Orthopaedics Flashcards
What is the presentation of a hip fracture?
externally rotated and shortened
pain in groin, can be referred to knee
decreased mobility
obvious deformity with inflammation
usually geriatric patient with low impact trauma
what are the two types of hip fracture?
intertrochanteric line between greater and less trochanter - either intra or extra capsular
an extra capsular: inter-trochanteric - inbetween the trochanters or sub trochanteric - 5cm distal from lesser trochanter
what is the initial management of a hip fracture?
investigations:
- AP and lateral hip x ray
- FBC, U and E, coagulation screen, group and save,CK (fall)
- urine dip and ecg - why fall
management:
- A-E approach
- opioid or regional analgesia such as fascia-illiaca block
- surgery
how does a colle’s fracture present?
dinner fork deformity - dorsal angulation and dorsal displacement
what are the causes of a colles’ fracture?
FOOSH, forcing wrist into supination
usually due to osteoporosis in elderly
what is the initial management of a colles’ fracture?
if displaced - closed reduction immediately using traction and manipulation under anesthetic (haematoma block or bier’s block) and then placed in a below elbow backslab cast….1 week check up
if significantly displaced or unstable - surgery using ORIF with plating or k wire fixation
how does an ankle fracture present?
ankle pain
visible bruising and inflammation
decreased mobility
unable to weight bear
visible deformity
what is the initial management of an ankle fracture?
investigations -
plain radiograph AP and lateral, check for talar shift
management -
immediate fracture reduction and below knee back slab
neurovascular exam
depends on fracture time
how does an open fracture present?
direct communication between fracture site and external environment
or if pelvic - into vagina or rectum
what are the causes of an open fracture?
high energy trauma
define ankle fracture
a fracture of any malleolus (lateral, medial, or posterior), with or without disruption to the syndesmosis (where tibia and fibula join).
what are the possible causes of acute joint pain
Vascualr
Infective
Trauma
Autoimmune
Metabolic
Iatrogenic
Neoplastic
Congenital
Degenerative
Endocrine
Functional
what are the possible causes of lower back pain?
Cauda equina
Lumbar stenosis
Mechanical back pain
Age related changes
how do you apply a plaster?
Choose stockinette of the appropriate width; it should be form fitting but not so tight that it compromises circulation.
Apply stockinette to cover the area (eg, about 5 to 10 cm) proximal and distal to the anticipated extent of casting material.
Place several layers of padding (typically, 4).
Wrap the padding circumferentially, from distal to proximal, over the area to which the cast will be applied. Overlap the underlying layer by half the width of the padding.
Apply the padding firmly against the skin without gaps but not so tightly that it compromises circulation.
Extend the padding slightly (about 3 to 5 cm) past the anticipated extent of the plaster or fiberglass.
Smooth the padding as necessary to avoid protrusions and lumps. Tear away some of the padding in areas of wrinkling to smooth the padding.
Add separate, non-circumferential pieces of padding over and around bony prominences.
Immerse the casting material in lukewarm water.
Gently squeeze excess water from the casting material. Do not wring out plaster.
Apply the casting material circumferentially from distal to proximal, overlapping the underlying layer by half the width of the casting material.
Use 4 to 6 layers of plaster (typically) or 2 to 4 layers of fiberglass to ensure adequate strength of the cast.
Smooth out casting material to fill in the interstices in the plaster, bond the layers together, and conform to the contour of the extremity. Use your palms rather than your fingertips to prevent the development of indentations that will predispose the patient to pressure ulcers.
Fold back the stockinette before adding the last layer of casting material. Roll back the extra stockinette and cotton padding at the outer margins of the cast to cover the raw edges of the splinting material and create a smooth edge; secure the stockinette under the casting material.
Hold the body part in the desired position until the cast material hardens sufficiently, typically 10 to 15 minutes.
Check for distal neurovascular status (eg, capillary refill and distal sensation) and motor function.
what are the causes of soft tissue injury to the shoulder joint?
Rotator cuff tears
Glenohumeral, coracohumeral, traverse humeral ligament tear
Bankart lesion
Impingement - damage to bursa
what are the causes of soft tissue injury to the fingers?
Extensor tendon injuries?
how does a knee dislocation present?
Crush injury or fall from height or dashboard injury (axial load to flexed knee)
Deformity of knee
Pain
Unstable
what is the initial management of a knee dislocation?
Neurovascular exam
Ap and lateral x ray
Ct for other fractures
Closed reduction
May require surgery
what are the complications of an ankle fracture?
post traumatic arthritis
what are the two types of ankle sprain?
high ankle sprains, which are injuries to the syndesmosis, or low ankle sprains, which are injuries to the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL)
how are ankle sprains usually causes?i
inverted and plantarflexed
what is the difference in treatment of an intracapsular v extracapsular nof?
replacement - extracapsular
fixation - intracapasular because of risk of avascular necrosis
how is a nof fracture surgically fixed?
nail or dynamic hip screw
what is shenton’s line/
Shenton line is an imaginary curved line drawn along the inferior border of the superior pubic ramus (superior border of the obturator foramen) and along the inferomedial border of the neck of femur. This line should be continuous and smooth - if isnt could be a fracture
how do you differentiate between an intracapsular and extracapsular nof fracture?
intertrochanteric line - across lesser and greater trochanter is where capsule joins
how are intracapsular hip fractures classified?
I
Non-displaced and Incomplete
II
Complete fracture but nondisplaced
III
Complete fracture, partial displacement
IV
Complete fracture fully displaced
what rules can be utilized to decide if an ankle fracture requires a radiograph?
ottawa ankle rules
how are intracapsular hip fractures classified?
Gardens’:
I
Non-displaced and Incomplete
II
Complete fracture but nondisplaced
III
Complete fracture, partial displacement
IV
Complete fracture fully displaced
Pauwels classification
The Pauwels classification (figure 3) classifies fractures according to the angle of the fracture line from horizontal:
Type I: between 0 and 30 degrees
Type II: between 30 and 50 degrees
Type III: more than 50 degree
describe the blood supply of the neck of femur
Retrograde
Predominantly through medial circumflex femoral artery so if intracapsular this causes avascular necrosis
how do you differentiate surgical treatment for intra v extra capsular NOF fracture?
if intracapsular - replacement
hemi if older, and full if younger
if extracapsular - fixation usually through DHS
what examinations are required for NOF fracture?
full neurovascular exam
investigate cause of fall
what is a differential diagnosis for a nof fracture?
fracture of pelvis or acetabulum
what are the long term complications of nof fracture?
joint dislocation, peri-prosthetic fracture, joint infection
what is a smith’s fracture?
the volar angulation of the distal fragment of an extra articular fracture of the distal radius
caused by falling backwards and planting outstretched hand, forcing pronation
what is a barton’s fracture?
this is an intrarticular fracture of distal radius with dislocation fo the radio-carpal joint
what are the risk factors for distal radial fractures?
age
female
early menopause
smoking or alcohol
prolonged steroid use
what do you assess for in a colles’ fracture and how would you go about doing this?
neurological exam:
median nerve(most likely) - abduct thumb, palmar surface of thumb and index
ulnar - adduct thumb, palmar little finger
radial - extension of IPJ of thumb, dorsal 1st web space
capillary refill time and pulses
limb above and below
what are some differentials for colles?
carpal bone fracture, tendonitis
what are the criteria for diagnosing a colles’ fracture from a plain radiograph?
reduced radial height (less than 11mm)
reduced radial inclination (less than 22 degrees)
dorsal/volar tilt (more than 11 degrees)
see workbook
what are some complications following distal radius fractures?
malunion
median nerve compression
osteoarthritis
how do you classify an ankle fracture?
Weber A = below syndesmosis
Weber B = at level
Weber C = above syndesmosis
in which circumstances is surgical management opted for an ankle fracture?
