Orthopaedics Flashcards
Supracondylar Fracture
Distal third of humerus, proximal to trochlea or capitalum
Classification - Gartland
I = undisplaced
II = Angulated (<20 deg) with retained intact posterior cortex
III = Posterior displacement of distal fragments, no cortical contact
Complications
Brachial
Median nerve
Compartment syndrome
Late
Stiff elbow
Fracture Complications
EARLY
Haemorrhagic shock - femur, pelvis, tib/fib
Neurovascular compromise
Skin integrity
Compartment syndrome
Infection - cellulitis, septic joint, osteomyelitis
Ligamentous injury
Complications of surgery
Fat embolism Syndrome
MIDDLE
VTE with immobilisation esp lower limb
LATE
Mal-alignment, mal-union, non-union
Joint stiffness
Joint instability
CRPS
OA
Avascular necrosis - femur, talus, scaphoid, lunate, capitate
Joint aspiration
Indications
Septic arthritis
Gout / Pseudogout
Rheumatological inflammation
Large haematomas
CI
Skin infection over aspiration site
Uncooperative pt
Joint prosthesis
Anticoagulated
Lis Franc Fracture-Dislocation Injury
Most common midfoot fracture
CT scan of foot required
ORIF usually required
Mechanism
High velcocity
Hyper-extension of forefoot on the mid-foot
Fall form horse when rider’s foot trapped in stirup
X-ray
Only 70% sensitive - will need CT foot
Gap sign - visible space between base of 1st and 2nd metatarsals
Classification
Horizontal
- Lateral displacement of 1-5th or 2-5th metatarsals with 1st MTP remaining intact
Partial or Isolated
- 1-2 metatarsals displaced
Divergent
- First MTP moves medially
- Others move laterally
Compartment Syndrome
Causes
Compartment pressure = 0
Delta pressure = DBP - Compartment Pressure
Delta pressure > 30mmHg = risk of compartment syndrome
RF = male < 35,
Sites: tibia, forearm , thigh, hand and foot
Causes:
1. Increased compartment contents
Bleeding - fracture, vasc injury, coagulation disorder
Inc capillary filtration - trauma, burns, repurfusion after injury, intense muscle use (athletes)
Inc capilary pressure - DVT, venous ligation
-
Decreased compartment volume
Closure fascial defects
Excessive traction of fractures -
External pressure
Casts, splints, dressings
Lying on limbs -
Misc
Muscle hypertrophy, leaky cannulae, popliteal cyst
Compartment Syndrome
Assessment / Mx
Assessment
1. Pain out of proportion to physical findings (POOP to PxF)
2. Deep, burning, unrelenting, difficult to localize pain
3. Increasing need for analgesics
4. Pain on passive stretching of the muscle groups (most sensitive finding b4 ischaemia)
5. Pain with active flexion of the muscle groups
6. Hypoesthesias or paresthesias in the distribution of nerves crossing the compartment
7. Tender / tense of the compartment
Mx
1. Do NOT elevate limb
2. Stryker needle insertion to confirm pressure > 30mmHg
3. Fasciotomy
STAT vs 12 hrs
4. Support BP if hypotensive in trauma
5. Mx complications - rhabdomyolysis, inc K+, lactic acidosis
Methods of measuring compartment pressures:
Stryker needle
Arterial line trasnducer
Complications of prolonged immobilsation
Fracture complications
Immobility
DVT / thrombophlebitis / PE
Decubitus ulcers
Muscle atrophy
Elderly
Pneumonia
UTI
Wound infection
Stress Ulcers
GI bleeding
Thumb Fractures
Bennets - 2 part base of 1st metacarpal
Rolando - 3 or more parts (comminuted) base of 1st metacarpal
Both require ORIF
Complications
Instability => mal union, non-union
Severe OA
Gamekeepers / Skier’s thumb
Ulnar collateral ligament injury
Mechanism: forced abduction of thumb
Signs
* Thenar ecchymosis
* Swelling to ulnar aspect MCP
* Weak/painful pincer grip
* Stress test - CONTRAINDICATED IF FRACTURE - will show opening up of joint space
* Perform stress test in flexion (lax accessory UCL) and extension (outstretched accessory UCL => some stability)
Xray - may show concurrent avulsion fracture DIPJ
Mx
Incomplete rutpture: Thumb spica for 4-8 weeks
Complete rupture : surgical repair
Complications
Stener lesion = avulsed end of the UCL gets caught under the proximal edge of the adductor aponeurosis and folds into itself
Significance = joint instability, chronic pain, chronic dysfunction i.e pincer grip weakness
Bones at risk of AVN
- Carpals - scaphoid, lunate
- Femoral neck
- Foot - Talus, navicular
- Mandible
- Humerus
Flexor tenosynovitis
Infection of the synovial sheath that surrounds the flexor tendon.
