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Year 3 Surgery > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

What is a positive Hoffman’s Sign

What does it indicate

A

Flexion of thumb and DIP of tested finger, signifies cervical compression

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2
Q

What does Scarf test look for

A

Acromioclavicular Joint pain

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3
Q

Why does the Medial knee predispose to compartment arthritis

A

Takes on more pressure than the lateral side

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4
Q

List 2 specific signs of patellar dislocation

A

Palpable gap between quadriceps and Patellar tendon

Unable to straight leg raise

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5
Q

Why can knee dislocations be very dangerous

A

Popliteal artery fixed in Politeal fossa and Adductor hiatus

Common Peroneal nerve injured in 1/4 of cases

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6
Q

List the 2 most common organisms causing knee and prosthetic infections

A

Staph aureus

Coagulase negative Staph

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7
Q

List key Qs to ask if knee pain

A

Duration and progression

How far can walk

Any night pain? Waking?

Painkillers?

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8
Q

How is Hallux Rigidus treated?

A

Conservative management

If necessary, Arthrodesis

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9
Q

Why aren’t Arthroplasties done often to treat bunions, arthritis etc?

A

Shortens toe, and develops across midfoot instead

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10
Q

Flat feet is normal in children but not in adults.

What are 3 features of it?

A

Progressive deformity
Uncommon to have history of trauma
Pain behind Medial Malleolus

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11
Q

Outline treatment of Flat feet

A

Conservative, Stiff insoles, PhysioT

If Flexible, reconstruct
If stiff, Arthrodesis

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12
Q

Which ankle ligament is most prone to damage?

How long does a tear take to heal?

A

Anterior talofibular

12mths

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13
Q

What is DAIR?

What is it used for

A

Debridement Antibiotics and Implant Retention

Used for Peri-prosthetic Joint Infection (PJI)

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14
Q

What is Shenton’s Line on a Pelvic X-ray?

How should it appear?

A

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

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15
Q

What are 2 conditions an abnormal Shenton’s line can indicate?

A

Fractured NOF

Developmental Dysplasia of Hip

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16
Q

What are the 3 sources of blood supply to the talus

Risk of Avascular necrosis after fracture

A

Posterior tibial artery (majority)

Anterior tibial artery (may be only undamaged source after displaced fracture)

Perforating Peroneal/ Fibular artery

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17
Q

Actions of Tibialis Posterior?

A

Inversion
Plantarflexion
Maintains medial arch of foot

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18
Q

List signs of Charcot-Marie-Tooth

Peroneal Muscular Atrophy, PMA

A
  • Cavovarus feet
  • Claw foot deformities
  • Scoliosis
  • Muscle weakness + Sensory changes
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19
Q

Outline Silfverskiold Test

What is its purpose?

A

Purpose: Distinguish Gastrocnemius from Soleus contracture

  • Assess DFlexion with Hip + Knee extension
  • Assess DFlexion with Hip + Knee Flexion
  • If improvement, Gastrocnemius contracture present
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20
Q

Compartment syndrome is defined as a critical pressure increase within a confined compartmental space

Which fascial compartments are most commonly affected

A

Thigh, Leg, Foot

Forearm, Hand

Buttock

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21
Q

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

A

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)

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22
Q

How does Compartment syndrome present

Symptoms tend to present within hours, but can take upto 48hrs to present

A

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)

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23
Q

Outline investigations for Compartment Syndrome

A

Clinical- Based on Symptoms and RFs

IC Pressure Monitor (If uncertain, or pt unconscious/ intubated)

CK level may aid diagnosis

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24
Q

Outline INITIAL Compartment Syndrome Management

A

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

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25
Q

Outline DEFINITIVE Compartment Syndrome Management

A

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

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26
Q

List the 4 radiological features of OA

A

Reduced joint space
Osteophytes
Subchondral Cysts
Subchondral Sclerosis

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27
Q

Outline Conservative OA Management

A

Joint protection

Strengthening + Exercise, Weight loss

Heat/ Ice packs
Joint Supports
PT

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28
Q

Outline Medical OA Management

A

Simple Analgesia + Topical NSAIDs

Intra-articular Steroid injections, if pain remains

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29
Q

Outline Surgical OA Management

A

Osteotomy

Arthroplasty

Arthrodesis

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30
Q

In what ways can outcomes of an open fracture be considered?

A

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

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31
Q

Outline Examination and Investigations for Open Fractures

A

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

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32
Q

Outline Initial Management of Open Fractures

A

Resuscitation + Stabilisation

Urgent Realignment + Splinting
Broad Abx, Tetanus vaccine if needed

Remove debris + Take Photo of wound
Dress wound with saline-soaked gauze

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33
Q

Outline Definitive Management of Open Fractures

A

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

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34
Q

List the main causative organisms of Septic Arthritis

A

S. aureus (more common in adults)
Strep species

Gonorrhoea (more common in Sexually active)
Salmonella (more common in Sickle Cell pts)

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35
Q

How may Bacteria ‘seed’ to the joint?

A

From;

  • Bacteraemia (Cellulitis, UTI, Chest infection)
  • Direct Inoculation
  • Spread from adjacent Osteomyelitis
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36
Q

How can Septic Arthritis progress

A

Can cause permanent Articular Cartilage damage leading to Severe OA

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37
Q

List RFs for Septic Arthritis

A

Age >80, Chronic renal failure
DM, Immunosuppression, IV Drug use

Pre-existing joint disease (E.g RA)
Hip/ Knee Joint Prosthesis

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38
Q

How may Septic Arthritis present?

