Orthopaedics Flashcards
What is a positive Hoffman’s Sign
What does it indicate
Flexion of thumb and DIP of tested finger, signifies cervical compression
What does Scarf test look for
Acromioclavicular Joint pain
Why does the Medial knee predispose to compartment arthritis
Takes on more pressure than the lateral side
List 2 specific signs of patellar dislocation
Palpable gap between quadriceps and Patellar tendon
Unable to straight leg raise
Why can knee dislocations be very dangerous
Popliteal artery fixed in Politeal fossa and Adductor hiatus
Common Peroneal nerve injured in 1/4 of cases
List the 2 most common organisms causing knee and prosthetic infections
Staph aureus
Coagulase negative Staph
List key Qs to ask if knee pain
Duration and progression
How far can walk
Any night pain? Waking?
Painkillers?
How is Hallux Rigidus treated?
Conservative management
If necessary, Arthrodesis
Why aren’t Arthroplasties done often to treat bunions, arthritis etc?
Shortens toe, and develops across midfoot instead
Flat feet is normal in children but not in adults.
What are 3 features of it?
Progressive deformity
Uncommon to have history of trauma
Pain behind Medial Malleolus
Outline treatment of Flat feet
Conservative, Stiff insoles, PhysioT
If Flexible, reconstruct
If stiff, Arthrodesis
Which ankle ligament is most prone to damage?
How long does a tear take to heal?
Anterior talofibular
12mths
What is DAIR?
What is it used for
Debridement Antibiotics and Implant Retention
Used for Peri-prosthetic Joint Infection (PJI)
What is Shenton’s Line on a Pelvic X-ray?
How should it appear?
An imaginary curved line along the inferior border of the superior pubic ramus and along the inferomedial border of the NOF
Should be continuous and smooth
What are 2 conditions an abnormal Shenton’s line can indicate?
Fractured NOF
Developmental Dysplasia of Hip
What are the 3 sources of blood supply to the talus
Risk of Avascular necrosis after fracture
Posterior tibial artery (majority)
Anterior tibial artery (may be only undamaged source after displaced fracture)
Perforating Peroneal/ Fibular artery
Actions of Tibialis Posterior?
Inversion
Plantarflexion
Maintains medial arch of foot
List signs of Charcot-Marie-Tooth
Peroneal Muscular Atrophy, PMA
- Cavovarus feet
- Claw foot deformities
- Scoliosis
- Muscle weakness + Sensory changes
Outline Silfverskiold Test
What is its purpose?
Purpose: Distinguish Gastrocnemius from Soleus contracture
- Assess DFlexion with Hip + Knee extension
- Assess DFlexion with Hip + Knee Flexion
- If improvement, Gastrocnemius contracture present
Compartment syndrome is defined as a critical pressure increase within a confined compartmental space
Which fascial compartments are most commonly affected
Thigh, Leg, Foot
Forearm, Hand
Buttock
Compartment syndrome can be caused by Trauma/ Crush injuries/ Fractures causing vascular injury
Other causes are Iatrogenic, Tight casts/ splints, DVT and post-reperfusion swelling
Outline what the Pathophysiology of Compartment Syndrome
As intra-compartmental pressure rises, veins compressed-> High Hydrostatic pressure causing fluid to move out, increasing IC Pressure more
Traversing nerves compressed-> Sensory +/- Motor deficit distally
As IC Pressure reaches Diastolic BP, Arterial inflow compromised-> Ischaemia (Late stage)
How does Compartment syndrome present
Symptoms tend to present within hours, but can take upto 48hrs to present
Severe pain, disproportionate to injury- Not improved by Analgesia/ Elevation/ Splitting a tight cast
Pain made worse by passively stretching muscles in compartment
Parasthesia distally
Compartment may feel Tense, but not swollen
Late stage: Leg ischaemia (5Ps)
Outline investigations for Compartment Syndrome
Clinical- Based on Symptoms and RFs
IC Pressure Monitor (If uncertain, or pt unconscious/ intubated)
CK level may aid diagnosis
Outline INITIAL Compartment Syndrome Management
Keep limb at neutral level (No elevation or depression)
High flow O2, Opioid Analgesia (usually IV)
IV Crystalloids Fluid Bolus (improves perfusion)
Remove all Dressings/ Splints/ Casts
Outline DEFINITIVE Compartment Syndrome Management
Urgent Fasciotomy, w/ incisions left open
Re-look after 24-48hrs to look for + remove dead tissue
Wound then closed, but subtending fascia left open
Monitor Renal Function for signs of Rhabdomyolysis or Re-perfusion Injury
List the 4 radiological features of OA
Reduced joint space
Osteophytes
Subchondral Cysts
Subchondral Sclerosis
Outline Conservative OA Management
Joint protection
Strengthening + Exercise, Weight loss
Heat/ Ice packs
Joint Supports
PT
Outline Medical OA Management
Simple Analgesia + Topical NSAIDs
Intra-articular Steroid injections, if pain remains
Outline Surgical OA Management
Osteotomy
Arthroplasty
Arthrodesis
In what ways can outcomes of an open fracture be considered?
Skin – Very small wound to significant tissue loss, where plastic surgery needed (Graf or local/free flap)
Soft tissues – Very little tissue devitalisation to significant muscle/tendon/ligament loss, needing reconstructive surgery
Neurovascular Injury – N/V may be compressed due to limb deformity, Go into arteriospasm, develop intimal dissection or be transected altogether
Infection – Very high rate due to direct contamination, reduced vascularity, systemic compromise, insertion of metalwork for fracture stabilisation
Outline Examination and Investigations for Open Fractures
Examination;
- NV Status, Skin/ tissue loss
- Evidence of contamination
Basic Bloods- Including Clotting and Group + Save
X-ray
CT can help, if Comminuted/ Complex fracture
Outline Initial Management of Open Fractures
Resuscitation + Stabilisation
Urgent Realignment + Splinting
Broad Abx, Tetanus vaccine if needed
Remove debris + Take Photo of wound
Dress wound with saline-soaked gauze
Outline Definitive Management of Open Fractures
Debridement of wound + fracture site (Debris an dead tissue)
Wound Washout with Saline
Ensure skeletal stabilisation
If soft tissue coverage needed, do <72hrs or as guided by plastic surgeon
If vascular injury, immediate surgical exploration
List the main causative organisms of Septic Arthritis
S. aureus (more common in adults)
Strep species
Gonorrhoea (more common in Sexually active)
Salmonella (more common in Sickle Cell pts)
How may Bacteria ‘seed’ to the joint?
From;
- Bacteraemia (Cellulitis, UTI, Chest infection)
- Direct Inoculation
- Spread from adjacent Osteomyelitis
How can Septic Arthritis progress
Can cause permanent Articular Cartilage damage leading to Severe OA
List RFs for Septic Arthritis
Age >80, Chronic renal failure
DM, Immunosuppression, IV Drug use
Pre-existing joint disease (E.g RA)
Hip/ Knee Joint Prosthesis
How may Septic Arthritis present?
Features moe obvious in Native Joint vs Prosthetic Joint infection
Pyrexia in 60% of cases
Single swollen joint-> Severe pain
O/E;
- Red, Swollen, Warm. Possible Effusion
- Pain on Active/ Passive movement
Unable to weight bear or tolerate passive movement
List Ddx for Septic Arthritis
OA Flare, RA, Reactive Arthritis
Haemarthrosis
Crystal Arthropathies
Lyme disease
Outline non-imaging Investigations for Septic Arthritis
Bloods: FBC, CRP, ESR, Urate etc Blood culture (At least 2 separate samples)
Joint aspiration before Abx; (unless septic)
- If Prosthetic joint, only done in OR
Joint fluid analysis sent for Gram stain, WCC, Microscopy, Fluid culture
Outline Imaging Investigations for Septic Arthritis
X-ray of joint;
- Early stages: May not be any evidence of disease
- Progression: Capsule + Soft tissue swelling, Fat pad shift, Joint space widening
USS can be useful to guide joint aspiration + drainage
Rarely, CT/ MRI: Used if uncertainty or assessing specific joint infections for spread into Pelvis/ Mediastinum
Outline Management of Septic Arthritis
Abx (Flucoxacillin);
- ASAP, after planned Cultures + Aspirates taken
- Usually for 4-6wks, normally IV for first 2wks
Native joints;
- Irrigation + debridement (washout) in theatre
Prosthetic joints;
- Washout still needed, but revision surgery needed
Reduction involves restoring the anatomical alignment of a fracture or dislocation.