- displaced bimalleolar or trimalleolar fracture
- weber C
- weber B with talar shift
- open fractures
what are the main complications of an ankle fracture?
post traumatic arthritis
infection, DVT, PE, neurovascular exam, non union
what is adhesive capsulitis?
the glenohumeral joint capsule becomes contracted and adherent to femoral head - pain and reduced ROM
what are the risk factors for adhesive capsulitis?
women
40-70 yrs old
previously affected, more likely to be in contralateral shoulder
diabetes
what are the causes of adhesive capsulitis?
idiopathic
rotator cuff tendinopathy
subacromial impingement syndrome
biceps tendinopathy
previous surgery
how does a person with adhesive capsulitis present?
generalised deep and constant pain of shoulder
joint stiffness esp on external rotation and flexion
atrophy of deltoid muscle
how can you diagnose adhesive capsulitis?
clinical features
can see the glenohumeral joint thickening on MRI
how is adhesive capsulitis managed?
reassure patient
physio
simple analgesics, possible corticosteroid injections
possibly surgery involving joint manipulation to remove capsular adhesion to humerus
define radiculopathy and radicular pain
radiculopathy is a state of neurological loss which could cause radicular pain. it is a conduction block in the axons of a spinal nerve or its roots so therefore motor and sensory axons can not function
radicular pain is caused by damage/irritation of spinal nerve tissue such as DRG
what are some causes of radiculopathy?
intervertebral disc prolapse - due to rupture of annulus fibrosus and sequestration of the disc material
degenerative disease - causing spinal canal stenosis usually C5/6 or C6/7
fracture
malignanavy
infection - osteomyelitis, extradural abscesses
what are the clinical features of radiculopathy?
sensory - paraesthesia
motor - weakness
^ dermatome and myotome involvement
radicular pain - burning, deep pain
what are the red flag symptoms of radiculopathy that indicate cauda equina syndrome?
faecal incontinence
painless urinary retention
saddle anaesthesia
erectile dysfunction
what are the red flag symptoms of radiculopathy that indicates infection?
immunosupression
IV drug abuse
unexplained fever
what are the red flag symptoms of radiculopathy that indicate fracture?
chronic steroid use
what are the red flag symptoms of radiculopathy that indicate malignancy?
new onset after 50 yrs old
what are the red flag symptoms of radiculopathy that indicate metastatic disease?
history of malignancy
give 3 examples of differential diagnoses for radiculopathy?
referred pain -from MI, or UTI
meralgia paraesthesia - compression of lateral cutaneous nerve of thigh as it passes under inguinal ligament
piriformis syndrome - anatomical variations of the muscle or sciatic nerve causing pain in sciatic region
what is the first line drug for treatment of radiculopathy?
amitriptyline
define degenerative disc disease and some causes
the natural deterioration of the intervertebral disc structure
caused by age - progressive dehydration of nucleus pulposus and daily activities causing tears in annulus fibrosis or any spinal fractures
what are the clinical features of degenerative disc disease?
local spinal tenderness, contracted paraspinal muscles, hypomobility, painful extension of back/neck
can cause radicular leg pain (reproduced by passively raising extended leg - lasegue sign)
what are the differential diagnoses of DDD?
cauda equina, malignancy
what is the gold standard investigation for DDD?
MRI of spine - degeneration, reduce of disc height, presence of annular tears
how do you manage DDD?
analgesia
mobility
physio
pain clinic
which cervical vertebrae are more likely to be fractured?
C2 and 7
which system is used to classift cervical spine fractures?
AO classification
what are the clinical features of cervical fractures?
usually older patients with low impact injury
neck pain
neurological involvement
if injury to vertebral artery - posterior circulation stroke
what is the jefferson’s fracture?
fracture of the atlas due to axial loading resulting in occipital condyles being driven into lateral masses of C1
what is a hangman’s fracture?
traumatic spondylolithesis of axis, fracture through pars interarticularis of C2 bilaterally usually with subluxation of C2 on C3
what is n odontodid peg fracture?
low impact older patients causing fracture of odontoid peg
what investigations are requried for cervical fracture?
CT in adults, MRI in children
how is a patient with a suspected cervical fracvture maahed?
3 point c spine immobilisation until confirmed then given rigid collars and halo vests. if unstable treated with surgery to fuse to injured segment of the spine to uninjured segments above and below
what is the most commonly fractured region of the spine?
thoracolumbar (T11-L2)
how are thoracolumbar fractures classified?
AO classification:
A = compression injury
B = distraction injury
C = translation injury
what are the cllinical features of a throacolumbar fracture?
back pain
neuro involvement
what is the investigations required for throacolumbar fracture?
plain film radiograph and then CT if abnormal
how are thoracolumbar fractures managed?
immobilisation - extension bracing and lumbar corsets
analgesia
physio
operative - decompression and instrumented spinal fusion
what is the pathophysiology behind osteoarthritis?
degradation of cartilage causing remodelling of bone due to an active response of chondrocytes in the articular cartilage and the inflammatory cells releasing enzymes which break down collagen and proteoglycans which destroy cartilage
what are the clinical features of OA?
pain and stiffness
worse with activity and over day
reduced ROM
bouchard nodes (swelling of PIPJ) or herberden nodes (swelling of DIPJ)
fixed flexion defomity in knees
what are the radiological features of OA?
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
what is the management of OA?
conservative management
simple analgesia and topical NSAID’s
intra-articular steroid injections
arthroplasty, osteotomy and arthrodesis (joint fusion)
what are the principles of fracture management?
REDUCE- restore anatomical alignment,
label an mri scan of the spine
https://learningneurology.com/diagnostic-tests/approach-to-mri-spine/
from which level does it becomes lower motor neurone signs?
L1
what are 4 upper motor neurone signs?
weakness
hypertonia
hypereflexia
extensor plantar reflexes
what are 5 lower motor neurone signs?
fasciculations
atrophy
hyporeflexia
hypotonia
flaccid muscles
define osteomyelitis
infection of the bone - usually vertebrae in adults
what are the common causative organisms of osteomyelitis
staph aureus, streptococci, enterobacteur spp, h.influenzae, p.aerginosa, salmonella spp
how can necrosis occur in osteomyelitis?
the infection can lead to devascularisation of the affected bone and resorption of surrounding bone
what are some risk factors for developing osteomyelitis?
diabetes(diabetic foot), immunosuppression (steroids, AIDS), alcohol, IV
what are the clinical features of osteomyelitis?
severe pain
pyrexia
tender
swelling
erythema
previous history of trauma
look for potential sources of infection - pock marks or sinuses, wounds
whats a special case of osteomyelitis in the spine?
potts disease - mycobacterium tuberculosis
which investigations are required for osteomyelitits?
FBC, CRP, ESR, blood cultures from bone biopsy at debridement
plain radiograph - osteopenia, periosteal thickening, endosteal scalloping, focal cortical bone loss
MRI for definitive diagnosis
how do you manage a patient with osteomyelitis?
long term IV antibiotic therapy for more than 4 weeks
what are some complications of osteomyelitis?
sepsis
associated septic arthritis or soft tissue infections
children experience growth disturbances
recurrence of infection - chronic osteomyelitis
based on different symptoms alongside an acutely swollen joint, which arthritis would be suspected?
GI - enteropathic arthritis
genitourinary - reactive
skin changes - psoriatic
what would the findings of a joint aspiration be to suspect septic arthritis?
turbid in appearance
very high white cell
high percentage of neutrophils
what are the differential diagnoses for an acutely swollen joint?
