Orthopaedics Flashcards
signs of fracture
pain
swelling
crepitus
deformity
management of fractures
- reduce (closed or open)
- hold (closed - plaster or traction, fixation - internal or external)
- rehab
when do you do external fixation?
when extensive soft tissue injury/complex periarticular fracture
general fracture complications
fat embolus
DVT
infection
prolonged immobility –> infections
specific fracture complications
NV injury
muscle/tendon injury
non-union/mal-union
local infection
degenerative change
OA management
conservative: analgesic, physio, walking aids, avoidance of exacerbating activity, injection
operative: replace, realign
shoulder conditions - 15-45yo
dislocation, fracture
shoulder conditions - 45-60yo
impingement
dislocation
ACJ OA
rotator cuff tears
fractures
shoulder conditions - >60yo
glenohumeral OA
impingement
cuff tears
fracture
hip conditions, 15-45yo
DDH
leg length discrepancy
impingement
hip conditions, 45-60yo
OA
avascular necrosis
impingement
hip conditions, >60yo
OA
post THR
knee conditions, 15-45yo
patellofemoral maltracking
ACL/PCL
meniscal tears
fractures
knee conditions, 45-60yo
OA
patellofemoral maltracking
ACL/PCL
meniscal tears
fractures
knee conditions, >60yo
OA
management of septic arthritis
immobilize joint in acute phase
physio onceover acute phase
testing supraspinatus tendon
empty can test
testing infraspinatus
external rotation against resistance
testing teres meinor
horn blower test
testing subscapularis
internal rotation against resistance
4 stages to fracture healing
- reactive: first 48 hrs
reparative phase = 2 days to 2 weeks - proliferation: reparative phase part 1
- consolidation: reparative phase part 2
- remodelling: 1 week - 7 years
managing open fractures
analgesia
assess: NV status, soft tissues, photograph
alignment: align fracture, splint
anti-sepsis
anti-tetanus
abx
open fractures classification
Gustilo
complication of fracture management
anaesthetic: anaphylaxis, damage to teeth, aspiration
intra-operative: bleeding, damage to local structures, tx failure
early post-op: compartment syndrome, infection, VTE, abx colitis
late post-op: scarring, function loss, neuropathy, pain
what are the fracture sites most associated with compartment syndrome?
suprachondylar fractures
tibial shaft fractures
what are the Ottawa knee rules?
<55yo
isolated patellar tenderness
cannot flex to 90 degrees
inability to weight bear >4 steps
what are the Ottawa foot tules?
malleolar zone pain +
1. lateral or medial mallelous tenderness
2. no weight bearing
mid foot pain +
1. 5th metatarsal base pain
2. unable to weight bear
3. navicular tenderness
risk factors for NOF fracture
SHATTERED
Steroids
Hyperthyroid/hyperparathyroid
Alcohol/smoking
Thin (BMI <22)
Testosterone low
Erosive bone disease
Renal failure
Early menopause
Dietary Ca low, DM
how do you classify degree of displacement of intracapsular NOF fracture/
Garden classification (grades I-IV)
what nerve is damaged by suprachondylar fracture?
median nerve damage
Colle’s fracture definition
posterior displacement and angulation of distal radius fragment
Lisfranc injury
injury of foot
one or more of metatarsal bones are displaced from tarus
Subacromial impingement cause
supraspinatus tendon catches on acromion
management of subacromial impingement
cons: rest, physio
medical: NSAIDs, subacromial bursa steroid
surgical: athroscopic acromioplasty
partial vs complete rotator cuff tear
partial: painful arc
complete: shoulder tip pain, full range of passive movement but can’t abduct arm. can abduct once past 90 degrees
what is adhesive capsulitis?
condition characterized by loss of active AND passive movement
no clear cause
lateral vs medial epicondyltiis
lateral: worse on wrist extension (Tennis)
medial: worse on wrist flexion (Golfers)
what is the cause of radial tunnel syndrome
posterior interosseous branch of radial nerve
symptoms similar to lateral epicondylitis (worse on wrist extension, decreased grip strength)
ix for carpel tunnel
EMG
ulnar nerve entrapment symptoms
pins and needles in 4th and 5th digit
claw hand
what causes De Quervain’s tenosynovitis?
sheath containing extensor pollicis brevis and abductor pollicis longus tendons becomes inflamed
test used to investigate De Quervain’s?
Finkelstein’s test
management of Ganglions
50% disappear
aspiration +/- steroid and hyalurounic injection
surgical excision
knee locking differentials
obstructive causes:
meniscal/cruciate tear
osteochondritis dissecans
osteophytes
symptoms of torn meniscus in knee
delayed knee swelling
joint locking
recurrent pain/effusion
McMurray’s test +ve
osgood schlatter’s disease, what happens?
tibial tuberosity apophysis
patellar tendonitis
what special test for Chondromalacia patellae?