Reduction allows for what 4 things?
Tamponade of bleeding at the fracture site
Reduction in the traction on the surrounding soft tissues-> less swelling
Reduction in the traction on the traversing nerves-> less risk of neuropraxia
Reduction of pressure on traversing blood vessels, restoring any affected blood supply
How may Fracture Reduction be performed?
Typically performed closed in emergency setting
Some are reduced open or intra-operatively
Outline the Clinical Requirements for Fracture Reduction
Analgesia;
- Regional/ Local blockade if possible
- More commonly, Conscious Sedation by A&E
Specific manoeuvre requires;
- 1 person to perform reduction manoeuvre
- 1 person to provide counter-traction
- 1 person to apply plaster
Fracture Holding means immobilising a fracture
Outline this
Consider if traction needed- Muscular pull may mean instability of fracture
Simple splints or Plaster casts;
- For 1st 2wks, Plasters not circumferential (Not always case in children)
- Allows fracture to swell, preventing Compartment Syndrome
If Axial Instability (Can rotate along long axis);
- Plaster should cross both the joint Above+Below
Metastatic spread from other cancer types is the most common cause of bone cancer, the most common primary sites being renal, thyroid, lung, prostate, and breast.
The most common site for a bony metastases is what?
The spine
What is Osteomyelitis?
Which bones are mostly affected in adults and children?
Bone infection
Adults: Hips, Spine, Feet
Children: Arm+Leg bones
What can happen in Chronic cases of Osteomyelitis
Devascularisation of bone-> Necrosis and resorption of surrounding bone
This leads to a SEQUESTRUM (‘floating piece’ of dead bone), which acts as a reservoir for infection and isn’t reached by Abx as it is avascular
An INVOLUCRUM can form, where a region becomes encased in Periosteal new bone
List Osteomyelitis RFs
DM
IV Drug use, Immunosuppression
Alcohol excess
Recent fracture, Recent surgery
Bone prosthesis
Foot infection frequently occurs in DM pts, increasing risk of Osteomyelitis.
How is any suspected cases investigated
MRI
Suspect Osteomyelitis in any DM pt with Deep/ Chronic foot infection
How can Osteomyelitis present
Low grade Pyrexia
Severe pain in affected region (Maybe not in DM pts as Neuropathy);
- Constant, can be worse at night
O/E;
- Site tender, Swollen, Red
- Unable to weight bear
- Look for infection sources
Outline Osteomyelitis investigation
Basic Bloods, Blood culture
X-rays often used, but poor accuracy (signs only visible 7-10 days post-infection)
Definitive diagnosis: MRI
Gold standard: Culture from Bone biopsy at Debridement
How is Osteomyelitis managed?
IV Abx (> 4wks), if clinically well
If clinical deterioration/ progressive bone destruction, Surgical management involving Curettage of area
Most common site of shoulder fractures is where?
What’s the most common cause?
Proximal humerus
Low energy injuries: Elderly people falling onto outstretched hand, mainly in Osteoporosis
List RFs for Shoulder Fracture
Female, Early menopause
Prolonged steroid use
Recurrent falls, Fraility
How may Shoulder Fractures present
Pan around Upper Arm + Shoulder
Restriction of arm movement
Unable to abduct arm
O/E: Major shoulder Swelling + Bruising, can spread to Chest and down the Arm
Outline Investigations for Shoulder Fractures
Check NV Status, as close relationship with Axillary nerve + Circumflex vessels
Bloods;
- Including Coag, Group+Save
- If pathological cause suspected, Serum Ca + Myeloma screen
X-ray: AP, Lateral Scapular and Axillary views
CT: Pre-op planning/ if Humeral segments unclear
Outline the Gustilo-Anderson System
To classify Open Fractures
Type 1: Clean Wound <1cm
Type 2: Clean Wound 1-10cm
Type 3A: High-energy >10cm wound, adequate soft tissue coverage (Ortho input only)
Type 3B: High energy >10cm wound, inadequate soft tissue coverage (Plastics input also)
Type 3C: Any injury w/ Vascular Injury (Vascular input also)
Outline the Neer Classification system
To characterise Prox Humeral fractures, based on relationship between 4 segments of Prox Humerus;
- Greater tuberosity
- Lesser tuberosity
- Anatomical Neck (Articular segment)
- Surgical Neck (Humeral shaft)
Considered separate if >1cm displacement between segments OR if >/= 45º Angulation
Most Prox Humeral fractures can be managed Conservatively.
Outline those
Immobilisation w/ Early Mobilisation
Polysling allowing arm to hang (Gravity aids reduction of fragments of most Humeral fractures)
List Surgical Management options of Prox Humeral fractures
Indicated if: Displaced/ Open/ NV Compromised fractures
Inter-Medullary Nailing or ORIF, Open Reduction Internal Fixation
Hemi-arthroplasty
RSA, Reverse Shoulder Arthroplasty
(Involves total shoulder arthroplasty where Ball+Socket portions of joint are reversed)
Outline indications of ORIF and Inter-medullary Nailing for Prox Humeral fracture management
ORIF;
- Pts with multiple segment injuries
- Preferred in a Head splitting fracture
IM Nailing;
- If fracture involves Surgical Neck
- If fracture combined w/ Humeral Shaft fracture
Outline indications for Hemi-arthroplasty for Prox Humeral fracture management
Complex injuries
Injuries that include splitting of Humeral Head and are likely to have major complications if ORIF used to treat
Outline indications for RSA, Reverse Shoulder Arthroplasty for Prox Humeral fracture management
Low demand pts
Pts needing revision after failed previous procedure
List complications of Prox Humeral fractures
Reduced RoM- Extensive PT needed to regain function and reduce pain
Humeral head Avascular Necrosis (RSA or HA may be needed)
Why are Scapular Fractures rare?
Protection by surrounding muscles
Associated with high energy trauma
How are Scapular Fractures treated?
(Patients can expect good results with no functional deficits after nearly all nonoperative cases and in 70% of surgical cases)
Majority: Non-operative re-alignment
ORIF if;
- Glenohumeral instability
- Displaced Scapular neck
- Complex fracture patterns
When may you get Floating Shoulder in Scapular Fracture cases?
Scapular Neck Fracture w/ Clavicle Neck fracture
Almost always needs fixation
List Humeral Shaft Fracture RFs
Osteoporosis, Previous fractures
Increasing age
How may Humeral Shaft Fractures present?