`septic arthritis
haemarthrosis
crystal arthropathies - gout and pseudogout
rheumatological
osteo
bursitits
tendon injury
ankylosing spondylitis
psoritatic arthritis
which classification is used for open fractures?
gustilo-anderson:
type 1 - less than 1cm and clean
type 2 - 1 to 10cm and clean
type 3a - more than 10cm and high energy but adequate soft tissue
type 3 b - without adequate soft tissue
type 3 c - all injuries with vascular injury
which investigations are required for open fractures?
blood test - clotting screen and group and save
plain film radiograph
how are open fractures managed?
urgent realigment and splinting of limb
broad spectrum antibiotics
tetanus vaccination
photograph wound
remove debris
saline soaked gauze
wash out wound
sekeltal stablisiation
vascular compromise
give examples of benign bone tumours
bone forming-
osteoma
osteoid sarcoma
osteoblastoma
cartilage forming -
chondroma
osteochondroma
chondroblastoma
fibrous tissue -
fibroma
fibromatosis
giant cell -
benign osteoclastoma
give examples of malignant bone tumours
bone forming -
osteosarcoma
cartilage forming -
chondrosarcoms
fibrous tissue -
fibrosarcoma
giant cell -
malignant osteoclastoma
marrow -
ewing’s
myeloma
where is metastatic cancer spread to bone usually originate?
renal, thyroid, lung, prostate, breast
what are the risk factors for developing primary bone cancer?
genetic -RB1 (retinoblastoma) and p53 = osteocarcomas
- TSC1 and TSC2 = chondromas
exposure to radiation or alkylating agent in chemo
benign bone conditions - paget’s disease
what are the clinical features of bone cancer?
pain
worse at night
fracture without history of trauma
feature of osteoid osteoma
10-20 yrs old
males
<2cm
long bones
better with NSAIDS
radiolucent nidus with rim of reactive bone
conservatively managed
features of osteochondroma
10-20 yrs
male
asymptomatic
slow growing
radiographically show pedunculated bony growth
managed conservatively
features of chondromas
20-50 yrs old
long bones
asymptomatic or pathological fracture
well circumscribed
conservative or removed with curettage and bone grafting
features of giant cell tumour
20-30 yrs old
lone bones
pain, swelling, stiffness
radiographically show eccentric lytic area - ‘soap bubble’
features of osteosarcoma
very common malignant
either 10-14 yrs or those above 60
femur or tibia
constnant pain and tender soft tissue mass
radigraphically show medullary and cortical bone destruction
tissue biopsy required and surgical resection with chemo
features of ewing’s sarcoma
paediatric
long bones
painful and enlarge mass
tender and warm
lytic lesion and periosteal reactions
neoadjuvant chemo and surgical excision
features of chondrosarcoms
cartilage malignancy
40-60 affecting axial skeleton
painful and enlarging masss
lytic lesions with calcification, cortical remodelling and enodsteal scalloping
intralesional curettage and local excision
how are orthopaedic tumours classified?
enneking staging system
what are the main causative organisms of septic arthritis?
staph aureus
strep
gonorrhoea
salmonella
how can septic arthritis occur?
through bacteraemia - recent cellulitis or uti
direct innoculation
spreading from adjacent osteomyelitis
what are the main risk factors for septic arthritis?
age
pre existing joint disease
diabetes
CKD
joint prosthesis
IV drug use
how does septic arthritis present?
swollen joint
pain so unable to weight bear or move
red and warm
what investigations are required to diagnose septic arthritis?
FBC, CRP, ESR and urate
blood cultures
joint aspiration - gram stain, leukocyte count, polarising microscopy, fluid culture
plain film radiograph - soft tissue swelling, fat pad shift, joint space widening
how is septic arthritis managed?
antibiotic 4-6 weeks
irrigation and debridement
what are the 2 main complications of septic arthritis?
osteoarthritis
osteomyelitis
what are the main principles of fracture management?
- REDUCE
- HOLD
- REHABILIITATE
describe the principles of reduction
tamponade to stop bleeding
reduction in traction to reduce swelling
reduce in traction on traversing nerve to reduce neuropraxia
reduction of pressures on traversing blood vessels
how does the maoeuvre work to allow fracture reduction?
one person performs reduction, one provides counter traction and third to apply plaster
describe the principle of ‘hold’
required when the muscular pull across the fracture site is strong and fracture is therefore unstable
first 2 weeks plaster must not be circumferential to allow space for swelling
if axial instability (tibia fibula or radius-ulna fracture) then plaster should cross both joint above and below
describe the principles of rehabilitate
physio
define compartment syndrome
a critical pressure increase within a confined compartmental space
usually following high energy trauma, crush injury or fractures
fascial compartments are closed and cannot be distended so any fluid will increase intra compartmental pressure. as pressure increases veins get compressed, increasing hydrostatic pressure causing fluid to move down its gradient out of the veins in to the compartment increasing pressure further
this then compresses the nerves
what are the clinical features of compartment syndrome?
within hours - 48 hrs
severe pain disproportionate to injury
pain made worse by passively stretching muscle bellies
parasthesia
compartment feels tense
acute limb ischaemia may develop - Pain, Pallor, Perishingly cold, Paralysis, Pulseness
what are the investigations for compartment syndrome?
clinical features
intra-compartmental monitor
elevated CK
how do you manage a patient with compartment syndrome?
urgent fasciotomies - keep skin open for 24/48 hrs to then remove dead tissue and close
keep limb neutral
high flow oxygen
bolus of IV crystalloid fluids
remove all dressings and casts
opioid analgesia
what are at a greater risk from occuring through a tibial shaft fracture?
open fractures
compartment syndrome
what are the clinical features of a tibial shaft fracture?
trauma
severe pain and inability to WB
deformity
swelling
bruising
which investigations are required for a tibial shaft fracture?
FBC, coagulation, group and save
full length AP and lateral plain radiograph
how do you manage a tibial shaft fracture?
reduced and given above knee backslab
neurovascular exam
surgery with IM nailing or sarmiento cast
what is the role of the acl?
limits anterior translation of tibia relative to femur
what are the clinical features an ACL tear?
twisting of the knee whilst weight bearing
rapid joint swelling and pain
how is an ACL tested?
lachman’s and anterior draw test
which investigations are required for an acl tear?
plain film radiograph of knee - ap and lateral to check if bony injuries
segmond fracture = bony avulsion of lateral proximal tibia indicates ACL tear
MRI = gold standard to see ACL tear
how do you manage an ACL tear?
RICE
rehabillitation and cricket pad knee splint
surgical reconstruction using tendon or artificial graft
what is a complication of ACL injury and ACL reconstructive surgery?
post traumatic osteoarthritis
what are the risk factors for patellar fractures?
20-50 yr olds
males
direct trauma
or rapid eccentric contraction of quadriceps muscle
what are the clinical features of patellar fractures?
anterior knee pain
hard blow to patella
strong contraction of quadriceps
worse with movement
unable to straight leg taise
swollen and bruised
palpable patellar defect
which investigations are required for a patellar fracture?
plain film radiographs - AP, lateral and skuline
how do you classify patellar fractures?
AO foundation classification
1- extra-articular or avulsion
2 - partial articular
3 - complete articular
how do you manage patellar fractures?
brace or cylinder cast if non displaced
ORIF surgery using tension band wiring
what is a differential of knee OA?
meniscal or ligament injury
`
what is the classification used for knee OA?
kellgren and lawrence system
grade 0-4
what is the difference between a full and partial knee replacement?
unicondylar - either medial or lateral compartment
what is patellofemoral OA?
