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