Pain, Deformity
If Radial Nerve involved (high chance), reduced Wrist Extension and Sensation in radial distribution
What is a Holstein-Lewis Fracture
Requires surgical management
Fracture of distal 1/3 of humerus-> Radial nerve entrapment
Signs of Radial Nerve neuropraxia (Wrist drop and Reduced sensation)
Outline Investigations for Humeral Shaft Fractures
AP + Lateral X-rays
If severely comminuted, CT for pre-op planning
Outline Humeral Shaft Fracture Conservative Management
Use if <20º Ant angulation, <30º Varus/ Valgus angulation and with <3cm of shortening
Humeral brace
Regular follow-up with repeated X-ray imaging
Outline Surgical Management of Humeral Shaft Fractures
ORIF with a plate
Consider Intra-medullary Nailing if;
- Pathological features
- Polytrauma
- Severe Osteoporosis
Outline the Allman classification system
Type 1: Middle 1/3 Clavicle fracture, 75% of cases
- Generally stable, major deformity
Type 2: Lateral 1/3 Clavicle fracture, 20% of cases
- Often unstable
Type 3: Medial 1/3 Clavicle fracture, 5% of cases
- NV Compromise, Pneumo/ Haemo- thorax
How may Clavicle Fractures present
Sudden severe pain, worse on active movement
O/E: Focal tenderness, Deformity+Mobility at site
Outline Investigations for Clavicle Fractures
Look for open injuries/ threatened skin (Tented, Tethered, White, Non-blanching skin)
Check NV Status (Brachial Plexus injuries)
AP + Modified-axial X-rays
CT: May be used for Medical Clavicle injuries
Most Clavicle Fractures are managed Conservatively
Outline it
Sling for 2wks. Kept on until movement is painless and then RoM exercises
Early movement of shoulder joint to prevent Frozen Shoulder developing
Outline Surgical management of Clavicle Fractures
ORIF, if fractures failed to unite (2-3mths after injury)
For Open, Bilateral and very Shortened/ Comminuted fractures
Outline Prognosis of Clavicle Fractures
What’s the healing time
Non-union is a major one
NV Injury Puncture injury (Haemo or Pneumo- thorax)
Healing time: 4-6wks
What is Frozen Shoulder
Glenohumeral Joint capsule becomes contracted and adherent to Humeral head
List Frozen Shoulder RFs
Female
DM, Breast Cancer, Parkinson’s, CT Disease
Previously had Contralateral Frozen Shoulder
Compare Primary and Secondary Frozen Shoulder
Primary: Idiopathic
Secondary- Associated with;
- Rotator Cuff tendinopathy
- Subacromial impingement syndrome
- Biceps tendopathy
- Previous surgery/ trauma
- Joint arthropathy
Frozen Shoulder progresses in what 3 stages, classically?
Painful stage
Freezing stage
Thawing stage
Pain w/ limited movement is present thoughout, little segregates between stages
How can Frozen Shoulder present
Deep, Constant Shoulder Pain;
- May radiate to Bicep
- Often disturbs sleep
Joint stiffness, Reduced RoM- External rotation and Flexion affected mainly
O/E;
- Loss of arm swing
- Deltoid Atrophy
- Generalised tenderness
Outline Frozen Shoulder Investigation
Diagnosis is typically clinical, off features alone
HbA1c and Blood glucose (more common if DM)
X-rays usually unremarkable, useful to rule out acromioclavicular pathology or fractures
MRI: Thickening of Glenohumeral Joint capsule, but also to rule out Impingement
Outline Frozen Shoulder Initial Management
Self-limiting, recurrence isn’t uncommon. Some pts never regain full RoM
Education, Reassurance, Advice to keep active
PT, Simple analgesia
Consider GH Joint Corticosteroid injections if no improvement
Outline Frozen Shoulder Surgical Management options
Symptoms majorly affect QoL, no Conservative improvement
Joint manipulation under GA to remove capsular adhesions to humerus
Arthrographic Distension
Surgical release of GH joint capsule
What is SAIS, Subacromial impingement syndrome
Inflammation + irritation of RC tendons as they pass through Sub-acromial space
Conditions such as;
- RC Tendinosis
- Subacromial Bursitis
- Calcific tendinitis
Who does SAIS most commonly occur in?
Under 25s
Typically active individuals/ in manual progressions
The Subacromial Space lies;
- Below the Coraco-acromial arch
- Above the Humeral head and Greater Tuberosity
What structures make the Coraco-acromial arch
Acromion
Coraco-acromial Ligament
Coracoid process
The underlying cause of subacromial impingement syndrome can be divided into intrinsic and extrinsic mechanisms
Outline Intrinsic Mechanisms
Muscular weakness;
- Humerus shifts proximally towards body due to RC weakness
Shoulder overuse;
- Repetitive microtrauma-> RC Tendon and SA Bursa inflammation-> Friction between Tendons and CA Arch
Degenerative tendinopathy;
- Degeneration of Acromion-> RC Tearing-> Proximal migration of Humeral Head
The underlying cause of subacromial impingement syndrome can be divided into intrinsic and extrinsic mechanisms
Outline Extrinsic Mechanisms
(Involve RC Tendon pathologies due to external compression)
Anatomical factors;
- Variations in Acromion shape/ gradient (Congenital or acquired)
Scapular musculature;
- Reduced SA space size due to reduced function of the muscles that allow Humerus to move past Acromion on overhead extension (SA or Trapezius)
GH Instability;
- GHJ abnormality/ RC Weakness-> Superior subluxation of humerus
- Causes increased contract between Acromion and Subacromial tissues
How can SAIS present
Progressive pain in Ant. Superior Shoulder
Exacerbated by Abduction, relived by rest
May be associated Weakness and Stiffness due to pain
Outline Investigations for SAIS
Neers Impingement test
Hawkins test
MRI;
- Subacromial Oesteophytes + Sclerosis
- Subacromial Bursitis
- SA Space narrowing
Outline Neers Impingement test
The arm is placed by the patient’s side, fully internally rotated and then passively flexed
Positive if there is pain in the anterolateral aspect of the shoulder.
Outline Hawkins test
The shoulder and elbow are flexed to 90 degrees, with the examiner then stablising the humerus and passively internally rotates the arm
Positive if pain is in the anterolateral aspect of the shoulder.
Outline SAIS Conservative Management
Analgesia (Usually NSAIDs), PT
Corticosteroid injections in SA Space, if further intervention needed
Outline SAIS Surgical Management options
If SAIS persists >6mths without response to conservative management
Repair of Muscular tears;
- Supraspinatus, Long head Bicps
- Improving RoM
Removal of SA Bursa (Bursectomy);
- Increased SA Space, reduced pain
Removal of part of Acromion (Acromioplasty);
- Increased SA Space, reduced pain
List complications of SAIS
RC Degeneration + tear
Frozen shoulder
Cuff tear arthropathy
RC Tears are Acute or Chronic (Lasting <3 or >3mths)
What are the the types
Partial thickness
Full thickness;
- Small (<1cm)
- Medium (1-3cm)
- Large (3-5cm)
- Massive (>5cm or multiple tendons)
List the 4 RC muscles and their primary actions
Supraspinatus– abduction
Infraspinatus – external rotation
Teres minor – external rotation
Subscapularis – internal rotation
They all act to stabilise the Humeral Head in Glenoid Fossa
Outline pathophysiology of Acute RC tears
Commonly in tendons with pre-existing degeneration, typically after minimal force
Can be due to large force in young people as well
Outline pathophysiology of Chronic RC tears
In people with degenerative microtears to tendon, mostly from Overuse
Seen more in older people
List RC Tear RFs
Age
BMI >25, Smoking, DM
Trauma, Overuse, Repetitive overhead shoulder movement
How may RC Tears present?
More common in dominant arm
Pain over lateral shoulder
Unable to Abduct past 90º
O/E;
- Tenderness over Greater Tuberosity and SA Bursa
- Supra + Infra- Spinatus Atrophy in Massive tears
List 3 Specific tests for RC Tears
What muscles are tested by each one?
Jobe’s test (Empty can test)- Supraspinatus
Gerber’s lift-off test- Subscapularis
Posterior cuff test- Infraspinatus + Teres Minor
Describe Jobe’s test (Empty can test)
Tests Supraspinatus
- Place shoulder in 90º Abducton and 30º Flexion
- Internally rotate fully
- Gently push downwards on arm
+ve if Weakness on resistance
Describe Gerber’s Lift-off test
Tests Subscapularis
- Internally rotate arm so that dorsal surface of hand rests on lower back
- Ask pt to lift hand away from back against examiner resistance
+ve if Weakness in actively lifting hand away from back
Describe Posterior Cuff test
Tests Infraspinatus + Teres minor
- Arm positioned at pt’s side, w/ elbow flexed to 90º
- Pt asked to Externally rotate arm against resistance
+ve if Weakness against resistance
Outline RC Tear Investigations
Urgent x-ray to rule out fracture;
- Most will be unremarkable
- If Chronic: May be less Acromio-humeral distance or Sclerosis+Cysts on RC insertion onto Greater Tuberosity
Ultrasonography: Establish Presence+Size of tear
MRI: Assess Size+Characteristics+Location of tear
Conservative Management of RC Tears is preferred in pts;
- Not limited by Pain/ Loss of Function
- Presenting within 2wks since injury
Outline it
Analgesia, PT
Can trial CS injections
Outline Surgical Management options of RC Tears
If;
- Presenting 2wks since injury
- Still symptomatic after conservative management
- Large and massive tears
Repair- Open or Arthroscopically
Outline Pathophysiology of Olecranon Fractures
Most commonly;
- Indirect trauma- Fall on outstretched arm-> Sudden pull of Triceps and Brachialis, pulling fracture apart further
Less commonly;
- Direct trauma high energy injuries
How may Olecranon Fractures present?