OA affecting articular cartilage along trochlear grrove and on underside of patella. presents with anterior knee pain, worse when climbing a flight of stairs
what is the illiotibial band?
branch of longitudinal fibres that form the shared aponeurosis of tensor fasciae latae and gluteus maximus. it can become inflamed
how does iliotibial band syndrome present?
lateral knee pain in athletes due to repetitive flexion and extension
examination is unremarkable
what special tests can be performed in iliotibial band syndrome?
nobles test
renne test
what is the management of iliotibial band syndrome?
similar to OA conservatively
or surgery to release iliotibial band
which structure is most important to keep intact in an knee arthroscopy
MCL
how is the MCL injured?
external rotation forced applies to lateral knee - impact to the outside of knee, may hear a pop
grade 1 - 3 depending if tear compete and laxity of MCL
what are the clinical features of MCL tear?
immediate medial joint line pain
increased laxity in valgus stress test
what investigations are required for an MCL tear?
plain film radiograph to exclude fracture
MRI is gold standard
how is an MCL tear managed?
grade 1 - RICE etc
grade 2 - analgesia, knee brace
grade 3 - knee brace, crutches
what are some complications of an MCL tear?
instability to joint and damage to saphenous nerve
what causes a tibial plateau fracture?
high energy trauma from elderly causing impaction of femoral condyle onto tibial plateau
lateral most commonly injured due to varus force being more common
what are the clinical features of a tibial plateau fracture?
sudden onset pain, unable to WB, swelling
ligament instability
check neurovascular status - popliteal vessel dissection or common fibular nerve
which investigations are required for a tibial plateau fracture?
plain film radiograph - fracture line and lipohaearthrosis
CT - for surgical planning
what is the classification of tibial plateau fractures?
schatzker - type 1-6
what is the management of tibial plateau fracture?
hinged knee brace, physio and analgesia
if complicated, open fracture or compartment syndrome - surgery with ORIF
what is a complication of tibial plateau fracture?
post traumatic osteoarthritis
what are the two main functions of the menisci?
shock absorber
increase articulating surface area
how are menisci torn?
trauma -young, twisted knee while flexed
degenerative - old
where is the menisci usually torn?
longitudinal
what are the clinical features of a menisci tear?
tearing sensation
sudden onset pain
swelling
locked in flexion
joint effusion
mcmurray’s test
which investigations are required for a meniscal tear?
plain film radiograph to exclude fracture
MRI is gold standard
how is a meniscal tear managed?
RICE
if in outer third - repaired using sutures
inner third - trimmed to reduce locking
what are the complications of a meniscal tear?
secondary OA
knee arthroscopy - DVT, saphenous nerve and vein, peroneal nerve and popliteal vessel damage
define hallux valgus
medial deviation of first metatarsal at MTPJ and lateral rotation of the hallux
what are the risk factors for hallux valgus?
female
connective tissue disorders
hypermobility syndromes
what are the clinical features of hallus valgus?
painful medial prominence
aggrevated by walking, weight bearing, wearing narrow towed shoes
crepitus
contraction of extensor hallucis longus tendon visible in longstanding joint subluxation and excessive keratosis on foot
what are the differentials for hallux valgus?
gout
septic arthritis
hallux rigidus
OA
RA
how do you diagnose hallux valgus?
radiographic imaging
angle is measured between first metatarsal and proximal phalanx, greater than 15 = diagnosis
how is hallux valgus managed?
analgesia
adjusting footwear
physio
surgically = chevron procedure, scarf procedure, lapidus procedure, keller procedure
what are the complications of hallux valgus?
avascular necrosis, non union, displacement, reduced ROM
define tibial pilon fractures
affects distal tibia
caused by high energy axial loads
what are the clinical features of a tibial pilon fracture?
trauma
high energy
severe ankle pain, unable to WB
obvious ankle deformity
swelling
skin blistering
look for evidence of open fracture and compartment syndrome
how do you classify tibial pilon fractures?
ruedi and allgower classification
type 1 - undisplaced intraarticular
type 2 - displaced intraarticular
type 3 - comminuted or impacted fracture
what investigations are required for a tibial pilon fracture?
urgent bloods - coag, group and save, serum calcium and myeloma screen
plain film radiograph - ap, lateral and mortise
how do you manage a tibial pilon fracture?
realigment of limb and below knee backslab
neurovascular exam
monitor for compartment syndrome
usually surgery = temporary spanning external fixator followed by definitive fixation
what are the complications of a tibial pilon fracture?
compartment syndrome, wound infection, non-union, post traumatic arthritis
how does a calcaneum usually fracture?
fall from height due to significant axial loading
how do you classify calcaneal fractures?
intra-articular - only articular suface of subtalar joint
extra -articular - avulsion of calcaneal tuberosity by achilles tendon
how can you further classify calcaneal fractures?
sanders classification
1. non displaced
2. one fracture line
3. two fracture lines
4.more than three fracture lines
what are the clinical features of a calcaneal fracture?
recent trauma
inability to WB
swollen and bruised
short and wide heel
varus deformity
which investigations are required for a calcaneal fracture?
plain film radiograph - ap, lateral and oblique
calcaneal shortening, varus deformity, decreased bohler’s angle
what is bohler’s angle?
posterior angle formed from one line from anterior to middle facet, and one line from posterior to middle facet= usually 20/40 degrees
how do you manage a calcaneal fracture?
surgical intervention - closed reduction and percutaneous pinning if minimally displaced of ORIF if more displaced
conservative if angle is less than 2mm displaced - cast immobilisation and non weight bearing for 10-12 weeks
what are some complications of calcaneal fractures?
subtalar arthritis
what causes achilles tendonitis?
high intensity activities such as running or jumping which causes microtears to form with localised inflammation…tendon becomes thickened and fibrotic
what can occur as a result of achilles tendonitis?
achilles tendon rupture - substancial sudden force
which muscles does the achilles tendon unite together?
gastrocneumius, soleus and plantaris
what are the clinical features of tendonitis versus rupture of the achilles?
gradual onset pain, stiffness and tenderness in posterior ankle, easily improved
versus
sudden onset pain in posterior calf and audible popping sound
marked loss of power in plantarflexion
…can be differentiated with USS as well
how can you test for achilles tendon rupture?
simmond’s test- patient kneeling on chair and squeeze calf. if not plantar flex then ruptured
what is the management of achilles tendonitis versus rupture?
supportive measures - stop precipitating exercise, ice, anti inflamm, physio
versus
ankle splinted in plaster with toes and ankles maximally pointed(equinus) for 2 weeks, then ‘semi-equinus’ for 4 weeks and then neutral position for 4 weeks
which part of the talus do talar fractures usually occur in?
talar neck
what are talar fractures most at risk of?
avascular necrosis due to interruption of extraosseus arterial supply
what are the clinical features of a talar fracture?
high impact trauma
immediate pain and swelling
clear deformity if dislocated
can be open fracture - skin threatened
neurovascular supply
which investigations are required for talar fracture?
plain film radiograph - AP and lateral (in dorsi and plantarflexion) to differentiate between type 1 and 2 injuries
CT may be required
how do you classify talar fractures?
hawkins classification - risk of avascular necrosis
type 1 - undisplaced - 1-15%
2 - subtalar dislocation - 20-50%
3 - subtalar and tibiotalar dislocation -90-100%
4 - subtalar, tibiotalar, talonavivular dislocation - 100%
how do you manage talar fractures?
if undisplaced - conservatively
if displaced - immediate reduction
type 1 - plaster, non WB for 3 months
type 2 -4 - closed reduction with cast, open reduction if closed reduction is not possible
what are the complications of talar fractures?
avascular necrosis
OA
malunion
define lisfranc injury
severe injuries to tarsometatarsal joint between medial cuneiform and base of 2nd metatarsal. the lisfranc ligament is the strongest ligament which connects these
how does one cause a lisfranc injury?
severe torsional or translational force applied through plantarflexed foot
what are the clinical features of lisfranc injury?
severe pain in midfoot
difficulty weightbearing
swelling and tenderness
plantar bruising
monitor for compartment syndrome
which investigations are required for lisfranc injury?
plain film radiograph - ap, oblique, lateral
see signs - but usually widening between 1st and 2nd metatarsal
how is a lisfranc injury classified?