Features moe obvious in Native Joint vs Prosthetic Joint infection

A

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

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39
Q

List Ddx for Septic Arthritis

A

OA Flare, RA, Reactive Arthritis
Haemarthrosis

Crystal Arthropathies
Lyme disease

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40
Q

Outline non-imaging Investigations for Septic Arthritis

A 
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

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41
Q

Outline Imaging Investigations for Septic Arthritis

A

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

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42
Q

Outline Management of Septic Arthritis

A

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

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43
Q

Reduction involves restoring the anatomical alignment of a fracture or dislocation.

Reduction allows for what 4 things?

A

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

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44
Q

How may Fracture Reduction be performed?

A

Typically performed closed in emergency setting

Some are reduced open or intra-operatively

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45
Q

Outline the Clinical Requirements for Fracture Reduction

A

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
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46
Q

Fracture Holding means immobilising a fracture

Outline this

A

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

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47
Q

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?

A

The spine

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48
Q

What is Osteomyelitis?

Which bones are mostly affected in adults and children?

A

Bone infection

Adults: Hips, Spine, Feet
Children: Arm+Leg bones

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49
Q

What can happen in Chronic cases of Osteomyelitis

A

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

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50
Q

List Osteomyelitis RFs

A

DM
IV Drug use, Immunosuppression
Alcohol excess

Recent fracture, Recent surgery
Bone prosthesis

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51
Q

Foot infection frequently occurs in DM pts, increasing risk of Osteomyelitis.

How is any suspected cases investigated

A

MRI

Suspect Osteomyelitis in any DM pt with Deep/ Chronic foot infection

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52
Q

How can Osteomyelitis present

A

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
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53
Q

Outline Osteomyelitis investigation

A

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

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54
Q

How is Osteomyelitis managed?

A

IV Abx (> 4wks), if clinically well

If clinical deterioration/ progressive bone destruction, Surgical management involving Curettage of area

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55
Q

Most common site of shoulder fractures is where?

What’s the most common cause?

A

Proximal humerus

Low energy injuries: Elderly people falling onto outstretched hand, mainly in Osteoporosis

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56
Q

List RFs for Shoulder Fracture

A

Female, Early menopause
Prolonged steroid use
Recurrent falls, Fraility

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57
Q

How may Shoulder Fractures present

A

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

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58
Q

Outline Investigations for Shoulder Fractures

Check NV Status, as close relationship with Axillary nerve + Circumflex vessels

A

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

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59
Q

Outline the Gustilo-Anderson System

A

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)

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60
Q

Outline the Neer Classification system

A

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

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61
Q

Most Prox Humeral fractures can be managed Conservatively.

Outline those

A

Immobilisation w/ Early Mobilisation

Polysling allowing arm to hang (Gravity aids reduction of fragments of most Humeral fractures)

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62
Q

List Surgical Management options of Prox Humeral fractures

Indicated if: Displaced/ Open/ NV Compromised fractures

A

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)

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63
Q

Outline indications of ORIF and Inter-medullary Nailing for Prox Humeral fracture management

A

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
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64
Q

Outline indications for Hemi-arthroplasty for Prox Humeral fracture management

A

Complex injuries

Injuries that include splitting of Humeral Head and are likely to have major complications if ORIF used to treat

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65
Q

Outline indications for RSA, Reverse Shoulder Arthroplasty for Prox Humeral fracture management

A

Low demand pts

Pts needing revision after failed previous procedure

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66
Q

List complications of Prox Humeral fractures

A

Reduced RoM- Extensive PT needed to regain function and reduce pain

Humeral head Avascular Necrosis (RSA or HA may be needed)

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67
Q

Why are Scapular Fractures rare?

A

Protection by surrounding muscles

Associated with high energy trauma

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68
Q

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)

A

Majority: Non-operative re-alignment

ORIF if;

  • Glenohumeral instability
  • Displaced Scapular neck
  • Complex fracture patterns
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69
Q

When may you get Floating Shoulder in Scapular Fracture cases?

A

Scapular Neck Fracture w/ Clavicle Neck fracture

Almost always needs fixation

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70
Q

List Humeral Shaft Fracture RFs

A

Osteoporosis, Previous fractures

Increasing age

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71
Q

How may Humeral Shaft Fractures present?

A

Pain, Deformity

If Radial Nerve involved (high chance), reduced Wrist Extension and Sensation in radial distribution

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72
Q

What is a Holstein-Lewis Fracture

Requires surgical management

A

Fracture of distal 1/3 of humerus-> Radial nerve entrapment

Signs of Radial Nerve neuropraxia (Wrist drop and Reduced sensation)

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73
Q

Outline Investigations for Humeral Shaft Fractures

A

AP + Lateral X-rays

If severely comminuted, CT for pre-op planning

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74
Q

Outline Humeral Shaft Fracture Conservative Management

Use if <20º Ant angulation, <30º Varus/ Valgus angulation and with <3cm of shortening

A

Humeral brace

Regular follow-up with repeated X-ray imaging

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75
Q

Outline Surgical Management of Humeral Shaft Fractures

A

ORIF with a plate

Consider Intra-medullary Nailing if;

  • Pathological features
  • Polytrauma
  • Severe Osteoporosis
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76
Q

Outline the Allman classification system

A

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

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77
Q

How may Clavicle Fractures present

A

Sudden severe pain, worse on active movement

O/E: Focal tenderness, Deformity+Mobility at site

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78
Q

Outline Investigations for Clavicle Fractures

A

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

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79
Q

Most Clavicle Fractures are managed Conservatively

Outline it

A

Sling for 2wks. Kept on until movement is painless and then RoM exercises

Early movement of shoulder joint to prevent Frozen Shoulder developing

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80
Q

Outline Surgical management of Clavicle Fractures

A

ORIF, if fractures failed to unite (2-3mths after injury)

For Open, Bilateral and very Shortened/ Comminuted fractures

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81
Q

Outline Prognosis of Clavicle Fractures

What’s the healing time

A

Non-union is a major one

NV Injury
Puncture injury (Haemo or Pneumo- thorax)

Healing time: 4-6wks

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82
Q

What is Frozen Shoulder

A

Glenohumeral Joint capsule becomes contracted and adherent to Humeral head

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83
Q

List Frozen Shoulder RFs

A

Female
DM, Breast Cancer, Parkinson’s, CT Disease

Previously had Contralateral Frozen Shoulder

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84
Q

Compare Primary and Secondary Frozen Shoulder

A

Primary: Idiopathic

Secondary- Associated with;

  • Rotator Cuff tendinopathy
  • Subacromial impingement syndrome
  • Biceps tendopathy
  • Previous surgery/ trauma
  • Joint arthropathy
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85
Q

Frozen Shoulder progresses in what 3 stages, classically?