History of fallen on outstretched hand, followed by Elbow pain, Swelling, Lack of Mobility
O/E;
- Tenderness, potentially palpable defect
- Inability to extend elbow against gravity
Outline Olecranon Fracture Investigations
Check NV Status, Shoulder+Wrist Joints
Basic bloods- Clotting, Group+Save
AP+Lateral X-ray of Elbow + joints above + below
CT: Assessing more complex injuries and degree of comminution
Outline Non-operative Olecranon Fracture Management
If Displacement <2mm, but increasingly being used for all pts >75, regardless of displacement
Immobilisation in 60º-90º Elbow Flexion for 4-6wks
Early re-introduction of RoM
Outline Operative Olecranon Fracture Management options
(Usually if displacement >2mm
Tension Band Wiring (If prox to Coronoid process)
Olecranon Plating (If at level/ distal to Coronoid process)
What is Dupuytren’s Contracture
Contraction of Longitudinal Palmar Fascia
Dupuytren’s Contracture is 6:1 Male:Female, peak onset is 40-60y/o.
Which fingers are most commonly affected?
List RFs
Ulnar digits- Ring+Little finger
Smoking (x3), Alcoholic cirrhosis, DM Occupation exposure (Vibrations, heavy manual work)
Outline the disease progression of Dupuytren’s Contracture
- Initial pitting+thickening of palmar skin + SC Tissue
- Firm painless nodule forms, fixed to skin + deep fascia
- CORD develops resembling a tendon, which begins to contract over mths to yrs
- Cord contraction pulls on MCPJs and PIPJs-> Flexion deformity in fingers
How may Dupuytren’s Contracture present
45% cases are Bilateral. If Unilateral, mostly on Right Hand
Ranging from Reduced RoM and Nodule to Complete Loss of Movement
O/E;
- Thickened band/ Firm nodule adherent to skin
- Skin blanching possible on Digit Extension
- If advanced, MCP/PIPJs may be affected
Outline Hueston’s test
For Dupuytren’s Contracture
+ve if pt can’t lay palm flat
Outline Investigations for Dupuytren’s Contracture
Diagnosis mostly clinical
Basic bloods, Random Glucose/ HbA1c
USS imaging can be used to accurately give Intralesional Injections
Outline Dupuytren’s Contracture Conservative Management
Along with monitoring, for pts presenting early with no functional disability
Hand therapy- Keep active with stretching exercises throughout day
Injectable Collagenase Clostridum Histolyticum (CCM)
Outline Surgical Management of Dupuytren’s Contracture
Indications: Functional impairment, Rapidly progressive, PIPJ Contracture, MCPJ Contracture >30º
Fasciectomy under LA/GA, can be;
- Regional: Entire cord (most common)
- Segmental: (Short segments of cord)
- Dermofasciectomy: Cord + Overlying skin, then skin graft
- Closed/ Percutaneous Needle Fasciotomy: Done Outpt w/ LA
- Amputation: V rare
State the post-op recurrence rate for Dupuytren’s Contracture
What Penile condition is Dupuytren’s associated with?
66%
Peyronie’s Disease
What is Trigger Finger/ Stenosing Flexor Tenosynovitis?
Mostly occurs spontaneously in otherwise healthy individuals
Finger/ thumb click/lock when in flexion, preventing return to extension
Most cases of Trigger Finger are preceded by Flexor Tenosynovitis, often from repetitive movements, leading to inflammation of Tendon+Sheath
Outline the Pathophysiology
Flexor tendons with local tenosynovitis at the MCP Head develop a local node, distal to the pulley (Mostly A1 pulley)
When fingers flexed, node moves proximal to the pulley, when pt attempts to extend digit, node fails to pass back under pulley, becoming locked in flexion.
List RFs for Trigger Finger
Prolonged gripping + Hand use (Occupation/ Hobby)
Increasing age
Female
RA, DM
How may Trigger Finger present
Initially;
- Painless Clicking/ Snapping/ Catching when extending
Over time;
- May become painful, especially over Volar MCPJ
- Digit starts to lock in flexion
Outline Investigations and Complications of Trigger Finger
Clinical diagnosis. Bloods/Imaging if suspect any ddx (Dupuytren’s, Infection, Ganglion, Acromegaly)
Post-op Recurrence uncommon, but adhesions may form if pt doesn’t begin motion immediately after surgery
Mostly Trigger Finger can be managed Non-surgically
Outline this
Advice about painful activities
Small splint to hold finger in Extension at night
If Unresponsive/ Severe, trial Steroid injections (can improve over few days)
Outline Surgical Management of Trigger Finger
Percutaneous Trigger Finger Release: Release of tunnel, via needle, under LA
If severe;
- Surgical decompression of tendon tunnel under LA/GA, where roof is slit
CTS, Carpal Tunnel Syndrome accounts for 90% of all nerve compression syndromes.
It is more common in women, and peak age of incidence is 45-60
List RFs for CTS
Female gender, Pregnancy, Increasing age, Obesity
Previous wrist injury
Repetitive hand/ wrist movements (Vibrating tools, Assembly line work)
List 3 conditions associated with CTS
DM, RA, Hypothyroidism
How may CTS present?
History, Exam
Pain, Numbness and/or Parasthesia in Median Nerve distribution
Palm is often spared, as Palmar Cutaneous branch is proximal to Flexor retinaculum and passes over Carpal Tunnel
Symptoms worse at night, can be relieved by hanging arm over bedside or shaking back+forth
O/E:
- Late stage: Weak Thumb Adduction, Thenar eminence wasting
O/E of CTS in Early stages, there are often no visible findings.
What tests can be used to reproduce sensory systems
Tinel’s Test: Percussing over Median nerve
Phalen’s Test: Holding wrist in full flexion for 1min
List and describe 3 ddx for CTS
Cervical Radiculopathy;
- C6 involvement may-> Pain/ Parasthesia in similar distribution
- Will often have Neck Pain or symptoms involving entire arm
Pronator Teres Syndrome;
- Median nerve compressed by Pronator Teres
- Symptoms extend to Prox Forearm
- Reduced palm sensation
Flexor Carpi Radialis Tenosynovitis;
- Tenderness at base of thumb
Outline Investigations for CTS
Clinical diagnosis
If uncertainty, may use Nerve Conduction Studies to confirm Median Nerve damage
(Normal doesn’t rule out CTS)
Outline CTS Non-surgical Treatment
PT, Training exercises, Wrist splint (commonly at night);
- Preventing flexion
- Prevents exacerbation of Tingling+Pain
Can trial Corticosteroid injections, some ppl may trial NSAIDs
Outline CTS Surgical Treatment
Only in severely limiting cases, where previous treatment failed
Carpal Tunnel Release surgery;
- Under LA as a day case
- Decompresses carpal tunnel, cutting through Flexor Retinaculum, reducing pressure on Median Nerve
List complications of Carpal Tunnel Release surgery
Long-term untreated CTS can lead to permanent neurological impairment that will not improve with surgery
Persistent CTS symptoms (incomplete ligament release)
Infection, Scar formation
Nerve damage, Trigger thumb
Distal Radius Fractures represent 25% of all fractures seen clinically.
List 3 types of Distal Radius Fractures
Colles’ (90% of all distal radius fractures)
Smith’s
Barton’s
Describe a Colles’ Fracture
(Typically occurs as a fragility fracture in osteoporotic bone)
Describe its pathophysiology
Extra-articular fracture of distal radius w/ Dorsal Angulation+Displacement, within 2cm of articular surface
Person falls on outstretched hand. Transfer of load as body falls, forces wrist into supination.
