Orthopaedics Flashcards
Paediatric Elbow Fracture
2022.1 Station
Interpret and teach approach to paediatric elbow xray to junior doctor
- Explore what they know about xray interpretation and paediatric elbow fractures
- Suggest radiopedia lectures for further learning
Explain your approach to elbow examination in the distressed child
- importance of establishing rapport with the parent and child
- consideration of the developmental age
- analgesia
- distration - ipad
- getting the parents on board
- minimal handling examination
Come up with a managaement plan
- analgesia
- back slab
- fracture clinic follow up
Explain return advice
Check understanding - ask parent to repeat main points
Any questions or concerns
Give written information
CRITOE
Capitellum 1yr
Radial head 3yr
Internal condyle 5yr
Trochlea 7yr
Olecranon 9yr
External condyle 11yr
Incidence of nerve injuries associated with supracondylar fractures is 10-20%. The median nerve and the radial nerve are most often injured.
Anterior interosseous nerve - inability to make “OK” sign
(loss of strength of the thumb interphalangeal joint in flexion as well as the index DIP joint in flexion. This injury renders the patient unable to perform the “OK” sign)
Radial nerve - inability to extend at the wrist
Brachial artery injury can lead to Volkmann’s contracture - compartment syndrome of the forearm.
MANAGEMENT is based on the GARTLAND’S CLASSIFICATION.
Type 1 fractures:
Nondisplaced or minimally displaced
long arm back slab with elbow at 90deg
fracture clinic follow up
Type 2 fractures:
- Displaced with posterior cortex attached
- Closed reduction and immobilisation in ED + orthopaedic consultation
Type 3 fractures:
- Complete displacement
- Operative management
COMPLICATIONS:
Neuropraxias – usually resolve spontaneously
- Anterior interosseous nerve (branch of median nerve) – most common injury
o Unable to flex interphalangeal joint of the thumb or flex DIP of index finger. Can’t make OK sign.
- Median nerve
o Loss of sensation over volar index finger
- Radial nerve – second most common
o Inability to extend wrist, MCP’s, thumb IP joint
- Brachial artery
o Palpate radial and ulnar artery
o Can use biphasic doppler
o Hand well perfused - warm, pink, OR poorly perfused – cold, pale, CRT >2sec
Bier’s Block
prilocaine 0.5% 2-3mg/kg
duration of action 30-60min
b) contraindications to biers block
- confused unco-operative patient
- uncontrolled hypertension SBP >180mmHg
- allergy to local anaesthetics
- bilateral upper limb humerus fractures
- compartment syndrome
- raynaud’s disease
- sickle cell disease
c)
Stop procedure
Call for help
Ensure tourniquet/cuff inflated (inflate cuff to 100mm Hg above systolic BP)
- Support airway - jaw thrust / chin lift - Supplemental oxygen 100% high flow 15L NRBM
- Terminate prolonged seizure with IV Midazolam 2.5-5mg
- Seek and treat ventricular dysrhythmias with sodium bicarbonate 2mmol/kg IV, repeat every min
- Seek and treat cardiovascular collapse with intralipid 20% 1ml/kg IV bolus
(Intralipid contraindicated in soy, egg, penut allergic patients)
Knee pain/injury
2022.1 Physical Examination: Lower Limb
Medical Expertise: Differential diagnosis/initial assessment (30%)
* Identifies the elements that must be sought on initial assessment to formulate an initial
management plan
* Seeks evidence of time critical diagnoses when performing assessment
* Generates a relevant list of differential diagnoses after synthesising clinical information found
on initial assessment
* Formulates a provisional diagnosis to match the immediate issues.
Medical Expertise: Physical examination (40%)
* Performs/describes a focused structured and relevant physical examination
* Performs/describes a proficient examination technique to elicit physical signs
* Describes expected physical signs for a diagnosis
* Differentiates expected physical signs for different conditions.
Prioritisation and Decision Making (30%)
* Highlights high-risk features identified during initial patient assessment
* Highlights which selected investigations has/have higher priority
* Explains the rationale for prioritising a particular diagnosis over others
* Prioritises a differential diagnosis to determine the most likely diagnoses.
Candidates were required to interact with the examiner and to:
* provide differential diagnoses, with justification
* describe a relevant and focused physical examination to distinguish between the differentials
* answer questions regarding the likely diagnosis.