A

Painful stage
Freezing stage
Thawing stage

Pain w/ limited movement is present thoughout, little segregates between stages

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86
Q

How can Frozen Shoulder present

A

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
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87
Q

Outline Frozen Shoulder Investigation

Diagnosis is typically clinical, off features alone

A

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

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88
Q

Outline Frozen Shoulder Initial Management

Self-limiting, recurrence isn’t uncommon. Some pts never regain full RoM

A

Education, Reassurance, Advice to keep active

PT, Simple analgesia
Consider GH Joint Corticosteroid injections if no improvement

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89
Q

Outline Frozen Shoulder Surgical Management options

Symptoms majorly affect QoL, no Conservative improvement

A

Joint manipulation under GA to remove capsular adhesions to humerus

Arthrographic Distension

Surgical release of GH joint capsule

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90
Q

What is SAIS, Subacromial impingement syndrome

A

Inflammation + irritation of RC tendons as they pass through Sub-acromial space

Conditions such as;

  • RC Tendinosis
  • Subacromial Bursitis
  • Calcific tendinitis
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91
Q

Who does SAIS most commonly occur in?

A

Under 25s

Typically active individuals/ in manual progressions

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92
Q

The Subacromial Space lies;

  • Below the Coraco-acromial arch
  • Above the Humeral head and Greater Tuberosity

What structures make the Coraco-acromial arch

A

Acromion

Coraco-acromial Ligament

Coracoid process

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93
Q

The underlying cause of subacromial impingement syndrome can be divided into intrinsic and extrinsic mechanisms

Outline Intrinsic Mechanisms

A

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

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94
Q

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)

A

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
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95
Q

How can SAIS present

A

Progressive pain in Ant. Superior Shoulder
Exacerbated by Abduction, relived by rest

May be associated Weakness and Stiffness due to pain

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96
Q

Outline Investigations for SAIS

A

Neers Impingement test
Hawkins test

MRI;

  • Subacromial Oesteophytes + Sclerosis
  • Subacromial Bursitis
  • SA Space narrowing
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97
Q

Outline Neers Impingement test

A

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.

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98
Q

Outline Hawkins test

A

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.

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99
Q

Outline SAIS Conservative Management

A

Analgesia (Usually NSAIDs), PT

Corticosteroid injections in SA Space, if further intervention needed

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100
Q

Outline SAIS Surgical Management options

If SAIS persists >6mths without response to conservative management

A

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

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101
Q

List complications of SAIS

A

RC Degeneration + tear
Frozen shoulder
Cuff tear arthropathy

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102
Q

RC Tears are Acute or Chronic (Lasting <3 or >3mths)

What are the the types

A

Partial thickness

Full thickness;

  • Small (<1cm)
  • Medium (1-3cm)
  • Large (3-5cm)
  • Massive (>5cm or multiple tendons)
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103
Q

List the 4 RC muscles and their primary actions

A

Supraspinatus– abduction
Infraspinatus – external rotation
Teres minor – external rotation
Subscapularis – internal rotation

They all act to stabilise the Humeral Head in Glenoid Fossa

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104
Q

Outline pathophysiology of Acute RC tears

A

Commonly in tendons with pre-existing degeneration, typically after minimal force

Can be due to large force in young people as well

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105
Q

Outline pathophysiology of Chronic RC tears

A

In people with degenerative microtears to tendon, mostly from Overuse

Seen more in older people

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106
Q

List RC Tear RFs

A

Age
BMI >25, Smoking, DM
Trauma, Overuse, Repetitive overhead shoulder movement

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107
Q

How may RC Tears present?

More common in dominant arm

A

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
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108
Q

List 3 Specific tests for RC Tears

What muscles are tested by each one?

A

Jobe’s test (Empty can test)- Supraspinatus

Gerber’s lift-off test- Subscapularis

Posterior cuff test- Infraspinatus + Teres Minor

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109
Q

Describe Jobe’s test (Empty can test)

A

Tests Supraspinatus

  • Place shoulder in 90º Abducton and 30º Flexion
  • Internally rotate fully
  • Gently push downwards on arm

+ve if Weakness on resistance

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110
Q

Describe Gerber’s Lift-off test

A

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

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111
Q

Describe Posterior Cuff test

A

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

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112
Q

Outline RC Tear Investigations

A

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

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113
Q

Conservative Management of RC Tears is preferred in pts;

  • Not limited by Pain/ Loss of Function
  • Presenting within 2wks since injury

Outline it

A

Analgesia, PT

Can trial CS injections

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114
Q

Outline Surgical Management options of RC Tears

If;

  • Presenting 2wks since injury
  • Still symptomatic after conservative management
  • Large and massive tears
A

Repair- Open or Arthroscopically

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115
Q

Outline Pathophysiology of Olecranon Fractures

A

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

116
Q

How may Olecranon Fractures present?