Describe a Smith’s Fracture
Describe its pathophysiology
Volar angulation of distal fragment of extra-articular fracture of distal radius (w/ or w/o Volar displacement)
Falling backwards, planting outstretched hand behind body-> Forced pronation
Describe a Barton’s Fracture
Intra-articular fracture of Distal radius w/ dislocation of Radio-carpal joint
(Can be described as Volar/ Dorsal, depending on whether V/D rim of radius involved)
List RFs for Distal Radius Fractures
Female, Early menopause
Increasing age
Smoking, Alcohol excess
Prolonged steroid use
How may a Distal Radius fracture present
Immediate Pain +/- Deformity and sudden swelling around fracture, after trauma
Parasthesia/ Weakness, if neurological involvement
Outline Neurological Exam for a suspected Distal Radius fracture
(Also check Pulses+CRT)
Ulnar nerve;
- Motor: Thumb Adduction (Froment’s sign)
- Sensory: Ulnar surface of distal digit 5
Radial nerve;
- Motor: Extension of IPJ of thumb
- Sensory: Dorsal 1st webspace
Median nerve;
- Motor: Thumb Adduction
- Sensory: Radial surface of Distal digit 2
Outline Investigations for Distal Radius fractures
X-rays measuring;
- Radial height (Normal is <11mm)
- Radial inclination (Normal is <22º)
- Radial/ Volar tilt (Normal is >11º)
CT/ MRI: More complex, Pre-op planning
Outline Distal Radius fracture non-surgical management
- Closed reduction in A&E (Conscious sedation w/ a Haematoma or Bier’s Block)
- Below-elbow Backslab Cast for 3-4wks
- Radiographs repeated after 1wk to check for displacement
- Rehab via PT
Outline Distal Radius fracture Surgical management
(If:
- Significantly Displaced/ Unstable fractures as can displace further
- Intra-articular Step of radiocarpal joint >2mm)
ORIF w/ Plating or K-wire Fixation
Cast for 8-10wks before wrist functional
List the 3 main complications of Distal Radius Fractures
Malunion (Shorter radius than ulna-> Less wrist motion, Wrist pain, Less 4arm rotation)
Median Nerve compression
OA
List RFs for Knee OA
Genetic, Constitutional, Local
Genetic
Constructional;
- Increasing age, Female, Low bone density
Local;
- Previous joint injury
- Occupational/ recreational stresses on joint
- Reduced surrounding muscles strength
- Joint laxity/ malalignment
How may Knee OA present?
History, Exam
Pain;
- Typically around kne
- Can radiate to Thigh+Hip
- Worse on exercise, better on rest
Often Bilateral
Joint stiffness-> Reduced function
If severe: Joint swelling
O/E;
- Reduced RoM, Often muscle wasting
- If severe: Crepitus
Outline Investigations for Knee OA
X-ray;
- Lateral+AP Views (LOSS/ JOSS can be seen)
- Skyline view to assess for patellar involvement
MRI, if suspecting Ligament injury
Outline Initial Management of Knee OA
- Lifestyle changes (Weight loss, Exercise, Smoking)
- Analgesia
- PT (Slow progression, improve mechanics)
Outline Surgical Management of Knee OA
If conservative doesn’t work- typically Total/ Partial/ Unicondylar Knee Replacement
TKR is the standard treatment for advanced OA
(Most function for 10+yrs)
PKR needed for 10% of pts;
- Mainly in those with disease localised to Medial/Lateral compartment
- Faster recovery times
- May need conversation to TKR with time
What is Patellofemoral OA
OA affecting the articular cartilage along the Trochlear Groove, on underside of Patella
List RFs for Patellofemoral OA
Patella dysplasia (-> not fitting properly in Groove)
Hx of patella fracture (damages articular cartilage)
Patellofemoral OA can be confirmed with a Skyline view X-ray
How may it present
Anterior knee pain, worse with activities that put pressure on patella (Stairs)
Joint stiffness + Swelling
Outline Patellofemoral OA Management
Initial: Conservative- Same as for Knee OA
If unsuccessful: Patellofemoral Replacement
- Not if OA affects other parts of knee
- This would require a TKR instead
List the 2 main function of the Menisci of the knee
Rest on tibial plateau
Shock absorption
Increase articulating surface of knee
Compare the Medial to Lateral Meniscus
Medial;
- Less circular
- Attached to Medial Collateral Ligament
Lateral;
- More circular
- Not attached to Lateral Collateral Ligament
Most common causes for Meniscal Tears are;
- Trauma (Twisting a Flexed, W-bearing knee)
- Degenerative disease (more in older patients)
List the types of Meniscal Tears
Vertical
Degenerative
Transverse (Parrot-beak)
Longitudinal (Bucket-Handle)
How may Meniscal Tears present
History, Exam
Intense Sudden Pain + ‘Tearing’ sensation
Slow swelling over 60-12hrs
Locked in Flexion;
- If free body in knee due to tear
- Typically in Longitudinal types of tear
O/E;
- Joint line tenderness
- Major effusion
- Limited knee flexion
Outline Meniscal Tear Investigations
X-rays: To exclude fracture
MRI: Gold standard for diagnosis+Identification
Tests: McMurray’s, Apley’s Grind (V painful)
Outline Meniscal Tear Initial Management
RICE
Most small tears (<1cm) will initially swell, but pain will subside over next few days
Outline Meniscal Tear Further Management
Indications: Larger/ Still symptomatic tears
If in Inner 1/3: Trimmed
If in Middle 1/3: Trimmed or repaired (Sutured back together)
Outer 1/3: Repaired (sutured back together)
List complications of Meniscal Tears and Arthroscopy
Tears: RF for OA later in life
Arthroscopy- Risk of;
- DVT
- Damage to local structures (Saphenous N+V, Fibular Nerve, Popliteal vessels)
What does the ACL do?
Limits excessive;
- Anterior Displacement of Tibia
- Knee rotation (especially Internal)
Describe the typical mechanism of an ACL Tear and Meniscal
ACL: Twisting of Weight bearing knee
Meniscal: Twisting of Flexed, Weight bearing knee
How may an ACL Tear present?
50% of ACL tears will have a Meniscal tear, more commonly the Medial
Rapid joint swelling, Severe pain
Leg instability/ “Giving away”, if delayed presentation
(Swelling is due to ligament being highly vascular, so damage-> Haemarthrosis apparent within 15-30mins)
Outline ACL Tear Investigations
X-ray- AP+Lateral;
- Exclude Bony injury, Joint effusion, Lipohaemarthrosis
- Segond Fracture is a sign of ACL Injury
MRI: To confirm diagnosis + Detect Meniscal Tears
Tests: Lachman’s and Anterior Drawer
Describe a Segond fracture
Sign of ACL Injury
Bony avulsion of lateral proximal tibia
Lachman’s test is more sensitive than Anterior Drawer test for an ACL tear
Describe them
Lachman’s test:
- Place knee in 30º of flexion
- With 1 hand stabilise femur, pulling tibia forward
- Assess the amount of anterior tibia movement
- The other knee is then examined for comparison.
Anterior Drawer test;
- Flex knee to 90º
- Place thumbs on joint line and index fingers on hamstring tendons.
- Force applied anteriorly, assess tibial movement
- Compare to the opposite side
ACL Tear definitive management can be Conservative or Surgical
Outline Initial Management of ACL Tear
RICE (as for any acutely swollen knee)
Outline Conservative Management of ACL Tear
Rehab w/ PT- Quad strength training to stabilise knee
Cricked pad knee splint can be applied for comfort
(Inpt admission rarely required, as pt can often partially weight-bear)
Outline Surgical Management options of ACL Tear
ACL Reconstruction;
- Use of Tendon/ Artificial Graft
- Done after Rehab period
Acute Surgical ACL Repair;
- Possible, depending on tear location in ligament
- Re-suturing ends of torn ligament
- Needs assessment under GA Knee Arthroscopy
List ACL-damage related complications
Post-traumatic OA is a complication of ACL Injury and ACL Reconstructive surgery
What are the functions of the PCL
List common causes of PCL Tears
Prevent;
- Excessive posterior tibial movement
- Hyperflexion of knee
Trauma;
- Typically high-energy (Direct blow to Prox Tibia)
- Less common: Low-energy (Hyperflexion of knee, with plantar-flexed foot)
How may a PCL Tear present?