DIFFERENTIAL DIAGNOSES:
- extensor mechanism rupture (patellar tendon, quadriceps tendon)
- tibial plateau fracture
- occult knee dislocation/relocation
- ACL rupture/segonds fracture
- Meniscal injury/Locked knee
- fracture
- referred pain from hip/ankle
- compartment syndrome
- septic arthritis
- soft tissue injury
- abuse/domestic violence
ASSESSMENT:
mechanism of injury:
- direct blow
- valgus strain (MCL
- sudden deceleration (ACL)
- age (osteoporosis)
- obesity (low velocity, trivial mechanism with significant injury)
Ottawa knee rules:
- age >55
- patellar tenderness
- fibula head tenderness
- unable to flex to 90 degrees
- unable to weight bear at scene and in ED
EXAMINATION:
walk, can they weight bear
- patient lying supine with both knees exposed
- analgesia
- pillow under distal femur to put knee in 20 degrees flexion
Inspection:
- muscle bulk wasting
- asymmetry
- swelling
- bruising
- erythema
- open wounds
Palpation:
- hot
- tenderness
(joint line for tibial plateau fractures)
- effusion
Move:
- active/passive
Special tests:
- straight leg raise (patellar/quadriceps tendon rupture)
- lachman’s
- anterior posterior drawer
Neurovascular exam:
Ankle brachial index:
Use doppler
Brachial SBP/ankle (posterior tibial or dorsalis paedis) SBP
0.9-1.3 = normal
<0.9 = arterial insuficiency
Knee Dislocation
EM Rapid Bombs ep 254 & 256
High velocity mechanisms (MVA - dashboard injuries, fall from height)
Low velocity mechanism in obesity
Anterior dislocation most common (40%) - tibia moves forward
Posterior dislocation (30%) - tibia moves backward
Lateral dislocations (20%)
Medial dislocations (5%)
Signs:
- lose knee (3 of 4 tendons disrupted)
- foot drop/common peroneal nerve palsy
- passive straight leg raise (knee falls into hyperextension compared to the other knee)
COMPLICATIONS:
- Popliteal artery injury (needs revascularization within 6-8hrs to prevent ischemic complications)
- Common peroneal nerve injury (foot drop)
- Compartment syndrome of the leg
- Associated fractures, ligamentous and meniscal injury
- DVT
MANAGEMENT:
- splint knee in 20 degree flexion
admit to orthopaedics
serial neurovascular exam and ABI’s
Patients with distal pulses present before and after reduction and an ankle-brachial index ≥0.9 can be observed with serial neurovascular checks over 24 hours
CT angiography to assess injury to popliteal artery which requires emergency repair - risk of ischemia and amputation beyond 8hrs
vascular surgery consultation if concern for popliteal artery injury
Shoulder Examination
2021.1 Examination Station
2021.2 Examination Station
2023.2 Examination Station
Patient with shoulder pain
1) Outline differential diagnosis
2) Perform a focused examination of a patient post shoulder injury.
- Address patient comfort
- neurological exam
- musculoskeletal exam
Missed diagnosis on previous assessment.
Use open disclosure principles to gain the trust of the patient or relative.
List different types of quality improvement activities and measures.
Develop an appropriate management plan.
- Modify the initial treatment plan in response to newly discovered clinical information.
- Create a safe and clear discharge plan for a patient.
SHOULDER PAIN
Differential diagnoses:
- fracture
- dislocation/subluxation
- rotator cuff injury
- Subacromial bursitis
- referred pain from C-spine/elbow pathology
- septic joint
- compartment syndrome
- abuse/domestic violence
- arthritis
GLENOHUMERAL JOINT:
4 Rotator Cuff Muscles:
- Teres minor - external rotation
- Infraspinatus
- Subscapularis - internal rotation
- Supraspinatus - abduction
ACROMIOCLAVICULAR JOINT:
STERNOCLAVICULAR JOINT:
- dislocation
- septic joint in IVDU
Shoulder Dislocation
2023.1 procedure discussion
Shoulder joint discussion
EM Cases episode 135
Emergency procedures - joint reduction
POSTERIOR SHOULDER DISLOCATION:
<10% of shoulder dislocations
- often missed injury (less painful, subtle xray findings)
- suspect it if the patient can’t externally rotate arm
3E’s:
- epilepsy
- ethanol
- electrocution
Examination/Physical signs:
- Arm in internal rotation
- Mechanically locked in internal rotation. impaction fracture of humeral head engages with glenoid preventing external rotation
Xray:
- A lateral tran-scapular Y view or axillary view is essential to exclude a posterior shoulder dislocation, which may be missed in 50% cases.