A

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
117
Q

Outline Olecranon Fracture Investigations

Check NV Status, Shoulder+Wrist Joints

A

Basic bloods- Clotting, Group+Save

AP+Lateral X-ray of Elbow + joints above + below

CT: Assessing more complex injuries and degree of comminution

118
Q

Outline Non-operative Olecranon Fracture Management

If Displacement <2mm, but increasingly being used for all pts >75, regardless of displacement

A

Immobilisation in 60º-90º Elbow Flexion for 4-6wks

Early re-introduction of RoM

119
Q

Outline Operative Olecranon Fracture Management options

(Usually if displacement >2mm

A

Tension Band Wiring (If prox to Coronoid process)

Olecranon Plating (If at level/ distal to Coronoid process)

120
Q

What is Dupuytren’s Contracture

A

Contraction of Longitudinal Palmar Fascia

121
Q

Dupuytren’s Contracture is 6:1 Male:Female, peak onset is 40-60y/o.

Which fingers are most commonly affected?
List RFs

A

Ulnar digits- Ring+Little finger

Smoking (x3), Alcoholic cirrhosis, DM
Occupation exposure (Vibrations, heavy manual work)
122
Q

Outline the disease progression of Dupuytren’s Contracture

A
  1. Initial pitting+thickening of palmar skin + SC Tissue
  2. Firm painless nodule forms, fixed to skin + deep fascia
  3. CORD develops resembling a tendon, which begins to contract over mths to yrs
  4. Cord contraction pulls on MCPJs and PIPJs-> Flexion deformity in fingers
123
Q

How may Dupuytren’s Contracture present

45% cases are Bilateral. If Unilateral, mostly on Right Hand

A

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
124
Q

Outline Hueston’s test

A

For Dupuytren’s Contracture

+ve if pt can’t lay palm flat

125
Q

Outline Investigations for Dupuytren’s Contracture

Diagnosis mostly clinical

A

Basic bloods, Random Glucose/ HbA1c

USS imaging can be used to accurately give Intralesional Injections

126
Q

Outline Dupuytren’s Contracture Conservative Management

Along with monitoring, for pts presenting early with no functional disability

A

Hand therapy- Keep active with stretching exercises throughout day

Injectable Collagenase Clostridum Histolyticum (CCM)

127
Q

Outline Surgical Management of Dupuytren’s Contracture

Indications: Functional impairment, Rapidly progressive, PIPJ Contracture, MCPJ Contracture >30º

A

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
128
Q

State the post-op recurrence rate for Dupuytren’s Contracture

What Penile condition is Dupuytren’s associated with?

A

66%

Peyronie’s Disease

129
Q

What is Trigger Finger/ Stenosing Flexor Tenosynovitis?

Mostly occurs spontaneously in otherwise healthy individuals

A

Finger/ thumb click/lock when in flexion, preventing return to extension

130
Q

Most cases of Trigger Finger are preceded by Flexor Tenosynovitis, often from repetitive movements, leading to inflammation of Tendon+Sheath

Outline the Pathophysiology

A

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.

131
Q

List RFs for Trigger Finger

A

Prolonged gripping + Hand use (Occupation/ Hobby)

Increasing age
Female
RA, DM

132
Q

How may Trigger Finger present

A

Initially;
- Painless Clicking/ Snapping/ Catching when extending

Over time;

  • May become painful, especially over Volar MCPJ
  • Digit starts to lock in flexion
133
Q

Outline Investigations and Complications of Trigger Finger

A

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

134
Q

Mostly Trigger Finger can be managed Non-surgically

Outline this

A

Advice about painful activities
Small splint to hold finger in Extension at night

If Unresponsive/ Severe, trial Steroid injections (can improve over few days)

135
Q

Outline Surgical Management of Trigger Finger

A

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

136
Q

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

A

Female gender, Pregnancy, Increasing age, Obesity

Previous wrist injury
Repetitive hand/ wrist movements (Vibrating tools, Assembly line work)

137
Q

List 3 conditions associated with CTS

A

DM, RA, Hypothyroidism

138
Q

How may CTS present?

History, Exam

A

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

139
Q

O/E of CTS in Early stages, there are often no visible findings.

What tests can be used to reproduce sensory systems

A

Tinel’s Test: Percussing over Median nerve

Phalen’s Test: Holding wrist in full flexion for 1min

140
Q

List and describe 3 ddx for CTS

A

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

141
Q

Outline Investigations for CTS

A

Clinical diagnosis

If uncertainty, may use Nerve Conduction Studies to confirm Median Nerve damage

(Normal doesn’t rule out CTS)

142
Q

Outline CTS Non-surgical Treatment

A

PT, Training exercises, Wrist splint (commonly at night);

  • Preventing flexion
  • Prevents exacerbation of Tingling+Pain

Can trial Corticosteroid injections, some ppl may trial NSAIDs

143
Q

Outline CTS Surgical Treatment

Only in severely limiting cases, where previous treatment failed

A

Carpal Tunnel Release surgery;

  • Under LA as a day case
  • Decompresses carpal tunnel, cutting through Flexor Retinaculum, reducing pressure on Median Nerve
144
Q

List complications of Carpal Tunnel Release surgery

Long-term untreated CTS can lead to permanent neurological impairment that will not improve with surgery

A

Persistent CTS symptoms (incomplete ligament release)
Infection, Scar formation
Nerve damage, Trigger thumb

145
Q

Distal Radius Fractures represent 25% of all fractures seen clinically.

List 3 types of Distal Radius Fractures

A

Colles’ (90% of all distal radius fractures)

Smith’s

Barton’s

146
Q

Describe a Colles’ Fracture

(Typically occurs as a fragility fracture in osteoporotic bone)

Describe its pathophysiology

A

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.