Clarke’s test
pain on patellofemoral compression
Simmond’s triad
for Achille’s tendon rupture
1. Thomas’s test does not elicit plantar flexion
2. Angle of declination (greater dorsiflexion of injured foot)
3. Gap in tendon path
features of Charcot foot
deformity
debris
density change
destruction
dislocation
features of Brown-Sequard syndrome
ipsilateral paralysis
ipsilateral loss of proprioception and fine touch
contralateral loss of pain and temp
indications for bisphosphonates
fragility fracture and age >75
fragility fracture and T score 65y and on/about to start long term steroids
when do you need to give immediate bisphosphonates to pt on/about to start long term steroids?
- > 65
- < 65, do a DEXA, give if score < -1
2nd line treatment after bisphosphonate
SC denosumab
complications of TKR
immediate: vascular/nerve injury
early: DVT, prosthesis infection
late: loosening, instability from ACL
septic arthritis RFs
modifiable: crystal arthropathies
non-modifiable: age >90, RA, chronic renal failure, prosthetic joint
non-neoplastic bone tumours
fibrous dysplasia
simple bone cyst
muscles affected in Erb’s palsy
abductors and external rotators paralysed
= waiter’s tip
Fracture healing in general
- Reactive phase (injury - 48hrs)
- Reparative phase (2 days - 2 weeks)
- Remodelling (1 week - 7 years)
Reactive phase
- Bleeding into fracture site = haematoma
- Inflammation = cytokine release to cause granulation tissue
Reparative phase
- Proliferation of osteoblasts and fibroblasts = callous formation
- Consolidation: woven bone to lamellar bone
X rays needed in a fracture
AP and lateral
Images of joint above and below fracture
Describing a fracture (PAID)
- Demographics
- Pattern: transverse, oblique, spiral, multifragmentary, avlusion
- Anatomical: location
- Intra / extra articular: dislocation or subluxation
- Deformity (distal): translation, angulation, rotation, impaction
- Soft tissues: open/closed, NV status, compartment syndrome
- Amy specific classification
Methods of fracture reduction
Closed reduction
Open reduction (and internal rotation)
Traction (not common now )
Methods of restriction
Non-rigid (sling)
Plaster
Functional bracing
Ex-fix
Internal fixation
Late complications of fracture
Problems with union
AVN
Growth disturbance
Complex regional pain syndrome
Nerve damage and effect of anterior shoulder dislocation/numeral surgical neck
Axillary nerve
Numb axillary patch
Weak abduction
Nerve damage and effect of Humeral shaft fracture
Radial nerve
Waiters tip
Nerve damage and effect of elbow dislocation
Ulnar nerve
Claw hand
Nerve damage and effect of Hip dislocation
Sciatic nerve
Foot drop
Nerve damage and effect of Fracture of neck of fibula/knee dislocation
Fibular nerve
Foot drop
Union problems
- Delayed union: union takes longer than expected
- Non-union: fracture fails to unite
Causes of non union
Ischaemia
Infection
Inter current disease (malignancy/malnutrition)
Salter Harris Classification
SALT Crush
1. Straight across
2. Above (goes across and above growth plate)
3. Lower (goes across and below growth plate)
4. Through (straight through GP)
5. CRUSH
Management of low grade intracapsular hip fractures
ORIF with screws
Extracapsular management
ORIF with DHS
Management of unstable fractures
ORIF
Signs of shoulder impingement
Painful arc
Dec ROM
Weakness
Cause of shoulder impingement
Entrapment of supraspinatus tendon and subacromial bursa between acromion and greater tuberosity of humerus
Management of shoulder impingement
Rest/physio
NSAIDs
Injection
Acromioplasty
Signs of suorachondylar fracture of humerus
Elbow swollen and hand semi flexed
Management of suprachondylar fracture
Collar and cuff if no displacement
MUA and K wires if displacement
Weber classification of ankle injuries
A: below joint line
B: at joint line
C: above joint line
Problem with Weber B and C
Possible injury to syndesmosis so instability
Management of Weber fractures
A: boot
B/C: POP/ surgery
What is used in ACL repair ?
Autograft repair
Semitendinosus +/- gracillis tendon
What is spondyliothesis?
Displacement of one lumbar vertebrae on another
Usually L5 forward onto S1
Common causes of body mets
Bronchus
Thyroid
Breast
Kidney
Prostate
Commonest benign bone tumour
Osteochondroma
What is chondrosarcoma? Location? Appearance
Malignant cartilage tumours
Pelvis and axial skeleton
Popcorn calcification
X-ray changes on Osteosarcoma
Sunburst appearance
Cod man’s triangle