- If in doubt get a CT scanXray:
light bulb sign - symmetrical looking humerus on frontal view
rim sign - distance between glenoid and articulating surface of humerus >6mm
trough sign - impaction fracture in humeral head ‘reverse hilsach deformity’
Reduction technique:
Dr. Neil Cunninghams technique
support the affect arm
adduct across the midline
flex to the level of the shoulder
then externally rotate
- only one doctor required
External rotation shoulder brace for immobilization for reduced
posterior shoulder dislocation
ANTERIOR SHOULDER DISLCATION
Analgesia:
paracetamol 1g
ibuprofen 400mg
Intra-articular lignocaine
Regional block- US-guided interscalene nerve or suprascapular nerve blocks
CUNNINGHAMS:
one operator
no need for sedation
Analgesic position:
- patient seated
- arm fully adducted to side
- humerus in neutral position
- elbow flexed
- ask the patient to bring scapular together and push chest out
(reduces stretch on capsule relieving pain, flexed elbow allows bicep to relax)
- Place one hand on patient’s forearm applying downward traction.
- Other hand massages the trapezius, deltoid, and biceps
Proceed to Kocher’s
Low Back Pain
2022.1 History taking station
Take a focussed history
Interpret examination findings given
List differential diagnoses
EM Rapid Bombs ep 434, 229
DIFFERENTIAL DIAGNOSIS:
Intervertebral disc prolapse
Degenerative arthritis
Spinal stenosis
Inflammatory:
- Transverse myelitis
- Ankylosing spondylitis
- Rheumatoid arthritis
Infection:
- discitis
- osteomyelitis
- epidural abscess
Congenital:
- kyphosis
- scoliosis
Haematological:
- sickle cell crisis
- bleeding tendency causing epidural haematoma
Malignancy - spinal tumour
Vertebral fracture:
- pathological
- traumatic
Vascular:
- spinal cord infarction
Referred pain from abdominal pathology:
- AAA
- Renal colic
- UTI/pyelonephritis
- Prostatitis
- Pancreatitis
- Mesenteric ischemia
- PID
- Endometriosis
Referred pain from hips/pelvis
- arthritis
- occult fracture
RED FLAGS:
- pain worse at night lying supine
- fevers, weight loss, night sweats
- malignancy
- current infections (cellulitis, pneumoniae, UTI) homogenous spread
- immunesuppression (diabetes, HIV, transplant)
- immune suppression medication
- IVDU
- trauma
- chronic corticosteroids
- osteoporosis
- inflammatory arthritis
- saddle anaesthesia
- weakness, numbness or tingling in legs
- bowel or bladder dysfunction
YELLOW FLAGS:
- Belief that pain and activity are harmful
- Sickness behaviours
- Low or negative moods, mental illness
- Treatment that does not fit with best practice
- Problems with compensation system
- Previous history of back pain with time off work
- Problems at work, poor job satisfaction
- Overprotective family or lack of social support
History:
“can you tell me about the issues you’ve been experiencing”
Site -
Onset -
Character -
Radiation -
Alleviating & Aggrevating factors (worse pain at night and lying down)
Progression -
Response to analgesia -
Key Symptoms:
- numbness, tingling or weakness
- urinary incontinence or retention
- bowel incontinence or constipation
- fever
- infections (cellulitis, UTI, LRTI’s)
- constitutional symptoms (lethargy, weight loss, night sweats)
- trauma or injury
- malignancy
- previous spinal surgery
- IVDU
- medications - prolonged steroid use, analgesia, anticoagulation
- family history of arthritis (ankylosing spondylitis)
- impact on employment and daily activities
Dysuria (pyelonephritis, UTI)
AAA
Pain relief and pain management strategies
PMHX:
*Malignancy
*Osteoporosis
*Inflammatory arthritis - ankylosing spondylitis
*Bleeding disorder - epidural haematoma
*Clotting disorder - spinal infarction
*AAA
MEDICATIONS:
*chronic steroids - osteoporosis & immune compromise
*anticoagulation - epidural haematoma
*Immune suppression - azathioprine
SOCIAL:
*work - problems at work, sick days, poor job satifaction
*activities of daily living
*mental health - depression, suicidal ideation
*social supports
*IVDU
*alcohol
*smoking
COUNSELLING:
Back pain is very common
Only a very small proportion have a serious diagnosis
pain and activity is not harmful to your spine
*not for imaging in ED - cause harm
Radiation exposure:
- Xrays lumbar spine - equivalent to having 100 chest xrays
- CT lumbar spine - equivalent to having 500 chest xrays
- Overdiagnosis
*Trial analgesia and physiotherapy and if ongoing pain can discuss with GP about having an outpatient MRI
Non-pharmacological:
- get up and get moving
- physiotherapy referral - tailored exercise plan
- massage
Psychologist referral
Pharmacological:
- paracetamol 1g QID
- short course NSAID ibuprofen 400mg TDS (commence PPI)
- short course of oxycodone (advise prn, highly addictive, don’t mix with alcohol, cannot operate heavy machinery)
*Patients with spinal stenosis or disc prolapse with severe radicular pain may hand inpatient CT guided injections (lumber and sacral nerve root and facet joint injections)
Back Pain
2023.2 History taking station
take a history from a patient with back pain and to discuss the case further with the examiner.