147
Q

Describe a Smith’s Fracture

Describe its pathophysiology

A

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

148
Q

Describe a Barton’s Fracture

A

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)

149
Q

List RFs for Distal Radius Fractures

A

Female, Early menopause
Increasing age
Smoking, Alcohol excess
Prolonged steroid use

150
Q

How may a Distal Radius fracture present

A

Immediate Pain +/- Deformity and sudden swelling around fracture, after trauma

Parasthesia/ Weakness, if neurological involvement

151
Q

Outline Neurological Exam for a suspected Distal Radius fracture

(Also check Pulses+CRT)

A

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
152
Q

Outline Investigations for Distal Radius fractures

A

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

153
Q

Outline Distal Radius fracture non-surgical management

A
  • 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
154
Q

Outline Distal Radius fracture Surgical management

(If:

  • Significantly Displaced/ Unstable fractures as can displace further
  • Intra-articular Step of radiocarpal joint >2mm)
A

ORIF w/ Plating or K-wire Fixation

Cast for 8-10wks before wrist functional

155
Q

List the 3 main complications of Distal Radius Fractures

A

Malunion (Shorter radius than ulna-> Less wrist motion, Wrist pain, Less 4arm rotation)

Median Nerve compression

OA

156
Q

List RFs for Knee OA

Genetic, Constitutional, Local

A

Genetic

Constructional;
- Increasing age, Female, Low bone density

Local;

  • Previous joint injury
  • Occupational/ recreational stresses on joint
  • Reduced surrounding muscles strength
  • Joint laxity/ malalignment
157
Q

How may Knee OA present?

History, Exam

A

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
158
Q

Outline Investigations for Knee OA

A

X-ray;

  • Lateral+AP Views (LOSS/ JOSS can be seen)
  • Skyline view to assess for patellar involvement

MRI, if suspecting Ligament injury

159
Q

Outline Initial Management of Knee OA

A
  • Lifestyle changes (Weight loss, Exercise, Smoking)
  • Analgesia
  • PT (Slow progression, improve mechanics)
160
Q

Outline Surgical Management of Knee OA

If conservative doesn’t work- typically Total/ Partial/ Unicondylar Knee Replacement

A

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
161
Q

What is Patellofemoral OA

A

OA affecting the articular cartilage along the Trochlear Groove, on underside of Patella

162
Q

List RFs for Patellofemoral OA

A

Patella dysplasia (-> not fitting properly in Groove)

Hx of patella fracture (damages articular cartilage)

163
Q

Patellofemoral OA can be confirmed with a Skyline view X-ray

How may it present

A

Anterior knee pain, worse with activities that put pressure on patella (Stairs)

Joint stiffness + Swelling

164
Q

Outline Patellofemoral OA Management

A

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
165
Q

List the 2 main function of the Menisci of the knee

Rest on tibial plateau

A

Shock absorption

Increase articulating surface of knee

166
Q

Compare the Medial to Lateral Meniscus

A

Medial;

  • Less circular
  • Attached to Medial Collateral Ligament

Lateral;

  • More circular
  • Not attached to Lateral Collateral Ligament
167
Q

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

A

Vertical
Degenerative
Transverse (Parrot-beak)
Longitudinal (Bucket-Handle)

168
Q

How may Meniscal Tears present

History, Exam

A

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
169
Q

Outline Meniscal Tear Investigations

A

X-rays: To exclude fracture
MRI: Gold standard for diagnosis+Identification

Tests: McMurray’s, Apley’s Grind (V painful)

170
Q

Outline Meniscal Tear Initial Management

A

RICE

Most small tears (<1cm) will initially swell, but pain will subside over next few days

171
Q

Outline Meniscal Tear Further Management

Indications: Larger/ Still symptomatic tears

A

If in Inner 1/3: Trimmed

If in Middle 1/3: Trimmed or repaired (Sutured back together)

Outer 1/3: Repaired (sutured back together)

172
Q

List complications of Meniscal Tears and Arthroscopy

A

Tears: RF for OA later in life

Arthroscopy- Risk of;

  • DVT
  • Damage to local structures (Saphenous N+V, Fibular Nerve, Popliteal vessels)
173
Q

What does the ACL do?

A

Limits excessive;

  • Anterior Displacement of Tibia
  • Knee rotation (especially Internal)
174
Q

Describe the typical mechanism of an ACL Tear and Meniscal

A

ACL: Twisting of Weight bearing knee

Meniscal: Twisting of Flexed, Weight bearing knee

175
Q

How may an ACL Tear present?

50% of ACL tears will have a Meniscal tear, more commonly the Medial

A

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)

176
Q

Outline ACL Tear Investigations

A

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

177
Q

Describe a Segond fracture

Sign of ACL Injury

A

Bony avulsion of lateral proximal tibia

178
Q

Lachman’s test is more sensitive than Anterior Drawer test for an ACL tear

Describe them

A

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
179
Q

ACL Tear definitive management can be Conservative or Surgical

Outline Initial Management of ACL Tear

A

RICE (as for any acutely swollen knee)

180
Q

Outline Conservative Management of ACL Tear

A

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)

181
Q

Outline Surgical Management options of ACL Tear

A

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
182
Q

List ACL-damage related complications

A

Post-traumatic OA is a complication of ACL Injury and ACL Reconstructive surgery

183
Q

What are the functions of the PCL

List common causes of PCL Tears

A

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)
184
Q

How may a PCL Tear present?

How are they investigated

A

Immediate Post. Knee pain
Joint instability

Posterior Drawer test (w/ posterior sag)
MRI: Gold standard

185
Q

Outline PCL Tear management

A

Often Conservatively;
- Knee Brace + PT

Surgery;

  • If still symptomatic + recurrent instability
  • Insertion of Graft
  • If other injuries: Knee surgery for reconstruction
186
Q

The MCL, Medial Collateral Ligament is the most commonly knee ligament to be injured

What is its function?
How is it most often injured?

A

Acts as a Valgus stabiliser of knee

External rotational forces applied to lateral knee

187
Q

How may an MCL Tear present?