How are they investigated
Immediate Post. Knee pain
Joint instability
Posterior Drawer test (w/ posterior sag)
MRI: Gold standard
Outline PCL Tear management
Often Conservatively;
- Knee Brace + PT
Surgery;
- If still symptomatic + recurrent instability
- Insertion of Graft
- If other injuries: Knee surgery for reconstruction
The MCL, Medial Collateral Ligament is the most commonly knee ligament to be injured
What is its function?
How is it most often injured?
Acts as a Valgus stabiliser of knee
External rotational forces applied to lateral knee
How may an MCL Tear present?
History, Exam
- ‘Pop’ sound, Immediate Medial joint line pain
- Swelling after few hours, unless Haemarthrosis which is in mins
O/E;
- Increased laxity on Valgus Stress test
- Very tender along medial joint line
- May be able to weight bear
How is an MCL Tear investigated
X-ray: To rule out fracture
MRI: Gold standard
Outline the Grades of MCL Tears
Grade 1;
- Mild injury, Minimally torn fibres
- No loss of MCL integrity
Grade 2;
- Moderate injury, Incomplete tear
- Increased MCL laxity
Grade 3;
- Severe injury, Complete tear
- Gross MCL laxity
Outline MCL Tear Grade 1 Management
What’s the aim of treatment
RICE, Analgesia, PT (Strength training)
Aim: Return to full exercise within 6wks
Outline MCL Tear Grade 2 Management
What’s the aim of treatment
Analgesia, Knee brace, PT (Weight-bearing/ Strength training)
Aim: Return to full exercise around 10wks
Outline MCL Tear Grade 3 Management
What’s the aim of treatment
Analgesia, Knee brace + Crutches
If distal avulsion, consider surgery
Aim: Return to full exercise within 12wks
List complications of an MCL Tear
Joint instability
Saphenous nerve damage
Patella Fractures are 2:1 Male:Female
Usual causes?
Major: Direct trauma to Patella
Less common: Rapid eccentric contraction of Quad
How may Patella Fractures present
History, Exam
Anterior knee pain, worse with movement
Unable to Straight Leg raise
May be unable to weight bear
O/E;
- Major Swelling + Bruising
- Often, visible palpable Patellar defect between bone fragments
What congenital condition can be mistaken for a Patella Fracture
Describe it
Bipartite Patella;
- 2-3% of population, more common in males
- Failed patella fusion-> 2 separate bone fragments joined only by Fibrocartilaginous tissue
Typically Asymptomatic, rarely symptomatic;
- Anterior knee pain after exercise/ overuse
Outline Patella Fracture Investigations
X-ray: AP + Lateral + Skyline views
CT: Comminuted fractures, any uncertainty
Patella Fractures are often managed Conservatively. Outline this
(Indications: Non/ Minimally- displaced or with Vertical fractures where extensor mechanism functions)
Brace or Cylinder cast
Early weight-bearing in Extension
Increasing Flexion incrementally
Outline Patella Fracture Surgical Management
Indications: Major displacement/ Compromised Extensor Mechanism
ORIF w/ Tension Band Wiring;
- Converts tensile force from Quads to Compression force to (assist Reduction + Healing)
Screw fixation w/o Wires;
- Simple vertical/ transverse fractures
Partial/ Total Patellectomy;
- Rarely, when ORIF not possible
Outline Pathophysiology of Achilles tendonitis
Repetitive actions of tendon-> Microtears-> Local inflammation
Over time, the tendon becomes Thickened, Fibrotic and loses elasticity
List RFs for Achilles tendonitis or Rupture
Male, Increasing age
Unfit, Obesity
Sudden increase in exercise, Poor footwear
Recent use of Fluroquinolone (for tendon rupture)
Outline Achilles tendonitis management
Acute;
- Stop precipitating exercise
- Ice the area
- Use anti-inflammatories regularly
Chronic;
- Rehab and PT
Outline Acute Achilles Tendon Rupture Management
Acute: <2wks
Analgesia + Immobilisation;
- Given crutches, not allowed to weight bear
- Full Equinus for 2wks (Ankle fully Pflexed)
- Ankle held in Semi-Equinus for 4wks
- Ankle held in Neutral position for 4wks
Outline Chronic Achilles Tendon Rupture or Re-rupture Management
(>2wks)
Surgical fixation with end-to-end tendon repair
What is Hallux Valgus/ Bunions?
Deformity at MTPJ1, characterised by;
- Medial deviation of Metatarsal 1
- Lateral rotation +/- Rotation of Hallux
- W/ Joint Subluxation
List RFs for Hallux Valgus
Female, High-heeled or Narrow fitting footwear
CT Disorders, Hypermobility syndromes
Anatomical variations;
- Long 1st Metatarsal
- Non-alignment of MTPJ1
- Flat feet
How may Hallux Valgus present
Painful medial prominence;
- Worse on walking, weight-bearing, wearing narrow toed shoes
If Cartilage Degeneration: Pain+Crepitus on movement
O/E;
- Lateral Hallux deviation
- May be Inflammation or Skin breakdown over prominence at Hallux base
- EHL Tendon contracture, if long-standing joint subluxation
- Excessive keratosis, if abnormal weight distribution from altered gait
Outline Hallux Valgus Investigations
Radiographic imaging (X-ray) to Lateral Deviation Degree
HV diagnosed if angle between Metatarsal 1 and 1st Prox Phalanx is >15º
Outline non-surgical management of Hallux Valgus
Analgesia, PT
An Orthosis if pt has flat feet, to prevent deterioration
Advice on footwear changes;
- Prevent deformity worsening
- Prevent irritation of skin over medial eminence
List Surgical Management options for Hallux Valgus
(If QoL significantly impaired)
List complications for all the procedures
Procedures;
- Chevron (Common for mild deformities)
- Scarf (Moderate-Severe deformities)
- Lapidus (If due to Tarsometatarsal Joint hypermobility)
- Keller (Common if severe MTPJ1 Arthritis)
Wound infection, Delayed healing
Nerve injury, Osteomyelitis
Recurrence not uncommon
List complications of Hallux Valgus
Avascular necrosis
Non-union
Displacement
Reduced RoM
The Calcaneum is the most commonly fractured tarsal bone
Due to what cause?
