8. could it be pathological
325
Q

what 3 factors describe a distal fragment relative to the proximal one in a fracture?

A
  1. displacement (anterior, posterio, medial, lateral)
  2. angulation (anterior posterior, valgus, varus)
  3. Rotation (internal or external)
326
Q

how is immediate pain relief in a fracture achieved?

A
  1. drugs - morphine or pethidine injections

2. splintage - a device which holds a fracture steady

327
Q

what is the main requirement of a splint?

A

must encompass above and below the injured joint

328
Q

what can be used as an alternative to splintage in immediate pain relief in fracture

A

traction

329
Q

in what fractures sites is blood loss most significant

A

major long bones - particularly femur and tibia to a lesser extent

unstable pelvic fractures

330
Q

how much blood can be lost in a femoral fracture

A

2-3 units

331
Q

how much blood can be lost in a tibial fracture

A

1 unit

332
Q

how much blood can be lost ina major pelvic fracture

A

6 units

333
Q

what immediate management should be given in major long bone or pelvic fractures to help with blood loss

A

cross matching

venous line for transfusion should be established as soon as possible

pelvic fractures: 2 lines and a central venous line so that transfusion iskeeping up with loss

334
Q

what is the immediate management of an open fracture

A
  • surgery
  • removal of debris and dead tissue to prevent the contamination of bone becoming an infection
  • leave wound open for a few days so that closure can be achieved without any tension on the skin
  • give broad spec ABx
335
Q

what does the term ‘definitive Mx’ of a fracture mean

A

the technique used (after bleeding and pain have been controlled) to restore normal function to the injured part of the body

336
Q

is a ‘perfect result’ always the aim in fixing fractures?

A

no -benefits must outweigh risks in Tx strategy

in an older person, perfect function may only be achieved at the expense of risk of complication

337
Q

name for the process where a fracture is returned to normal position

A

reduction

338
Q

name for the process where a fracture is held in its normal position whilst healing

A

holding

339
Q

what are the two types of reduction and explain them

A
  1. closed reduction
    - traction on the distal fragment then manipulation of the fragment back onto the proximal fragment
  2. open reduction
    - done if closed reduction is unsuccessful
    - fracture site is opened and fragments are relocated under vision
340
Q

list the 4 types of method for holding fractures in place

A
  1. casting
  2. external fixation
  3. internal fixation
  4. traction
341
Q

what is the main requirement of a cast?

A

immobilise the joints above and below the fracture site

342
Q

how does a cast work?

A

acts as a splint. controls joint movement therefore can control posture. exerts pressure at 3 points so holds the fractured bone in the correct position

343
Q

disadvantages of casts

A
  • heavy
  • immobilise the joints
  • can’t examine covered part or use x-ray
  • costly and inconvenient
  • result in muscle wasting and stiffness
344
Q

what method is used to overcome the disadvantages of casting

A

Functional bracing - free the joints. permit motion in one direction

345
Q

what is a disadvantage of functional bracing

A

very dependent on an extremely accurate fit - so can’t be used immediately after fracture when there is swelling

346
Q

what are the properties of modern casting materials

A
  • stronger and lighter than plaster of paris
  • glass fibre and polyurethane resin combinations
  • used as secondary casts 1 or 2 weeks after injury
347
Q

what type of cast is modern casting materials ideal for?

A

cast bracing - a cast that is broken up with a hinge in the middle

348
Q

when is external fixation appropriate as a holding technique in fracture healing

A

high energy fractures with soft tissue damage - provides stability of bones and allows access to soft tissues for dressings and grafts etc

349
Q

can fractures be fixed definitively with external fixation?

A

potentially - if the fixator can be adjusted to permit movement in the later stages, although pin sites are an easy route for infection

350
Q

what is internal fixation

A

the holding of a fractured bone using screws, nails or plates

351
Q

when is internal fixation appropriate as a holding technique in fracture healing

A
  • high level of accuracy required

- other methods have failed

352
Q

list the possible ways which internal fixation may be used in fracture holding

A
  • apposition
  • interfragmentary compression
  • interfragmentary compression with onlay device
  • inlay device
353
Q

describe the method of apposition in internal fixation

A

holds the fracture together in alignment using K-wires
still mobile, so fracture heals by natural callus formation
can be easily pulled out when union is established

354
Q

describe the method of interfragmentary compression in internal fixation

A

holds two bone fragments firmly together by screws

355
Q

describe the method of interfragmentary compression with onlay device in internal fixation

A

an onlay device (plate of metal) provides extra support to the screws in interfragmentary compression

356
Q

what is a disadvantage of onlay devices

A

inhibit natural bone union and delay healing

357
Q

what are inlay devices

A

intramedullary devices (normally screws) used in internally fixing fractures

358
Q

advantage of using inlay devices as method of internal fixation

A

achieve correct alignment of bones without disturbing natural bone healing

high strength means they are ideal for long bone fractures

359
Q

disadvantage of using inlay devices as method of internal fixation

A

relatively innacurate method of restoring anatomical position so can’t be used around joints

360
Q

explain in general terms how traction functions as a method for holding a fracture in place

A

applying a relatively small weight to a limb exerts a pull along the axis of the broken limb which stimulates the muscles to contract and hold a broken bone in position

361
Q

different types of traction as a fracture holding method

A
  1. static
  2. balanced
  3. dynamic
362
Q

what is static traction

A

the pull is applied against another part of the body - used for short periods

363
Q

example of static traction?