History, Exam

A
  • ‘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
188
Q

How is an MCL Tear investigated

A

X-ray: To rule out fracture

MRI: Gold standard

189
Q

Outline the Grades of MCL Tears

A

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
190
Q

Outline MCL Tear Grade 1 Management

What’s the aim of treatment

A

RICE, Analgesia, PT (Strength training)

Aim: Return to full exercise within 6wks

191
Q

Outline MCL Tear Grade 2 Management

What’s the aim of treatment

A

Analgesia, Knee brace, PT (Weight-bearing/ Strength training)

Aim: Return to full exercise around 10wks

192
Q

Outline MCL Tear Grade 3 Management

What’s the aim of treatment

A

Analgesia, Knee brace + Crutches
If distal avulsion, consider surgery

Aim: Return to full exercise within 12wks

193
Q

List complications of an MCL Tear

A

Joint instability

Saphenous nerve damage

194
Q

Patella Fractures are 2:1 Male:Female

Usual causes?

A

Major: Direct trauma to Patella

Less common: Rapid eccentric contraction of Quad

195
Q

How may Patella Fractures present

History, Exam

A

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
196
Q

What congenital condition can be mistaken for a Patella Fracture

Describe it

A

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

197
Q

Outline Patella Fracture Investigations

A

X-ray: AP + Lateral + Skyline views

CT: Comminuted fractures, any uncertainty

198
Q

Patella Fractures are often managed Conservatively. Outline this

(Indications: Non/ Minimally- displaced or with Vertical fractures where extensor mechanism functions)

A

Brace or Cylinder cast

Early weight-bearing in Extension
Increasing Flexion incrementally

199
Q

Outline Patella Fracture Surgical Management

Indications: Major displacement/ Compromised Extensor Mechanism

A

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

200
Q

Outline Pathophysiology of Achilles tendonitis

A

Repetitive actions of tendon-> Microtears-> Local inflammation

Over time, the tendon becomes Thickened, Fibrotic and loses elasticity

201
Q

List RFs for Achilles tendonitis or Rupture

A

Male, Increasing age
Unfit, Obesity
Sudden increase in exercise, Poor footwear

Recent use of Fluroquinolone (for tendon rupture)

202
Q

Outline Achilles tendonitis management

A

Acute;

  • Stop precipitating exercise
  • Ice the area
  • Use anti-inflammatories regularly

Chronic;
- Rehab and PT

203
Q

Outline Acute Achilles Tendon Rupture Management

Acute: <2wks

A

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
204
Q

Outline Chronic Achilles Tendon Rupture or Re-rupture Management

(>2wks)

A

Surgical fixation with end-to-end tendon repair

205
Q

What is Hallux Valgus/ Bunions?

A

Deformity at MTPJ1, characterised by;

  • Medial deviation of Metatarsal 1
  • Lateral rotation +/- Rotation of Hallux
  • W/ Joint Subluxation
206
Q

List RFs for Hallux Valgus

A

Female, High-heeled or Narrow fitting footwear
CT Disorders, Hypermobility syndromes

Anatomical variations;

  • Long 1st Metatarsal
  • Non-alignment of MTPJ1
  • Flat feet
207
Q

How may Hallux Valgus present

A

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
208
Q

Outline Hallux Valgus Investigations

A

Radiographic imaging (X-ray) to Lateral Deviation Degree

HV diagnosed if angle between Metatarsal 1 and 1st Prox Phalanx is >15º

209
Q

Outline non-surgical management of Hallux Valgus

A

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
210
Q

List Surgical Management options for Hallux Valgus

(If QoL significantly impaired)

List complications for all the procedures

A

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

211
Q

List complications of Hallux Valgus

A

Avascular necrosis
Non-union
Displacement
Reduced RoM

212
Q

The Calcaneum is the most commonly fractured tarsal bone

Due to what cause?

A

Fall from height (Axial loading directly onto bone)

Thus, it is associated with Concurrent fractures (spinal or contralateral calcaneus)

213
Q

Compare the 2 types of Calcaneal Fractures

A

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
214
Q

Outline the Sanders Classification

A

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

215
Q

How may a Calcaneal Fracture present

Uncommonly present as Stress fractures, where there is pain on activity, w/o trauma history

A

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)

216
Q

Outline Calcaneal Fracture Investigation + Results

A

Initially X-ray: AP+Lateral+Oblique views show;

  • Calcaneal shortening
  • Varus tuberosity deformity
  • Reduced Böhler’s Angle

CT: Gold standard, perform whenever suspected

217
Q

Outline treatment for Intra and Extra articular Calcaneal Fractures

A

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

218
Q

Outline the surgical management for Calcaneal Fractures

A

Closed reduction with Percutaneous Pinning;
- May be attempted for >1cm but minimally displaced fractures

ORIF;
- Usually needed

219
Q

List a complication of Calcaneal Fractures and how it is treated

A

Subtalar arthritis

Treated Conservatively;

  • Analgesia, PT
  • If unsuccessful, may need Subtalar Arthrodesis
220
Q

The Talus is the 2nd largest tarsal bone and the 2nd most common tarsal bone to fracture

Outline the mechanism

A

Usually after high-energy trauma, where ankle forced into Dorsiflexion

This causes Talus to press against Tibial Plafond, causing a fracture

221
Q

Outline investigations for Talar Fractures

A

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

222
Q

Talar Fractures are mostly in the Talar Neck

Outline their classification

A

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

223
Q

Outline Management of Hawkins Type 1 Talar Neck fractures

A

Conservatively;

  • Plaster
  • Non-weight bearing crutches for 3mths
224
Q

Outline Management of Hawkins Type 2-4 Talar Neck fractures

A
  • 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
225
Q

List complications of Talar Fractures

A

Avascular Necrosis

OA 2ndary to AVN/ Malunion of any Talar joints

226
Q

What is Hawkins sign

What does it indicate

A

Subchondral lucency of the talar, visible 6-8 weeks following injury

Sufficient vascularity of the talus, so low risk of AVN

227
Q

What are (Plafond) Tibial Pilon Fractures?