Take a focused history from the patient.
- Interpret examination findings provided by the examiner and prioritise your differential
diagnoses.
- Describe and justify further investigations for the patient
IMAGING:
CT Lumbar spine:
- if suspect vertebral fractures in major trauma
- MRI is contraindicated
Xray Lumbar spine:
- suspect vertebral fracture with no trauma (osteoporosis)
MRI:
- gold standard
- very little radiation
Neck Pain
2023.1 History taking
Take a history from a patient presenting with neck pain.
List differential diagnosis
Intervertebral disc prolapse
Degenerative arthritis
Spinal stenosis
Inflammatory:
- Transverse myelitis
- Ankylosing spondylitis
- Rheumatoid arthritis
Infection:
- discitis
- osteomyelitis
- epidural abscess
Congenital:
- kyphosis
- scoliosis
Haematological:
- sickle cell crisis
- bleeding tendency causing epidural haematoma
Malignancy - spinal tumour
Vertebral fracture:
- pathological
- traumatic
Vascular:
- spinal cord infarction
Referred pain from head:
- SAH
- migraine
Referred pain from shoulder
- arthritis
- occult fracture
- dislocation
RED FLAGS:
- fevers, weight loss, night sweats
- pain worse at night
- neurological deficit
- syncope
- malignancy
- immunocompromise
- IVDU
- osteoporosis
- increasing age
HISTORY:
SOCRATES
Site
Onset
Character
Radiation
Aggravating or Alleviating factors
Timing
Excacerbating factors
Severity
Pain relief
Associated symptoms:
- weakness, numbness, parasthesia
Syncope on head turning
Headache
Trauma
History of cancer (metastatic disease)
Previous injuries or surgeries
Shoulder pain or injury (referred pain)
Constitutional symptoms:
- fever
- weight loss
- night sweats
Lymphadenopathy - infection/malignancy
IVDU - osteomyelitis
Sore throat
Difficulty swallowing
Choking on food or water
Stridor or difficulty breathing
PMHx:
Medications:
Allergies:
Social:
- work (affect daily living)
- IVDU
Back Pain
2024.1 Examination Station
perform an examination of
a patient presenting with an acute onset of lower back pain with no history of trauma
Prioritisation and Decision Making: Differential Diagnoses and Historical Features (35%)
* Prioritise a differential diagnosis list.
* Highlight high risk features identified during initial patient history.
Medical Expertise: Physical
Examination – 45%
* Perform a focused, structured and relevant physical examination.
* Perform a proficient examination technique to elicit physical signs.
* Differentiate expected physical signs for different conditions.
* Recognise signs on physical examination that indicate the patient is at risk of imminent
deterioration.
Prioritisation and Decision Making: Interpretation and Justifying Investigations – 20%
* Correctly interpret examination findings.
* Prioritise differential diagnoses to determine the most likely diagnosis in the patient.
* Justify investigation selection.
Candidates were required to interact with the role player and examiner and to:
* Outline their differential diagnoses and key features that would be sought on history.
* Demonstrate how they would perform a relevant and focused examination of a patient with
back pain and explain what they are looking for.
* When given examination findings, interpret these and justify further investigations.
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