Fall from height (Axial loading directly onto bone)
Thus, it is associated with Concurrent fractures (spinal or contralateral calcaneus)
Compare the 2 types of Calcaneal Fractures
Intra-articular;
- 75% of Calcaneal Fractures
- Involves articular surface of Subtalar joint
Extra-articular;
- 25% of Calcaneal Fractures
- Commonly Avulsion fractures, with sparing of articular surface of Subtalar joint
Outline the Sanders Classification
Used to classify Intra-articular Calcaneal Fractures
Type 1: Nondisplaced posterior facet
Type 2: 1 fracture line in posterior facet
Type 3: 2 fracture lines in posterior facet
Type 4: >3 fracture lines in posterior fact
How may a Calcaneal Fracture present
Uncommonly present as Stress fractures, where there is pain on activity, w/o trauma history
Pain + Tender, around Calcaneal region
Unable to weight-bear
O/E;
- Significant swelling, Brusing
- Heel may be Shortened+Widened
- May have Varus deformity
May have Posterior Heel skin Tenting/ Blanching (Needs emergent surgery)
Outline Calcaneal Fracture Investigation + Results
Initially X-ray: AP+Lateral+Oblique views show;
- Calcaneal shortening
- Varus tuberosity deformity
- Reduced Böhler’s Angle
CT: Gold standard, perform whenever suspected
Outline treatment for Intra and Extra articular Calcaneal Fractures
Intra;
- Most need surgery
- <2mm displacement OR near normal Böhlers angle may be treated conservatively
Extra;
- Cast Immobilisation and Non-weight bearing for 10-12wks
Outline the surgical management for Calcaneal Fractures
Closed reduction with Percutaneous Pinning;
- May be attempted for >1cm but minimally displaced fractures
ORIF;
- Usually needed
List a complication of Calcaneal Fractures and how it is treated
Subtalar arthritis
Treated Conservatively;
- Analgesia, PT
- If unsuccessful, may need Subtalar Arthrodesis
The Talus is the 2nd largest tarsal bone and the 2nd most common tarsal bone to fracture
Outline the mechanism
Usually after high-energy trauma, where ankle forced into Dorsiflexion
This causes Talus to press against Tibial Plafond, causing a fracture
Outline investigations for Talar Fractures
X-rays: AP + Lateral
Lateral films should be taken in D+P-Flexion, as Pfexion will reduce any Subluxation present
CT: for complex injuries, aid in management planning
Talar Fractures are mostly in the Talar Neck
Outline their classification
Hawkins Classification: Aids in management and determining risk of Avascular Necrosis
Type 1: Undisplaced, 0-15% risk of AVN
Type 2: Subtalar dislocation, 20-50% risk of AVN
Type 3: Subtalar+Tibiotalar dislocation, 90-100% risk of AVN
Type 4: Subtalar + Tibiotalar + Talonanvicular dislocation
- 100% risk of AVN
Outline Management of Hawkins Type 1 Talar Neck fractures
Conservatively;
- Plaster
- Non-weight bearing crutches for 3mths
Outline Management of Hawkins Type 2-4 Talar Neck fractures
- Attempt Closed reduction in A&E
- Once reduced, place Cast and repeat Radiographs to ensure it remains in position
If reduction not possible;
- Surgical fixation
- Post-op: Extended period of non-weight bearing
List complications of Talar Fractures
Avascular Necrosis
OA 2ndary to AVN/ Malunion of any Talar joints
What is Hawkins sign
What does it indicate
Subchondral lucency of the talar, visible 6-8 weeks following injury
Sufficient vascularity of the talus, so low risk of AVN
What are (Plafond) Tibial Pilon Fractures?
What are they caused by?
Severe injuries affecting distal tibia
Caused by High energy axial load, as Tibial Plafond is injured by Talus punching upto it
Tibial Pilon Fractures are characterised by Articular Impaction, Severe Comminution and often associated with Soft Tissue injury
How may they present
Severe ankle pain, Unable to weight-bear
O/E;
- May be Ankle deformity
- Swelling+Bruising are common
- Skin Blistering (fracture blisters) may occur over several hours
Outline Investigations for Tibial Pilon Fractures
Urgent bloods- Including Coag, G+S
X-ray;
- AP+Lateral+Mortise views
- Also, full length views of Tibia+Knee
CT: For further assessment + pre-op planning
Outline initial Tibial Pilon Fracture management
- Limb realignment, then Below-knee backslab
- Repeat NV exam and X-rays
- Limb must be elevated and monitored for Compartment Syndrome
Simple undisplaced pilon fractures are rare but may be treated non-operatively.
Outline Surgical management of Tibial Pilon fractures
Staged approach;
- Temporary spanning external fixator
- Definitive fixation (ORIF) 7-14 days later once soft tissues healed
List complications of surgical repair of Tibial Pilon fractures
Compartment syndrome
Wound infection/ dehiscence
Post-traumatic arthritis
Delayed/ non- union (commonly in Metaphyseal region)
Ankle Fractures are more common in Young Males/ Older Females
Describe the Syndesmosis
This is where the Tibia and Fibular are joined
It is a very strong fibrous structure comprised of the;
- Anterior Inferior Tibiofibular Ligament, AITFL
- Posterior Inferior Tibiofibular Ligament, PITFL
- Intra-osseus membrane
What is an Ankle Fracture?
Fracture of any Malleosus w/ or w/o Disruption to the Syndesmosis
(There are Medial, Lateral and Posterior Malleoli)
Classify Ankle fractures anatomically
- Isolated Lateral Malleolar fractures
- Isolated Medial Malleolar fractures
- Bimalleolar fractures (Medial+Lateral)
- Trimalleolar fractures
Outline the classification of Lateral Malleolar fractures most widely used in A&E
Weber classification
Type A: Below Syndesmosis
Type B: At level of Syndesmosis
Type C: Above Syndesmosis
More proximal = higher chance of instability
(Type C almost always needs Surgical fixation)
Which classification system is mostly used for Ankle Fractures in Orthopaedic practice
Lauge-Hansen classification
Based on ankle position at time of injury and deforming force involved
How may an Ankle Fracture present
Ankle pain
May be Deformity if dislocation present
Very deformed ankles;
- May have NV compromise
- Often open fractures (typically over medial side)
The Ottawa Ankle Rules can be applied where there is diagnostic uncertainty of Ankle fractures (e.g able to mobilise and no deformity)
Outline them
X-ray must be taken if any of these features present;
- Tender Bone at Post. edge/tip of Lateral M
- Tender bone at Post. edge/tip of Medial M
- Unable to weight bear both Immediately + in A&E for 4 steps
When can the Ottawa Ankle Rules not be used?
Pt;
- Intoxicated/ Uncooperative
- Other distracting painful injuries
- Diminished sensation in legs
- Gross swelling
Outline Ankle Fracture Investigations
X-ray: AP+Lateral views (When Dorsiflexed)
Check for Talar Shift
CT for surgical planning: For Complex fractures, especially if disabled posterior malleolus fragment
Outline Conservative Management for Ankle Fractures
Used in Non-displaced Medial M fractures, Weber A/B fractures w/o Talar shift, Pts unfit for surgery
- Immediate fracture reduction (usually A&E, Sedated)
- Below-knee back slab
- Repeat NV Exam, X-ray
Outline Surgical Management for Ankle Fractures
What are 4 indications
ORIF
Displaced Bimalleolar/ Trimalleolar fractures
Open fractures
Weber C fractures
Weber B fractures w/ Talar Shift
List complications of Ankle fractures
Risk of post-traumatic arthritis
Additional RFs post-ORIF;
- Wound infection
- DVT/ PE
- NV injury
- Non-union
- Metalwork prominence
Compare the 2 types of Ankle sprains
High: Injuries to Syndesmosis
Low: Injuries to ATFL and CFL (CFL more common)
What is Degenerative Disc Disease
Natural deterioration of the Inter-vertebral Disc structure, so they become progresviyl weak and begin to collapse
Degenerative Disc Disease is often related to Aging
List factors which which precipitate damage to the Inter-vertebral discs
- Progressive dehydration of Nucleus Pulposus
- Daily activities cause tears in Annulus Fibrosis
- Injuries/ Pathology-> Instability
The cascade of changes seen in Degenerative Disc Disease can be divided into 3 stages, the duration of which can vary significantly
Outline them
Dysfunction;
- Outer annular tears + Separation of the Endplate
- Cartilage Destruction, and Facet Synovial Reaction
Instability;
- Disc Resorption and Loss of Disc Space Height, along with Facet Capsular Laxity
- Can lead to Subluxation + Spondylolisthesis
Restabilisation;
- Degenerative changes -> Osteophyte formation and Canal Stenosis
How may Degenerative Disc Disease present?