hardcastle and myerson:
type A - complete homolateral dislocation
type B1 - partial injury, medial column dislocation
type B2 - partial injury, lateral column dislocation
type C1 - partial divergent dislocation
type C2 - complete divergent dislocation
how is lisfranc injury managed?
closed reduction - gentle traction to midfoot and corrective pressure to metatarsal base and then backslab. then surgery with screw fixation between medial cuneiform and second metatarsal
or managed conservatively with cast and non weight bearing mobilisation
what are some complications of lisfranc injury?
post traumatic arthritis
compartment syndrome
define plantar fasciitis
inflammation of the plantar fascia of the foot causing infracalcaneal pain. due to a microtears to plantar fascia causing chronic breakdown. during gait cycle, hallux dorsiflexed and plantar fascia shortens and elevates medial longitudinal arch - chronic repeated damage
what are the risk factors of plantar fasciitis?
excessive pronation or pes cavus (high arches)
weak plantar flexors
prolonged standing and excessive running
leg length discrepancy
obesity
unsupportive footwear
what are the clinical features of plantar dasciitis?
sharp pain on plantar aspect of foot, mostly in heel
worse with first few steps then eases off
examination - over pronation, high arches, leg length discrepancy, femoral anterversion
what are some differentials for plantar fasciitis?
achilles tendonitis
calcaneal stress fracture
how do you determine plantar fasciitis?
MRI shows plantar fascial thickening, associated oedema
what is the management of plantar fasciitis?
activity moderation and regular analgesics
better footwear
physio
corticosteroid injections
plantar fasciotomy
define ganglionic cysts
non cancerous soft tissue lumps that occur along any joint or tendon, arising from the degenetation within the joint capsulse or tendon sheath so it fills up with synovial fluid, in hands, feet or dorsum of wrist, usually women 20-40
what are the clinical features of ganglionic cysts?
small spherical painless lump adjacent to joint affected
lump is soft and will transilluminate
reduced ROM
can cause parasthesia, pain or motor weakness if cyst exerts pressure upon an adjacent nerve
what are some differentials for ganglionic cysts?
tenosynovitis
lipoma
giant cell tumour of tendon sheath
OA
sarcoma
which investigations are required for ganglionic cysts?
any imaging to confirm
then aspirated for temporary symptomatic relief, microsocpy and cytology
what management is required for ganglionic cysts?
monitor
if pain = aspiration and steroid injection, cyst excisision
define trigger finger
finger or thumb click or lock when in flexion
associated with other condiitons - RA, amyloidosis, diabetes and jobs which involve prolonged gripping and use of hand
preceded by flexor tenosynovitis causing inflammation of tender and sheath causing nodal formation on tendon distal to the pulley so node can not pass under pulley
which types of pulleys are involved in trigger finger?
palmar aponeurosis
annular ligaments - A2 and A4 prevent bowstringing, A1,A3, A5 overlie the different joints
cruciate ligaments
what are the clinical features of trigger finger?
painless clicking when trying to extend finger
can become painful over time
possible lumps on proximal part of phalynx
what are some differentials for trigger finger
dupuytren’s contracture
infection
ganglion
how is trigger finger managed?
conservatively - splint with finger in extension
percutaneous trigger finger release via needle
surgical decompression of tendon tunnel
what are the main risk factors for carpal tunnel syndrome?
female
old age
pregnancy
obesity
previous injury
other conditions - diabetes, RA, hypothyroidism
repetitive hand or wrist movements
what are the clinical features of carpal tunnel?
pain
numbness
parasthesia in median nerve distribution
worse during night
movement helps
sensory symptoms can be reproduced using percussion over the median nerve - tinel’s test, holding wrist in full flexion for one minute - phalen’st test
weakness in thumb abduction and wasting of thenar eminence
what are some differenitals for carpal tunnel?
cervical radiculopathy
pronator teres syndrome
how is carpal tunnel diagnsoed?
clinically, can use nerve conduction studies
how is carpal tunnel managed?
wrist splint
corticosteroid injects
nsaids
carpal tunnel release surgery - cutting through flexor retinaculum
what are some complications of carpal tunnel surgery?
recurrence
persistent symptoms
infection
scar formation
nerve damage
trigger finger
what is the cause of a scaphoid fracture?
FOOSH
men
aged 20-30
what is the blood supply to the scaphoid?
dorsal branch of radial artery = 80%, travels in retrograde fashion towards proximal pole
….AVN (if more proximal, higher risk)
what are the clinical features of scaphoid fracture?
trauma
sudden onset wrist pain and bruising
tenderness in anatomical snuffbox
which investigations are required for a scaphoid fracture?
plain radiograph - ‘scaphoid series’ should be requested = AP, L, oblique
if sufficient clinical suspicion but x ray negative - immobilise in thumb splint and redo in 10-14 days, if still not then MRI
how are scaphoid fractures managed?
undisplaced - immobilisation in plaster with a thumb spica spint
undisplaced proximal pole and displaced- percutaneous variable pitched screw
what are some complications of scaphoid fractures?
AVN
non union
define de quervain’s tenosynovitis
inflammation of the tendons within first extensor compartment of wrist (extensor pollucis brevis and abductor pollucis longus)
30-50, women, repetitive movements of wrist
what are the clinical features of de quervain’s tenosynovitis
pain near base of thumb
swelling - thickening of tendon sheath
pinching and grasping painful
finkelstein’s test positive by applying longitudinal traction and ulnar deviation = pain
what are some differentials of de quervain’s tenosynovitis?
arthritis of CMC
intersection syndrome
how is d.q.t diagnosed?
plain film radiograph to exclude, but made as clinical diagnosis
how is d.q.t managed?
conservative - avoid repetitive actions, wrist splint, steroid injections
surgical decompression of extensor compartment
define dupuytren’s contracture
contraction of the longitudinal palmar fascia causing fibrous cords and flexion contractures at MCP and IP
men, 40-60
what is the pathophysiology of dupuytren’s contracture?
fibroplastic hyperplasia and altered collagen matrix of palmar fascia
what are the risk factors of dupuytren’s contracture?
cause is idiopathic
smoking
alcoholic liver cirrhosis
diabetes
occupational exposures (vibration tools, heavy manual work)
what are the clinical features of dupuytren’s contracture?
progressive
reduced ROM
nodular deformity
a thickened band or nodule
skin blanching on active extension
hueston’s test - can not lay palm flat on table
which investigations are required for dupuytren’s contracture?
routine bloods, LFT’s and random glucose - risk factors
USS - increased accuracy for injections
how do you manage dupuytren’s contracture?
steroid injections and radiotherapy for hand
injectable collagenase clostridum histolyticum - early stages
excision of diseased fascia - fasciectomy
finger amputation
what is at a higher risk in a femoral shaft fracture?
does its own haemopoeisis and supplied by profunda femoris artery = blood loss
what are the clinical features of a femoral shaft fracture?
pain , swelling in thigh, hip, knee
unable to WB
obvious deformity
assess skin - if open or threatened
proximal fragment flexed and external rotated
full neurovascular exam
what is the classification of femoral shaft fracture?
winquist and hansen:
type 0 - no comminution
type 1 - insignificant amount
2 - greater than 50% cortical contact
3 - less than 50%
4 - segmental fracture with no contact between proximal and distal fragment
which investigations are required for femoral shafr fractures?
plain film radiograph - AP and lateral of entire femur
what is the management of a femoral shaft fracture?