What are they caused by?

A

Severe injuries affecting distal tibia

Caused by High energy axial load, as Tibial Plafond is injured by Talus punching upto it

228
Q

Tibial Pilon Fractures are characterised by Articular Impaction, Severe Comminution and often associated with Soft Tissue injury

How may they present

A

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
229
Q

Outline Investigations for Tibial Pilon Fractures

A

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

230
Q

Outline initial Tibial Pilon Fracture management

A
  • Limb realignment, then Below-knee backslab
  • Repeat NV exam and X-rays
  • Limb must be elevated and monitored for Compartment Syndrome
231
Q

Simple undisplaced pilon fractures are rare but may be treated non-operatively.

Outline Surgical management of Tibial Pilon fractures

A

Staged approach;

  • Temporary spanning external fixator
  • Definitive fixation (ORIF) 7-14 days later once soft tissues healed
232
Q

List complications of surgical repair of Tibial Pilon fractures

A

Compartment syndrome
Wound infection/ dehiscence
Post-traumatic arthritis

Delayed/ non- union (commonly in Metaphyseal region)

233
Q

Ankle Fractures are more common in Young Males/ Older Females

Describe the Syndesmosis

A

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
234
Q

What is an Ankle Fracture?

A

Fracture of any Malleosus w/ or w/o Disruption to the Syndesmosis

(There are Medial, Lateral and Posterior Malleoli)

235
Q

Classify Ankle fractures anatomically

A
  • Isolated Lateral Malleolar fractures
  • Isolated Medial Malleolar fractures
  • Bimalleolar fractures (Medial+Lateral)
  • Trimalleolar fractures
236
Q

Outline the classification of Lateral Malleolar fractures most widely used in A&E

A

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)

237
Q

Which classification system is mostly used for Ankle Fractures in Orthopaedic practice

A

Lauge-Hansen classification

Based on ankle position at time of injury and deforming force involved

238
Q

How may an Ankle Fracture present

A

Ankle pain
May be Deformity if dislocation present

Very deformed ankles;

  • May have NV compromise
  • Often open fractures (typically over medial side)
239
Q

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

A

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
240
Q

When can the Ottawa Ankle Rules not be used?

A

Pt;

  • Intoxicated/ Uncooperative
  • Other distracting painful injuries
  • Diminished sensation in legs
  • Gross swelling
241
Q

Outline Ankle Fracture Investigations

A

X-ray: AP+Lateral views (When Dorsiflexed)
Check for Talar Shift

CT for surgical planning: For Complex fractures, especially if disabled posterior malleolus fragment

242
Q

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

A
  • Immediate fracture reduction (usually A&E, Sedated)
  • Below-knee back slab
  • Repeat NV Exam, X-ray
243
Q

Outline Surgical Management for Ankle Fractures

What are 4 indications

A

ORIF

Displaced Bimalleolar/ Trimalleolar fractures
Open fractures
Weber C fractures
Weber B fractures w/ Talar Shift

244
Q

List complications of Ankle fractures

A

Risk of post-traumatic arthritis

Additional RFs post-ORIF;

  • Wound infection
  • DVT/ PE
  • NV injury
  • Non-union
  • Metalwork prominence
245
Q

Compare the 2 types of Ankle sprains

A

High: Injuries to Syndesmosis

Low: Injuries to ATFL and CFL (CFL more common)

246
Q

What is Degenerative Disc Disease

A

Natural deterioration of the Inter-vertebral Disc structure, so they become progresviyl weak and begin to collapse

247
Q

Degenerative Disc Disease is often related to Aging

List factors which which precipitate damage to the Inter-vertebral discs

A
  • Progressive dehydration of Nucleus Pulposus
  • Daily activities cause tears in Annulus Fibrosis
  • Injuries/ Pathology-> Instability
248
Q

The cascade of changes seen in Degenerative Disc Disease can be divided into 3 stages, the duration of which can vary significantly

Outline them

A

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

249
Q

How may Degenerative Disc Disease present?

Clinical features depend on disease Region+Severity

A

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
250
Q

Outline Lasegue Test (AKA Straight leg raise)

A

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

251
Q

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)

A
  • Red flags present
  • Radiculopathy w/ pain for >6wks
  • Evidence of Spinal Cord compression
  • Imaging would significantly alter management

Most cases don’t need imaging

252
Q

Outline Imaging Investigations + Results for Degenerative Disc Disease

A

MRI Spine: Gold standard

  • Signs of degeneration
  • Reduced disc height
  • Presence of annular tears
  • Endplate changes
253
Q

Degenerative Disc Disease management is highly variable and pt-dependent

When is Emergency intervention needed?
Describe it

A

Only in cases of Cauda Equina Syndrome

Decompression of spinal canal within 24-48hrs of symptom onset, through either Laminectomy or Discectomy

254
Q

Radiculopathy is a conduction block in the axons of a spinal nerve or its roots

Compare Radicular Pain and Radiculopathy

A

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

255
Q

How may Radiculopathy present?

A

Parasthesia, Numbness, Weakness
Often: Radicular pain (Deep, Strap-like, Narrow), may be intermittent

Look for Red Flag symptoms

256
Q

O/E of ps with Radiculopathy, it is important to identify Myotomal+Dermatomal involvement

How do you evaluate for Cauda Equina syndrome?