Clinical features depend on disease Region+Severity
Early stage;
- Symptoms often localised, exam may find nothing
- Local spinal tenderness, Contracted paraspinal muscles
- Hypomobility, Painful Back/ Neck extension
Instability stage;
- Pain more severe, may include Radicular leg pain or Parasthesia
- Pain may come on by Passively raising extended log (Lasegue Sign)
Further disease progression;
- Worsening muscle tenderness
- Stiffness, Reduced movement
- Scoliosis
Outline Lasegue Test (AKA Straight leg raise)
To assess for disc herniation in pts with Low Back pain
- With pt supine, lift leg while knee straight
- Ankle can be Dflexed and/or Cervical spine flexed for further assessment
+ve if pain during Leg Raise +/- Ankle Dfexion or Cervical spine flexion
List indications for imaging investigations for suspected Degenerative Disc Disease
(Spine radiographs recommended only if pt has Hx of trauma, Osteoporosis or is >70 y/o)
- Red flags present
- Radiculopathy w/ pain for >6wks
- Evidence of Spinal Cord compression
- Imaging would significantly alter management
Most cases don’t need imaging
Outline Imaging Investigations + Results for Degenerative Disc Disease
MRI Spine: Gold standard
- Signs of degeneration
- Reduced disc height
- Presence of annular tears
- Endplate changes
Degenerative Disc Disease management is highly variable and pt-dependent
When is Emergency intervention needed?
Describe it
Only in cases of Cauda Equina Syndrome
Decompression of spinal canal within 24-48hrs of symptom onset, through either Laminectomy or Discectomy
Radiculopathy is a conduction block in the axons of a spinal nerve or its roots
Compare Radicular Pain and Radiculopathy
Radiculopathy: State of neurological loss, may be associated with pain
Radicular Pain: Pain due to damage/ irritation of spinal nerve tissue, particularly the Dorsal Root ganglion
How may Radiculopathy present?
Parasthesia, Numbness, Weakness
Often: Radicular pain (Deep, Strap-like, Narrow), may be intermittent
Look for Red Flag symptoms
O/E of ps with Radiculopathy, it is important to identify Myotomal+Dermatomal involvement
How do you evaluate for Cauda Equina syndrome?
Assess;
- Pinprick sensation in peri-anal Dermatome
- Anocutaneous reflex
- Anal tone
- Rectal pressure sensation
All reduced in CES
Most Radiculopathy cases are due to IV Disc Prolapse and can be managed non-operatively
List indications for Surgical Management
- Unremitting pain, despite Conservative managment
- Progressive weakness
- New/ progressive Myelopathy (Cord compression)
Outline Symptomatic (Conservative) management of Radiculopathy
Analgesia: Neuropathic meds often used;
- 1st line: Amitryptilline
- 2nd line: Pregabalin, Gabapentin
Benzodiazepines/ Baclofen: Pts may have muscle spasms
Physiotherapy
List complications of Colles’ Fractures
Smith’s causes Garden spade
Dinner fork deformity
Median Nerve palsy, Post-traumatic CTS
EPL tendon tear
2dary OA
Outline the Garden Classification
Type 1: Incomplete, non-displaced fracture
Type 2: Complete, non-displaced fracture
Type 3: Complete, partially displaced fracture
Type 4: Complete, fully displaced fracture
How are these types of #NOF treated?
- Displaced Intra-capsular/ Subcapital
- Inter-trochanteric + Basocervical
- Non-displaced intracapsular
- Sub-trochanteric
- Hemiarthroplasty (If young, ORIF+Cancellous Screws)
2;
- Dynamic Hip Screw, if Stable (2/3 parts)
- Short IM Nail, if Unstable (4/+ parts) - Cannulated hip screw
- IM Nail
What nerve injuries are associated with Tibial Shaft fractures
How does this present
Sural nerve (Only sensory)
Sensory deficit over;
- Posterolateral distal 1/3 of leg
- Lateral aspect of foot
Suggest a compication of a Total Hip Replacement
Posterior Hip Dislocation
Outline patterns of Radial Nerve injury
Very High lesions:
- Due to impingement (e.g Crutches, Saturday night palsy)
- Wrist drop, Tricep weakness
High lesions:
- Humeral shaft fracture
- Wrist drop, Reduced sensation in Anatomical snuffbox, no triceps weakness
Low lesions:
- Forearm fracture (E.g radial head)
- Finger drop, no sensory loss
Outline the Female Athletic Triad
Osteoporosis
Eating disorders
Amenorrhoea
Compare Monteggia+Galeazzi fractures
These involve Radius/ Ulna shaft fractures and a dislocatio
Moneggia;
- Fracture of Prox 1/3 of Ulnar shaft
- Ant dislocation of Radial Head at
Capitellum
Galeazzi;
- Fracture of Distal 1/3 of Radial shaft
- RUJ dislocation
List the most likely causes of a limping child aged;
- 1-3yrs
- 3-6yrs
- 6-10yrs
- 10-14yrs
1-3: DDH (more common in girls)
3-6: Septic arthritis
6-10: Perthes (can affect ages 3-11)
10-14: SCFE/ SUFE
Outline Perthes’ Disease pathology
Part/ all of Femoral head loses blood supply, leading to AVN
How does Perthes’ disease present?
Roll test: While Supine roll hip into I+E Rotation, +ve if Guarding/ Spasm
Typically Unilateral
- Subacute Limp
- Limited hip rotation
- Groin/ Thigh/ Knee pain, worse w/ activity
- All hip movements limited
Initally: Antalgic gait
Later: Trendelenburg gait
Oultine Perthes’ Investigations
FBC, ESR
X-ray;
- Early: May show joint space widening
- Later: Reduced nuclear femoral head size, w/ patchy density
Outline Non-surgical treatment of Perthes’
If Bone age<6
- Restrict activities+weight bearing until ossified
- PT, NSAIDs
Outline the Prognosis of Perthes’
Mostly good outcomes, at least 50% do well w/o treatment
Common complications;
- Pain, OA, Ongoing hip dysfunction
List Perthes’ disease RFs
- Male gender
- More common in Whites than Blacks
- Genetic conditions
SUFE is often atraumatic/ due to minor injury
List the 4 separate clinical groups
(Can be Stable or Unstable- Able to walk or not)
Pre-slip: Wide epiphyseal line w/o slippage
Acute (10-15%): Slippage occurs suddenly
Acute-on-chronic: Slippage occurs acutely where there is already existing chronic slip.
Chronic (85%): Steadily progressive slippage
List SUFE RFs
Obesity
Local trauma, Inflammatory conditions
Chemo, Previous Pelvis radiation
Deficiencies;
- Hypothyroidism
- Hypopituitarism
- GH deficiency
- Vit D deficiency
Outline SCFE/ SUFE pathology (Slipped Upper/Capital Femoral Epiphysis)
Epipysis + Diaphysis slipped out of normal position
How does SUFE present?
- Limp, May be unable to walk
- Discomfort in Groin/ Hip/ Medial thigh when walking
- Limited hip motion due to pain (esp IR+Abduction)
- Leg may be shortened (if Chronic)
Outline Investigations for SUFE
AP+Lateral X-rays show either/ both;
- Epiphyseal line widening
- Femoral head displacement
USS can detect effusion
CT: Consider if complex surgery planned
List DDH RFs
- Sibling with DDH
- Female gender
- Breech presentation (Vag delivery/ C-section)
- Prematurity
List complictions of Surgery to treat DDH
Re-dislocation
Stiffess
Blood loss
AVN of Capital Femoral Epiphysis
2 ddx for Hip OA are Trochanteric Bursitis and Gluteus Medius Tendinopathy
Compare these
Trochanteric Bursitis;
- Lateral hip pain radiating down lateral leg
- Point tenderness over greater trochanter
Gluteus Medius Tendinopathy;
- Lateral hip pain
- Point tenderness over the muscle insertion at the greater trochanter
How are distal tibia fractures treated and how long does it take to recover?
IM Nailing
3-7 months
List 3 long term complications of a Hip replacement (Total or Hemi)
Re-dislocation
Acetabulum erosion
Leg length discrepancies
Why does smoking prolong fracture healing time
- Nicotine inhibits ostroegen
- Unopposed osteoclast activity
List 2 major complications of compartment syndrome
How can they be monitored for
Re-perfusion syndrome, Rhabdomyolysis
Monitor Kidney function and CK Levels
List 2 characteristic features of the pathogenesis of OA
Articular cartilage degradation
Bone remodelling
Outline tibial plateau fracture Conservative Mx
Surgery if Displaced/ Open
Hinged knee brace for 8-12wks