Clinical diagnosis by 4 Kanavel signs.
Rx urgent irrigation and debridement of the flexor tendon sheath + IV antibiotics
Clinical
Pain and swelling (ususally palmar) - delayed presentation
Warmth /redness over digit
Kanavel SIgns
1. Flexed posture of involved digit
2. Tender over flexor tendon sheath
3. Pain with passive extension of digit
4. Fusiform swelling
Mx
Nonoperative (rare)
Hospital admission, IV antibiotics, hand immobilization, observation
Operative
I&D followed by culture-specific IV antibiotics
- Low threshold to operative once suspected (orthopaedic emergency)
- Late presentation
- No improvement w/ 24 hours of non-operative treatment
Complications
- Stiffness
- Tendon or pulley rupture
- Spread of infection
- Loss of soft tissue
- Osteomyelitis
Kanavel’s signs Flexor tenosynovitis
- Flexed posture of involved digit
- Tender over flexor tendon sheath
- Pain with passive extension of digit
- Fusiform swelling of affected digit
Open Fractures
Gustilo/Anderson classification
1. G1 - <1cm lac, clean, no skin crush
2. G2 - >1cm lac, minor crush, moderately comminuted #
3. G3 - > 10cm lac + crushing/coontamination
A. + adequate ST coverage
B. - adeqaute ST coverage
C. ascco vasc injury
4. G4 - subtotal or total amputation
Mx
Irrigate / Debride
ADT
IV cephazolin for Gd1+2
IV tazocin for G3/4
Complications
Wound infection
Tetanus
OM
NV injury
Compartment syndrome
Skin infections + unusual exposures
Freshwater - Aeromonus hydrophilia
Salt water - Vibrio
Cat scratch - Bartonella henslae
Cat bite - Pasteurella mutidoca
Dog bite - Capnocytophaga canimosus, Pasteurella canic
Human bite - Eikenella corrodens
Posterior Shoulder dislocation
Uncommon, < 5% dislocations
Mech: trauma, seizure, electricution
Presents with shoulder adducted, internally rotated and elbow flexed
XR:
Light bulb sign
Empty glenoid sign (ant glenoid fossa empty)
+ve rim sign (wide GH space)
Closed reduction technique:
1. Firmly and gently hold upper arm + forearm
2. Further adduct and internally rotate
3. Lift elbow to level of shoulder
4. Externally rotate
Associated Lesions
Common: Reverse Hill-Sachs, Posterior Bankart, Greater and Lesser tuberosity #, posterior glenoid rim #, recurrent dislocation
Anterior Shoulder Dislocation
Common
Mech: anteriorly force on the arm when the shoulder is abducted and externally rotated
XR: Subcoracoid / Subglenoid in 95%, Subclavicular or intrathroacic anterior dislocation of GHJ
Associated lesions:
Salter Harris Classification
Type I and V hard to differentiate as there may nbe no xray changes
Type I - shearing or avulsion type force
Type V - axial loading
Upper limb nerv injury Testing
Monteggia vs Galeazzi #
MUGR
Monteggia - # proximal 1/3 ulna + Dislocation radial head
Galeazzie - # distal 1/3 radius + dislocation DRUJ
Radial Fracture Reduction Parameters
Acceptable parameters for radial Fractures:
* Dorsal tilt < 10 degrees
* Radial shortening (on PA view): loss of >2mm more should be corrected
* Radial shift (on PA view): any shift should be corrected
* Radial inclination (on PA view): <15 degrees
* Volar tilt (on lateral view): <20 degrees (normal volar tilt is 10–25 degrees).
* Dorsal displacement
Lines on XR indicating
Dotted line C - Radial shortening
Line B - radial inclinaiton or ulna tilt
Line D -radial tilt
Scapholunate dislocation
Scapholunate dissociation, also known as rotary subluxation of the scaphoid, refers to an abnormal orientation of the scaphoid relative to the lunate and implies severe injury to the scapholunate interosseous ligament and other stabilizing ligaments.
Mech: Fall onto outstretched hand
Clincal:
Pain in snuff box / wrist region
Inc pain with dorsiflexion
Xray
Terry Thomas Sign: Widening of Scapholunate distance > 3mm (closed fist AP view)
Signet ring sign:
> 70 degree SL angle due to dorsal tilt of lunate
Mx
CLosed reduction or ORIF
Perilunate dislocation
Mech: fall onto hyperextended hand
The four stages of ligamentous injuries in the
wrist are:
* stage I: scapholunate dissociation (less force)
* stage II: perilunate dislocation
* stage III: perilunate dislocation with associated
dislocation/fracture of triquetrum
* stage IV: lunate dislocation.