A-E
pain relief - opioid, regional blockade(fascia iliaca block)
immediate reduction, but most require surgery (antegrade IM nail)unless undisplaced - long leg casts
what are some complications of femoral shaft fracture?
nerve (pudendal, femoral) injury or vascular injury
malunion
infection
fat embolism
venous thromboembolism
what are the risk factors for a quadriceps tendon rupture?
age
CKD
DM
RA
corticosteroids
what are the clinical features of quadriceps tendon rupture?
pop
pain in anterior knee
difficulty WB
usually by sudden excessive loading on quadriceps- landing from a jump
localised swelling
tender palpable defect
which investigations are required for quadriceps tendon rupture?
plain film radiograph - caudally displaced patella
uss -degree of rupture
what is the management of a quadriceps tendon rupture?
partial tears - immobilisation in brace, intensive rehab
complete - longitudinal drill holes or suture anchors if at point of insertion with patella, end to end sutures if intra-tendinous tears
what are the risk factors for OA in hip?
age
obesity
female
vit d defiency
trauma
muscle weakness
joint laxity
high impact sports
what are some differentials for OA in the hip?
trochanteric bursitis
gluteus medius tendinopathy
sciatica
femoral neck fracture
what are some common post op complications of oa in hip?
thromboembolic disease
bleeding
dislocation
infection
loosening of prosthesis
leg length discrepancy
what is the most common approach hip replacement surgery?
in relation to gluteus medius:
- posterior: common as preserves abductor
- anterolateral
- anterior
what are the causes of pelvic fractures?
high energy blunt trauma - road traffic, falls from height
what are the clinical features of pelvic fractures?
obvious deformity
pain
swelling
full neurovascular exam - anal tone (sacral nerve roots and iliac vessels can be damaged)
possible abdo, urethral injuries and open fractures
ecchymosis or haematoma - perineal, scrotal, labia
which investigations are required for a pelvis fracture?
3 plain film radiograph - AP, inlet, and outlet views
CT if required
how is a pelvis fracture classified?
young and burgess - AP or lateral compression or vertical shear
tile - A type - rotationa, and vertically stable,B - horizontally unstable but vertically stable, C - both horizontally and vertically unstable
what classifies fractures of sacrum?
denis
what is the management of a pelvis fracture?
blood loss - hypovolaemic shock
pelvic binder
method of surgery - guided by young and burgess classification. APC1 andLC1 - analgesia and mobility but if ongoing sx then surgery
what are some complications following pelvic fracures?
urological injury
VTE (requires prophylaxis)
long standing pelvic pain
what are the causes of acetabular fracture?
high energy RTC
what are the cinical features of an acetabular fracture?
pain
swelling
inability to WB
secondary survey for other injuries
neurovascular status
open fractures
which investigations are required for acetabular fracture?
plain film radiographs - AP view, judet view (tilting patient 45 degrees laterally in both directions)
CT - gold standard
what is the classification of acetabular fracture?
judet and letournel classification:
elementary or associated
what is the management of acetabular fractures?
hip dislocation managed
undisplaced managed conservatively - not WB for 6-8 weeks
displaced - fracture fixation then THR (if older) or anterior approach for full fixation
what are some complications of acetabular fractures?
secondary OA
VTE
nerve - sciatic or obtruator
what are the causes of distal femur fractures?
young patients from high energy trauma or older from low energy
how do you classify distal femur fractures?
extra-articular (a), partial articular (b), complete articular (c)
what are the clinical features of a distal femur fracture?
severe pain in distal thigh
unable to WB
obvious deformity
swelling and ecchymosis of thigh
knee effusion
open fracture
neurovascular exam
what are some differentials for distal femur fracture?
tibial plateau fracture, haemarthroris, tibial shaft fracture
which investigations are required for a distal femur fracture?
bloods - group and save, serum calcium and myeloma screen
AP and L plain film radiographs of knee and entire femur
CT for operative planning
what management is required for a distal femur fracture?
realignment immediately
majority are managed surgically - retrograde nailing or ORIF with distal femoral plate
what are some complications of distal femur fractures?
malunion, non union, secondary OA
what is the most common type of shoulder dislocation?
anteroinferior
if anterior - caused by force being applied to extender, abducted and external rotated humerus
posterior - electrocution, seizure
what are the clinical features of a shoulder dislocation?
painful
reduced mobility
asymmetry with contralateral side
loss of shoulder contours - flattened deltoid
anterior bulge from head of humerus
what are the associated bony injuries that can occur due to a shoulder dislocation?
bankart lesions are fractures of anterior inferior glenoid bone
hill sachs are defects caused by impaction injuries to the humeral head
fractures to the greater tuberosity and surgical neck of humerus
what are the associated labral/ligammentous/muscular injuries that can occur due to a shoulder dislocation?
soft bankart lesions of anterior labrum and inferior glenohumeral ligament
glenohumeral ligament avulsion
rotator cuff injuries
which investigations are required for shoulder dislocations?
plain radiographs - trauma shoulder series which is a AP, Y-scapular and/or axial views
anterior - head out of fossa
posterior - light bulb sign as humerus fixed in internal rotation
MRI - if soft tissue damage suspected
what is the management of shoulder dislocations?
A-E
analgesia
closed reduction - like hippocratic method
neurovascular status before and after
then placed in broad arm sling for 2 weeks
physio to strengthen rotator cuff
surgical treatment may be requiredif recurrent, pain, instability or bony lesions
which two things must be considered as likely in a humeral shaft fracture?
radial nerve injury
holstein-lewis fracture
what are the clinical features of a humeral shaft fracture?
pain
deformity
FOOSH
radial - reduced sensation over dorsal 1st webspace and weakness in wrist extension
define holstein lewis fracture
fracture of distal 1/3 of humerus resulting in entrapment of radial nerve…wrist drop
which investigations are required for a humeral shaft fracture?
AP and L plain film radiograph of humerus with elbow and shoulder visible
CT for pre op planning
what is the management of a humeral shaft fracture?
humeral brace
if less than 20 degrees anterior angulation, less than 30 valgus angulation and with less than 3cm shortening …just conservative management and follow ups
IRIF with plate or IM nails
what are the causes of biceps tendinopathy?
young individuals who are active or older with degenerative…leading to a structurally weaker tendon and risk of rupture
what are the clinical features of biceps tendinopathy?
pain
weakness in flexion and supination
stiffness
tenderness
muscle atrophy
which two special tests are required for biceps tendinopathy?
speed test (proximal biceps tendon) - patient stands with elbow extended and forearms supinated, then forward flex shoulders against examiners resistance
yergason’s test (distal biceps tendon) - elbow flexed to 90 degrees and forearms pronated and supinate against resistance
what are some differentials for biceps tendinopathy?
inflammatory arthropathy, radiculopathy, OA, rotator cuff disease
which investigations are required for biceps tendinopathy?
blood tests - FBC, CRP and plain film radiographs – exclude other differentials
how is biceps tendinopathy managed?
conservatively - analgesia such as NSAIDS, ice physio, USS guided steroid injections
surgery unlikely - arthroscopic tenodesis or tenotomy or decmpression
what causes a biceps tendon rupture?
sudden forced extension of flexed elbow
what are the risk factors for biceps rupture?
tendinopathy
steroids
smoking
CKD
flouroquinolone antibiotics
what are the clinical features of a biceps tendon rupture?
sudden onset pain
weakness
pop
marked swelling and bruising in antecubital fossa
as proximal muscle belly contracts and loss of counter traction - reverse popeye sign
which test can identify a biceps tendon rupture?
hook test- elbow flexed at 90 and fully supinated. examiner attempts to hook index finger under lateral edge of biceps - cannot be done if rupture
which investigations are required for biceps tendon rupture?