A

Thomas splint - the pull is applied against a ring which presses against the pelvis

364
Q

what is balanced traction

A

the pull against the ring (and thus the pelvis) is balanced by a weight attached to the whole splint, which takes the pressure off the skin round the ring whilst maintaining traction of the leg

365
Q

when is balanced traction used

A

when static traction is in danger of causing damage to the body by the pressure

366
Q

what is dynamic traction

A

weights provide the pull and the counter force is achieved by tilting the bed

367
Q

what is main purpose of traction

A

short-term pain relieving measure by changing muscle tone and relieving spasm

368
Q

give the general timeline of a bone healing process

A

1-2 weeks : swelling

2-6 weeks : callus formation

6-12 weeks : bone forming

6-12 months : bone formed

1-2 years : bone returns to normal

369
Q

movement in which direction stimulates healing in a broken bone?

A

micromovement directed along the long axis of the bone at right angles to the break

370
Q

if bones are rigidly fixed, will they still heal?

A

yes, but will do so slowly

371
Q

what is a ‘primary’ complication of a fracture

A

occurs as a consequence of injury

372
Q

what is a ‘secondary’ complication of a fracture

A

occurs as a consequence of treatment

373
Q

list the early primary complications of fracture

A 
blood loss
infection 
fat embolism 
renal failure
soft tissue injury 
compartment syndrome
374
Q

Mx of a stable fixed fracture with infection

A

will still heal despite infection, can be temporarily treated by drainage of pus and by antibiotics until union has occurred

375
Q

Mx of an unstable open fracture, or an unstable fixed fracture with infection

A

stabilisation by external fixation and surgical wound cleansing with later bone grafting

376
Q

what is the cause of fat embolism as an early primary consequence of fracture

A

unclear - thought to be a generalised abnormal response to injury

377
Q

typical presentation of a fat embolism after fracture

A
  • long bone fracture in male < 20 years old
  • 2-5 days post inury j
  • rapid and shallow breathing
  • mild confusion
  • rash on chest and back
378
Q

what type of fracture injuries make people more prone to developing kidney failure

A

massive soft tissue injury and trapped for prolonged periods, where the trapped limbs are starved of oxygen

379
Q

what is compatrtment syndrome

A

excessive localised soft tissue swelling

380
Q

pathophysiology of compartment syndrome

A
  • thick layers of fibrous sheath separate muscle groups creating compartments
  • when fracture occurs there is bleeding into adjacent compartments and causes increased pressure and swelling
  • there is decreased blood flow to the muscles as a result
  • results in ischaemia
381
Q

symptoms of compartment syndrome

A
  • pain out of proportion to injury
  • loss of muscle functioon
  • altered sensation over compartment
  • pulse distal to compartment is normal
382
Q

how is diagnosis of compartment syndrome made

A

stretch the muscle to precipitate extreme pain

383
Q

treatment of compartment syndrome

A
  • remove dressings and plasters

- if persists, surgical decompression is required

384
Q

list the early secondary complications of fracture

A 
plaster disease
renal stones
immobility 
infection 
compartment syndrome
385
Q

what is ‘fracture disease’

A

combination of musele wasting, stiffness and skin sores due to immobilsation of a fracture in a plaster

386
Q

what are some consequences of immobilisation of a fracture

A 
osteoporosis 
renal stones (caused by calcium from the thinning bone)
stiffness 
muscle wasting 
skin sores
387
Q

list the late primary complications of fracture

A 
non-union
delayed union 
mal-union 
growth arrest 
arthrits
388
Q

list the late secondary complications of fracture

A

mal-union

infection

389
Q

causes of fracture non-union

A 
excess or too little movement 
soft tisse between bone ends 
poor bloody supply 
infection 
excessive traction
390
Q

when is non-union said to have occured

A

20 weeks in lower limb (usually takes 12 weeks)

10 weeks tin he upper limb (usually takes 6 weeks)

391
Q

what is delayed union

A

a period betwene expected union and accepted non-union when the decision to do something is contemplated

392
Q

Tx of non-union

A

remove any underlying cause

stimulateunion by stabilisng the fracture and ading a bone graft

393
Q

what is mal-union

A

the fracture has healend i a position that precludes normal function

394
Q

causes ofal m-union

A

failure of treamtnet method
neglect of surgeon
failure to attend out-patient clinic

395
Q

Tx of malunion

A

open reduction and internal fixation

396
Q

what is growth arrest

A

whena fracture breaches the germinal layer of the epiphyiseal growth platre nd bone growth arrests, resulting in deformity

397
Q

why can arthritis develop at a fracture site

A

if the joint is excessivley stressed

BMSc (6 decks)

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