Xray:
Lateral view - Capitate disloation -> displaced dorsal to lunate
Lunate retains its normal contact with radius
PA view
Capitolunate joint space is obliterated and proximal and distal carpal rows overlap
Clinical:
Wrist swelling and tenderness but gross deformity absent
Mx
Ortho referral for arthroscopy reduction or ORIF
Lunate dislocation
Lateral view
Lunate is pushed off the radius into the palm (“spilled teacup” sign)
PA view
Lunate has triangular shape (“piece-of-pie sign”)
Segond #
A Segond fracture = ACL tear
Avulsion fracture on the lateral tibial condyle at the site of attachment of the lateral capsular ligament
Ankle Xrays
Joint effusion can be seen anterior and posterior to the lower end of the tibia as a ‘tear drop’ on the lateral view.
May suggest a subtle intra-articular fracture such as a fracture of the talar dome. In the .
Medial tibio-talar joint space in mortise view not > 4mm.
Tibiofibular diastasis = >5mm between medial fibular cortex and posterior edge of lateral tibial groove
Bone overlap between the distal tibia and fibula should be at least 10mm.
Shoulder relocation techniques
Hip relocation techniques
Allis - supine pt, hold leg at 90 degrees, traction in line with femur and externally rotate
Bigelow - supine pt, abduct hip flexed at 90 degrees, traction in line with femur whilst abducting, externally rotating andextending hip
Captain Morgan - place my knee flexed at 90 under distal knee and then apply downward force at ankle, upward force at knee +/- external rotation
Stimson - pt prone, knee flexed at 90 degrees and downward traction on calf and hand on ankle to apply internal/external rotation
Tennis Elbow
(lateral epicondylitis)
Lateral elbow pain
O/E Inc pain with forced palmar flexion + pronation
Golfer’s Elbow
Medial elbow pain
O/E
Foot pathology
High arched foot + spontaneous lateral ankle pain = subluxation of peroneal tendons
Sudden collapse longitudinal arch + heel in valgus = rupture of tibialis posterior tendon
Shoulder EXAM
Neer
Shoulder Pathology
Rotator Cuff
Acute
Chronic
Little power on abduction
Abduct with hunching of shoulder
Osteomyelitis organisms
Osteomyelitis Antibiotic Options
Osteomyelitis Diagnostic Options
In order of diagnostic utility
1. Bone biopsy + positive culture
2. Imagin demonstrating ST infection or bone destruction
3. Clinical signs of exposed bone
4. Chronic wound over surgical site or fracture
5. Labs - +ve cultures, elevated ESR/CRP
Knee EXAM
Look:
Position - valgus / varus, deformity
Effusion, bruising, redness, scars
Feel:
Warmth, swelling, crepitus, muscle mass, NV status
Collateral ligaments
Move:
Anterior / Posterior Draw Test
- Pt supine with knee flexed and foot on bed, anterior and posterior movement of knee in this position
Lachmann (ACL)
- Flex knee to 20-30 degrees and then draw tibia forward, inc anterior displacement c.f other knee indicated +ve test
McMurray (Meniscus)
- Pt supine and knee flexed and extended passively
- Internal rotation tests lateral meniscus
- External rotation tests medial meniscus
Apley (Meniscus)
- Pt prone and knee flexed to 90 degreeswith downward rotation of tibia on femur
- Pressure with lateral rotation = medial meniscal injury
- Pressure with medial rotation = lateral meniscal injury
Tibial Plateau Fractures
Septic Arthritis
Gout
Hand /Wrist Blocks
Median nerve blocks
5-10ml 1% lignocaine
Distal: Injected lateral to palmaris longus and medial to FCR
Proximal:
Ulnar
Distal: Medial to FCU 2-3cm proximal to wrist crease
Proximal: behind medial epicondyle at elbow
Radial
Distal: posterolateral aspect of radius 2-3cm proximal to radial styloid
Proximal: ID on USS proximal to radial head on medial border ot supinator (deep to brachioradialis)
Ankle / Foot blocks
Tibial
Distal: Supplies entire sole except lateral side and heel
Infiltrate 1cm lateral/superior to PTA behind medial malleolus perpendicular to posterior aspect of tibia
5-10ml LA
Proximal: ID on USS, immeidately superficial (posterior) popliteal vein
Infiltrate under USS
Deep peroneal, saphenous, and superficial peroneal
Deep peroneal nerve is between tibialis anterior and extensor hallucis longus tendons
Inject directly, then direct laterally, anterior and past extensor hallucis longus to block superficial peroneal nerve
Return to midline and direct medially, anterior and medial to tibialis anterior tendon to block saphenous nerve
DPN - dorsal web space
SPN - majority of dorsum of foot
Saphenous - medial ankle and foot