USS
how is a biceps tendon rupture managed?
conservative management - analgesia, physio
surgery - anterior single incision or dual incision technique - forms a bone tunnel in radius and re inserts ruptured tendon end
what are the main complications from biceps tendon surgery>
injury to lateral antebracial curaneous nerve, posterior interosseous nerve or radial nerve
what is subacromial impingement syndrome and which pathologies does it encompass?
inflammation and irritation of the rotator cuff tendons as they pass through subacromial space
encompasses rotator cuff tendinosis, subacromial bursitis, calcific tendinitis
usually under 25 with manual professions
what is the pathophysiology of subacromial impingement syndrome?
intrinsic: muscular weakness in rotators so humerus shifts proximall towards body, overuse causing soft tissue inflammation of tendons and degenerative changes of acromion
extrinsic: anatomical variations in shape or acromion, reduction in function of scapular muscles so humerus moves past acromion and reduces space, and glenohumeral instability leading to subluxation of humerus
what are the clinical features of SIS?
progressive pain in anterior superior shoulder
exacerbated by abduction
weakness
stiffness
which two tests can be performed to identify SIS?
neers impingement test - arm is placed by patient’s side, fully externally roated and flexed, if postive pain in anterolateral aspect
hawkins test - shoulder and elbow flexed at 90, examiner stabilises humerus and passively internally rotates arm, if positive pain in anterolateral aspect
give 3 examples of differentials of SIS
rotator cuff tear
frozen shoulder
acromioclavicular arthritis
which investigations are required for SIS?
MRI scan - formation of subacromial osteophytes and sclerosis, subacromial bursitis, humeral cystic change, narrowing of subacromial space
how is SIS managed?
conservative - analgesia, NSAIDS, physio, corticosteroid injections
surgery - repair of muscular tears, removal or bursa or removal of section of acromion
what are some complications of SIS?
rotator cuff degeneration, adhesive capsultitis, cuff tear arthropathy, CRPS
how are clavicular fractures classified?
allman classification:
type 1 - fracture of middle third
type 2 - fractures pf lateral third
type 3 - fracture of medial third
what are the clinical features of clavicular fractures?
trauma onto clavicle or shoulder
medial fragment superior as pull of SCM, lateral inferiorly as weight of arm
sudden onset localised severe pain
focal tenderness
open injuries
neurovascular exam - brachial plexus
what are some differentials of clavicle fractures?
sternoclavicular dislocations
acriomioclavicular separation
which investigations are requires for clavicle fractures?
plain film radiograph AP, and modified axial
how are clavicle fractures managed?
mostly conservately as more than 90 percenet unite
given sling, early movement
surgery - ORIF
recovery takes 4-6 weeks
what are the clinical features of a shoulder fracture?
foosh
pain around upper arm and shoulder
restriction in arm movement
inability to abduct
significant swelling and brusiing of shoulder
neurovascular status - axillary nerve, circumflex vessels
which investigations are required for a shoulder fracture?
urgent bloods - Group and save, serum calcium and myeloma
plain film radiographs - AP, lateral scapula, axillary
how is a shoulder fracture classified?
neer classification system
- greater tuberosity
- lessser
- anatomical neck
- surgical neck
how is a shoulder fracture managed?
conservatively with pendular exercises at 2/4 weeks, polysling
surgery with ORIF or IM nails
hemiarthoplasty can be performed if complex
a year for recovery
give 3 complications of shoulder fractures
AVN of humeral head
reduced ROM
axillary nerve damage
scapular fractures
ORIF
how are rotator cuff tears classified?
acute - less than 3 months
chronic - more than 3 monthjs
partial or full thickness
full, small - less than 1cm, medium - 1-3cm, large - 3-5 cm, massive - more than 5cm
role of rotator cuff muscles
supraspinatus - abduction
infra - external
teres minor - external
subscapularis - internal
what are the risk factors for rotator cuff tears?
age
trauma
overuse
repetitive overhead shoulder motion
obesity
smoking
DM
what are the clinical features of rotator cuff tears?
pain over lateral aspect of shoulder
unable to abduct more than 90
tenderness over greater tuberosity and subarcomial bursa regions
which specific tests can be used in rotator cuff tears?
jobe’ tests - empty can for supraspinatus
gerber’s lift off test - internally roatate arm so dorsal surface on lower back and lift hand away against resistance for subscapularis
posterior cuff test - elbow flexed at 90 - externally rotate against resistance for infra and teres minor
what are some differentials for rotator cuff tears?
shoulder fracture
glenohumeral subluxation
brachial plexus injury
which investigations are required for rotator cuff tears?
plain film radiograph to exclude fracture
ultrasonography - tear or MRI
how is a rotator cuff tear managed?
conservative if present two weeks since injury - analgesia and physio
surgery - arthroscopically or open approach
what are the causes of radial head fractures?
axial loading of the forearm causing radial head to be pushed against capitulum of humerus..when arm is in extension and pronation
what are the clinical features of radial head fractures?
tenderness on palpation over lateral aspect of elbow and radial head
pain and crepitus on supination and pronation
elbow effusions
limited supination and pronation
define essex-lopresti fracture
a fracture of radial head with disruption of distal radio ulnar joint - requires surgical intervention
which investigations are required for a radial head fractures?
routine blood- clotting screen, group and save
plain film and lateral radiographs - hard to see, effusion is indicative
in lateral - ‘sail sign’ - elevation of anterior fat pad
how do you classify radial head fractures?
mason classification:
type 1 - non displaced or minimally (<2mm)
type 2 - partial articular fracture with displacement (>2mm or angulation)
type 3 - comminuted fracture and displacement - a complete articular fracture
how is radial head fracture managed?
analgesia
neurovascular compromise
mason type 1- non op, immobilisation in sling less than 1 week and early mobilisation
type 2 - if no mechanical block treated as above, if present may need surgery with ORIF
type 3 - usually surgery via ORIF or radial head excision or replacement
what is the cause of an olecranon fracture?
FOOSH causing sudden pull of triceps and brachialis
what are the clinical features of an olecranon fracture?
elbow pain, swelling and lack of mobility
tenderness on palpation over posterior aspect with palpable defect
unable to extend elbow as triceps disrupted
neurovascular status
shoulder and wrist examination
which investigations are required for an olecranon fracture?
routine blood - clotting, group and save
plain AP and lateral radiographs of above and below too
how are olectanon fractures classified?
degree of displacment via mayo and/or schatzker classification
how are olecranon fractured managed?
analgesia
conservative: displacement <2mm, immobilisation in 60-90 degrees elbow flexion and movement at 1-2 weeks
operative: displacement >2mm -> tension band wiring or olecranon plating
what are some causes of olecranon bursitis?
repetitive flexion-extension movements or gout or RA or fluid in bursa becomes infected from puncture
what are the clinical features of olecranon bursitis?
pain
swelling
recent increase in size, discomfort, erythema
range of motion preserve as joint capsule unaffected
systemic symptoms such as fever and lethargy present
examine contralateral elbow and joints above and below
what are the differentials for olecranon bursitis?
inflammatory arthopathies
gout
cellulitis
septic arthritis
which investigations are required for olecranon bursitis?
routine bloods - FBC, CRP, serum urate
plain film radiographs - rule out bony injury
aspiration of fluid for microscopy and culture
how is olecranon bursititis managed?
analgesia- NSAIDS
rest
splinting of elbow
washout in theatre
IV antibiotics if systemic sx
bursectomy
what are some complications of olecranon bursitis?
septic arthritis
osteomyelitis
what are the causes of lateral epicondylitis?
overuse causing microtears in tendons attaching to epicondyles of elbow, where common attachment of extensor (lateral) muscles of forearm are…granulation tissue, fibrosis…tendinosis
lateral - tennis
medial - golfers
what are the clinical features of lateral epicondylitis?
pain in elbow and forearm
worsen after weeks to months
local tenderness on palpation
reduced grip strength
what are two special tests for lateral epicondylitis?
cozen’s test - patient’s elbow flexed at 90, with examiner’s hand over lateral epicondyle and other hand holds patients hands in radially deviated position with forearm pronated, extend wrist against resistance
mill’s test - lateral epicondyle palpated whilst pronating forearm, flexing wrist and extending elbow
what are some differentials for lateral epicondylitis?
cervical radiculopathy
elbow OA
radial carpal tunnel syndrom
how is lateral epicondylitis diagnosed?