A

Assess;

  • Pinprick sensation in peri-anal Dermatome
  • Anocutaneous reflex
  • Anal tone
  • Rectal pressure sensation

All reduced in CES

257
Q

Most Radiculopathy cases are due to IV Disc Prolapse and can be managed non-operatively

List indications for Surgical Management

A
  • Unremitting pain, despite Conservative managment
  • Progressive weakness
  • New/ progressive Myelopathy (Cord compression)
258
Q

Outline Symptomatic (Conservative) management of Radiculopathy

A

Analgesia: Neuropathic meds often used;

  • 1st line: Amitryptilline
  • 2nd line: Pregabalin, Gabapentin

Benzodiazepines/ Baclofen: Pts may have muscle spasms

Physiotherapy

259
Q

List complications of Colles’ Fractures

Smith’s causes Garden spade

A

Dinner fork deformity
Median Nerve palsy, Post-traumatic CTS
EPL tendon tear
2dary OA

260
Q

Outline the Garden Classification

A

Type 1: Incomplete, non-displaced fracture
Type 2: Complete, non-displaced fracture

Type 3: Complete, partially displaced fracture
Type 4: Complete, fully displaced fracture

261
Q

How are these types of #NOF treated?

  1. Displaced Intra-capsular/ Subcapital
  2. Inter-trochanteric + Basocervical
  3. Non-displaced intracapsular
  4. Sub-trochanteric
A
  1. Hemiarthroplasty (If young, ORIF+Cancellous Screws)
    2;
    - Dynamic Hip Screw, if Stable (2/3 parts)
    - Short IM Nail, if Unstable (4/+ parts)
  2. Cannulated hip screw
  3. IM Nail
262
Q

What nerve injuries are associated with Tibial Shaft fractures

How does this present

A

Sural nerve (Only sensory)

Sensory deficit over;

  • Posterolateral distal 1/3 of leg
  • Lateral aspect of foot
263
Q

Suggest a compication of a Total Hip Replacement

A

Posterior Hip Dislocation

264
Q

Outline patterns of Radial Nerve injury

A

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
265
Q

Outline the Female Athletic Triad

A

Osteoporosis
Eating disorders
Amenorrhoea

266
Q

Compare Monteggia+Galeazzi fractures

These involve Radius/ Ulna shaft fractures and a dislocatio

A

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
267
Q

List the most likely causes of a limping child aged;

  • 1-3yrs
  • 3-6yrs
  • 6-10yrs
  • 10-14yrs
A

1-3: DDH (more common in girls)
3-6: Septic arthritis
6-10: Perthes (can affect ages 3-11)
10-14: SCFE/ SUFE

268
Q

Outline Perthes’ Disease pathology

A

Part/ all of Femoral head loses blood supply, leading to AVN

269
Q

How does Perthes’ disease present?

Roll test: While Supine roll hip into I+E Rotation, +ve if Guarding/ Spasm

A

Typically Unilateral

  • Subacute Limp
  • Limited hip rotation
  • Groin/ Thigh/ Knee pain, worse w/ activity
  • All hip movements limited

Initally: Antalgic gait
Later: Trendelenburg gait

270
Q

Oultine Perthes’ Investigations

A

FBC, ESR

X-ray;

  • Early: May show joint space widening
  • Later: Reduced nuclear femoral head size, w/ patchy density
271
Q

Outline Non-surgical treatment of Perthes’

If Bone age<6

A
  • Restrict activities+weight bearing until ossified

- PT, NSAIDs

272
Q

Outline the Prognosis of Perthes’

A

Mostly good outcomes, at least 50% do well w/o treatment

Common complications;
- Pain, OA, Ongoing hip dysfunction

273
Q

List Perthes’ disease RFs

A
  • Male gender
  • More common in Whites than Blacks
  • Genetic conditions
274
Q

SUFE is often atraumatic/ due to minor injury
List the 4 separate clinical groups

(Can be Stable or Unstable- Able to walk or not)

A

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

275
Q

List SUFE RFs

A

Obesity
Local trauma, Inflammatory conditions
Chemo, Previous Pelvis radiation

Deficiencies;

  • Hypothyroidism
  • Hypopituitarism
  • GH deficiency
  • Vit D deficiency
276
Q

Outline SCFE/ SUFE pathology (Slipped Upper/Capital Femoral Epiphysis)

A

Epipysis + Diaphysis slipped out of normal position

277
Q

How does SUFE present?

A
  • 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)
278
Q

Outline Investigations for SUFE

A

AP+Lateral X-rays show either/ both;

  • Epiphyseal line widening
  • Femoral head displacement

USS can detect effusion
CT: Consider if complex surgery planned

279
Q

List DDH RFs

A
  • Sibling with DDH
  • Female gender
  • Breech presentation (Vag delivery/ C-section)
  • Prematurity
280
Q

List complictions of Surgery to treat DDH

A

Re-dislocation
Stiffess
Blood loss
AVN of Capital Femoral Epiphysis

281
Q

2 ddx for Hip OA are Trochanteric Bursitis and Gluteus Medius Tendinopathy

Compare these

A

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
282
Q

How are distal tibia fractures treated and how long does it take to recover?

A

IM Nailing

3-7 months

283
Q

List 3 long term complications of a Hip replacement (Total or Hemi)

A

Re-dislocation
Acetabulum erosion
Leg length discrepancies

284
Q

Why does smoking prolong fracture healing time

A
  • Nicotine inhibits ostroegen

- Unopposed osteoclast activity

285
Q

List 2 major complications of compartment syndrome

How can they be monitored for

A

Re-perfusion syndrome, Rhabdomyolysis

Monitor Kidney function and CK Levels

286
Q

List 2 characteristic features of the pathogenesis of OA

A

Articular cartilage degradation

Bone remodelling

287
Q

Outline tibial plateau fracture Conservative Mx

Surgery if Displaced/ Open

A

Hinged knee brace for 8-12wks

Year 3 Surgery (7 decks)

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