Orthopaedic Red Flags

Question 1

What usually happens in avascular necrosis of the scaphoid?

Answer 1

Normally, fracture demineralises

Can see change on x-ray quite quickly

Question 2

How can you tell there is avascular necrosis of the scaphoid on plain film?

Answer 2

Proximal pole quite dense

Question 3

What fracture of the wrist is common with a fall on outstretched hand?

Answer 3

Scaphoid fracture

Question 4

If you do not see a fracture on plain x-ray after a fall on outstretched hand, what modality do you use to image, and what does it show?

Answer 4

CT scan

Can show displacement

Question 5

What is the gold standard for scaphoid fractures?

Answer 5

MRI

Question 6

What used to be done for suspected scaphoid fractures that were not visible on x-ray?

Answer 6

Splint wrist > re-x-ray in a week

Question 7

Is a bone scan useful in detecting a scaphoid fracture?

Answer 7

Not immediately

Question 8

How long do scaphoid fractures take to heal?

Answer 8

In cast, 90% heal in 6 weeks

Question 9

What are the potential complications of a scaphoid fraacture?

Answer 9

Avascular necrosis
Non-union scaphoid > osteoarthritis = SNAC wrist
Non-union scaphoid > sometimes persistent pain

Question 10

What is a SNAC wrist?

Answer 10

Scaphoid
Non-union
Advanced
Collapse

Question 11

What is a Colles fracture?

Answer 11

Fracture of distal radius with dorsal and radial displacement of wrist and hand

Question 12

In what sort of injury is a Colles fracture common?

Answer 12

Fall on outstretched hand

Question 13

Why is it a bad sign if the ulnar is also involved in a Colles fracture?

Answer 13

Instability ++

Question 14

What are the options for anaesthesia for manipulation and plaster of a Colles fracture?

Answer 14

Bier block > highly dangerous
Prolocaine
Intra-haematomal block
Sedation

Question 15

In what position is a Colles fracture immobilised?

Answer 15

Flexion and ulnar deviation

Question 16

What is the sail, or rosethorn, sign?

Answer 16

Elevation of anterior fat pad in elbow, visible on x-ray

Because haematoma pushes it out

Question 17

In what fracture is the sail sign seen?

Answer 17

In children, commonly with supracondylar fracture

In adults, commonly with radial head fracture

Question 18

What happens if a displaced radial head fracture is missed?

Answer 18

Malunion

Affects pronation and supination

Question 19

Why is a radial head fracture not put in a cast?

Answer 19

Oedema can’t escape > fibrous deposit

Question 20

What is done with a radial head fracture for comfort?

Answer 20

Put in sling

Later, get them to flex and extend elbow

Question 21

What clinical findings in a suspected radial head fracture might you expect, which would encourage you to investigate further in the absence of diagnostic x-rays?

Answer 21

Tenderness of radial head
Intense pain due to tense haemarthrosis
Not much swelling because haematoma contained

Question 22

In what sort of dislocation of the shoulder can an x-ray look normal?

Answer 22

Posterior dislocation

Question 23

What is the lightbulb sign?

Answer 23

Abnormal AP radiograph appearance of humeral head in posterior shoulder dislocation
Looks like light bulb

Question 24

What is the lesion common after recurrent anterior dislocations of the shoulder?

Answer 24

Hill-sachs lesion = posterolateral humeral head compression fraction

Question 25

What is the lesion common after recurrent posterior dislocations of the shoulder?

Answer 25

Reverse Hill-Sachs lesion = McLaughlin lesion = impaction fracture of anteromedial humeral head

Question 26

What is chondromalacia patellae?

Answer 26

= “Runner’s knee”

Cartilage on under-surface of kneecap deteriorates and softens

Question 27

What are the symptoms of chondromalacia patellae?

Answer 27

Common in young, athletic people
Episodic pain
Inability to sit with knees flexed for long time without extending
Self-limiting

Question 28

What is a sun-raised spicule on plain x-ray a sign of?

Answer 28

Osteosarcoma

Question 29

What causes a sun-raised spicule?

Answer 29

Periosteum trying to heal

Question 30

Why is septic arthritis an orthopaedic emergency?

Answer 30

Pus very corrosive > destroys articular cartilage

Question 31

What are the principles of treatment of septic arthritis?

Answer 31

Drain and wash out joint
Identify organism
Appropriate Abx

Question 32

What associated features should you look for with sacral fractures?

Answer 32

Disruption of pelvic girdle

Question 33

What sort of neck of femur fractures should can be difficult to see on the A-P view of the pelvis? What should you do?

Answer 33

Impacted, undisplaced neck of femur fractures
Check trabecular lines
Consider further imaging

Question 34

What other site should you check in an elderly or osteopaenic patient with hip pain after a fall?

Answer 34

Pubic rami, especially if no neck of femur fracture

Question 35

What tibial fractures can be subtle?

Answer 35

Fractures of tibial plateua, especially if margins of plateau not displaced

Question 36

What clavicular injury can be fatal?

Answer 36

Dislocation of medial end

Question 37

How are dislocations of the medial end of the clavicle diagnosed?

Answer 37

Can’t diagnose with x-ray

Have to get CT

Question 38

What should you consider in a 11-13 year-old child who has had a limp for 4-5 days?

Answer 38

Slipped upper femoral epiphysis

• Common in males
• Commin in Pacific Islanders
• Surgical emergency

Question 39

What is a slipped upper femoral epiphysis?

Answer 39

Capital epiphysis not yet fused

Get stress fracture through it