clinically, USS or MRI to confirm
how is lateral epicondylitis treated?
self limiting - 1/2 years
modify activites, simple analgesia, corticosteroid injections, physio
open or arthroscopic debridement of tendinosis and/or release of damaged tendon insertions
which tendons are mostly affected in medial epicondylitis?
pronator teres
flexor carpi radialis
how is the elbow joint stabilised?
primary static stabilisers - humeroulnar joint, medial and collateral ligaments
secondary static stabilisers - radiocapetellar joint, joint capsule, common flexor and extensor origin tendons
dynamic stabilisers - surrounding muscles (anconeus, brachialis, triceps brachii)
what are the clinical features of elbow dislocation?
high energy fall
pain
deformed
swellling
decreased function
neurovascular exam - ulnar
which investigations are required for elbow dislocations?
plain film radiograph of elbow, both AP and lateral –> loss of radiocapitellar and ulnotrochlea congruence
how do you manage an elbow dislocation?
closed reudction with above elbow backslab at 90 degrees via in line traction or via manipulation of olecranon for 5-14 days
analgesia
early rehab
operation if open or neurovascular compromise with ORIF
what is the terrible triad?
elbow dislocation
lateral collateral ligament injury
radial head fracture
coronoid fracture
…..results from posterolateral dislocation
what is the mechanism of injury of a supracondylar fracture?
5-7 yrs old
FOOSH with elbow in full extension
what are the clinical features of a supracondylar fracture?
gross deformity
swelling
limited range of m
ecchymosis of anterior cubital fossa
median nerve, anterior interosseous nerve, radial nerve and ulnar nerve - check
vascular compromise
which investigations are required for supracondylar fractures?
plain film radiographs - AP and L
- posterior fat pad sign
- displacement of anterior humeral line
how are supracondylar fractures classified?
gartland classification-
type 1: undisplaced
2: displaced with an intact posterior cortex
3: displaced in two or three planes
4: displaced with complete periosteal disruption
how are supracondylar fractures managed?
immediate closed reduction with K wire fixation
conservative if type 1 or 2 - above elbow cast at 90
if open then open reduction with percutaneous pinning
what are some complications of supracondylar fractures?
nerve damage - anterior interosseous nerve, ulnar
malunion
cubitus varus defomity (extended forearm deviated towards midline)
volkmann’s contracture - permanent flexion
What is patellar resurfacing?
Patella resurfacing is occasionally necessary for patients with inflammatory arthritis, a deformed or maltracking patella, or symptoms and pathology that are virtually restricted to the patellofemoral joint. procedure that resurfaces the worn patella and trochlea of the femur (the grove at the end of the thigh bone) that together make up the patellofemoral joint.
define charcots arthopathy
Charcot arthropathy is a serious condition, which is more common if people lose feeling in their feet. The bones in the foot can become weak and lead to dislocations, fractures and changes in the shape of the foot or ankle. Charcot arthropathy may develop if you have diabetes and you fracture your foot or ankle. If it is not treated quickly, ulcers or other sores can develop. Symptoms of Charcot arthropathy include the foot feeling hot and painful, and looking swollen or red.
Charcot arthropathy is diagnosed and treated in hospital by the multidisciplinaryfoot care service. If a healthcare professional thinks you may have Charcot arthropathy,they should refer you to the multidisciplinaryfoot care service within 1 working day, and you should be seen within another working day. You should rest and not put any weight at all on the foot until your appointment with the multidisciplinaryfoot care service. You may have an X‑ray or a type of scan called an MRI.
The treatment for Charcot arthropathy usually involves having a plaster cast fitted.
what are the causes of bony fragments in the joint
trauma
RA
OA
define meralgia parasthesia
Meralgia paresthetica (also known as lateral femoral cutaneous nerve entrapment) is a condition characterized by tingling, numbness and burning pain in your outer thigh. It’s caused by compression of the nerve that provides sensation to the skin covering your thigh.
Tight clothing, obesity or weight gain, and pregnancy are common causes of meralgia paresthetica. However, meralgia paresthetica can also be due to local trauma or a disease, such as diabetes.
In most cases, you can relieve meralgia paresthetica with conservative measures, such as wearing looser clothing. In severe cases, treatment may include medications to relieve discomfort or, rarely, surgery.
define baker’s cyst
Baker’s cysts typically result from a problem inside the knee joint, such as osteoarthritis or a meniscus tear. These conditions cause the joint to produce excess fluid, which can lead to the formation of a cyst.
Most Baker’s cysts will improve with nonsurgical treatment that includes changes in activity and anti-inflammatory medications. Some cysts may even go away on their own, with no treatment at all.
How do you perform a neuro exam on a hand?
https://stmungos-ed.com/nurseeducate/rock-paper-scissors-ok
Bursitis treatment
Bursa Drainage and Removal
If the bursa is severely damaged, the surgeon may remove the entire inflamed sac. The incision is closed with stitches. Removal of a bursa does not affect the way the muscles or joints work and can permanently relieve the pain and swelling caused by bursitis.
Define osgood-schlatter disease
Inflammation of patellar tendon
Define spondylolithesis
the fractured pars interarticularis separates, allowing the injured vertebra to shift or slip forward on the vertebra directly below it.
Spinal fusion between the fifth lumbar vertebra and the sacrum is the surgical procedure most often used to treat patients with spondylolisthesis.
Cause of PCL tear
Dashboard injury
Define patellar dislocation
occurs by a lateral shift of the patella, leaving the trochlea groove of the femoral condyle. This mostly occurs as a disruption of the medial patellofemoral ligament
Twisting of the leg, with internal rotation of the femur on a fixed foot and tibia
Often associated with valgus stress
Locking and pain
Immobilization for 6 weeks (cylinder cast/back slab/knee range of motion brace)[18]
Or surgery
Define erb’s vs klumpke palsy
Erb’s palsy results from neuronal damage to the upper C5 and C6 nerves. The clinical presentation includes partial or full paralysis of the arm and often accompanied by loss of sensation. Klumpke’s palsy causes paralysis of the forearm and hand muscles as a result of mechanical damage to the lower C8 and T1 nerves. This neuronal lesion affects primarily the wrist and fingers, and often the position of the hand is “clawed.”
Define cause of winging of scapula
Long thoracic nerve injury
Define olecranon bursiits
Bursitis is inflammation of a bursa. This causes thickening of the synovial membrane and increased fluid production, causing swelling. This inflammation can be caused by a number of things:
Friction from repetitive movements or leaning on the elbow
Trauma
Inflammatory conditions (e.g., rheumatoid arthritis or gout)
Infection – referred to as septic bursitis
Differential - septic arthritis
Pus indicates infection
Straw-coloured fluid indicates infection is less likely
Blood-stained fluid may indicate trauma, infection or inflammatory causes
Milky fluid indicates gout or pseudogout
RICE and aspiration
Axillary nerve damage
Deltoid and teres minor
Fracture of surgical neck of humerus and anterior dislocation
Regimental badge area
Thus arm infernally rotated and adducted
Radial nerve dmaage
Triceps brachii
1st 3 and a half digits on posterior aspect of hand…test in 1st webspace
Caused by mid shaft humeral fracture
Results in wrist drop
Musculocutaneous nerve damage
Stab wound in axilla
Loss of sensation in lateral forearm
Wreaked arm flexion, elbow flexion, supination
Ulnar nerve damage
Caused by fracture of medial epicondyle or compression in cubital tunnel or guyon’s canal
If low - claw hand (hyperextension MCPJ, flexion of PIPJ as lumbricals 4 amd 4 lost
If high - loses flexor digitorum profondus on ulnar side so deformity less pronounced
Median nerve damage
Forearm muscle affected - loaf muscles
Hand of benediction
Caused by supracondylar fracture of humerus, Trauma, carpal tunnel
Dermatomes and myotome
