Orthopaedics Flashcards
Fracture Management
Resuscitate
- A-E, clinically stable
- analgesia
- Assess neurovascular status
- Obtain 2-view radiographs
Reduce
- Close e.g. MUA, Skin Traction, skeletal traction
- Open- ?where anatomic reduction is key e.g. intrarticular ‘#
Restrict (hold) prevents displacement/pain relief/facilitation of funciton and early mobilisation
-
Conservative:
- non-rigid e.g. sling
- rigid e.g. plaster of paris, bracing
-
Surgical:
- internal fixation; plates, screws, k wire
- External fixation
Rehabilitate
Early movement and physio
Fracture complications
(immediate, early, late)
Immediate <24hrs
- Neurovasc damage; arteriest, veins, nerves (neuropracia)
- Tissue damage; muscles
- Fat embolism; resp distress after #
Early <1wk
- Compartment syndrome
- Infection
- Gen; anaesthesia, prolonged bed rest (DVT)
Late <1mnth (long term >1mnth)
- Bone healing-malunion/non-union
- Avascular necrosis
- OA
- Myositis ossificans
- complex regional pain syndromes type 1 (Sudek’s atrophy)
Immediate ‘resuscitation’ Mx of open #
Resuscitation
- A-E resus
- Control bleeding; direct pressure
- Pain relief.
- Antibiotics within 3 hours. Vary with Gustilo classification (1-3: small wound/simple #, medium wound, large wound/compound #)
-
Assessment;
- Neurovascular damage?
- Soft tissue damage
- gross debris removal
- PHOTOGRAPH
- Dress with sterile saline-soaked gauze,
Splint until patient can go to theatre; Decreases pain, clot disruption and further neurovascular/soft tissue injury
‘Viva’; what is osteoarthritis (define)
OA is a degrenerative chronic joint disorder in which there is progressive loss of cartilage with new bone formation at the joint surface
Viva OA
- Presentation (history)
- Examination
- risk factors
- Joints affected (classic)
- Diagnosis
Presentation: Commonly an elderly patient complaining of joint pain. Worse on exertion and at the end of the day. Stiffness after resting.
Examination: Reduced range of movement, painful movement. Bouchards/Herbeden’s nodes.
Risk factors: Age, obesity, joint abnormality, previous trauma.
Joints classically affected: Knee, hip, DIPs and PIPs.
Diagnosis: History and examination. Imaging findings confirm.
Dx (and findings)
OA radiographic changes:
- Joint space narrowing
- Sclerosis
- Osteophytes
- subchondral cysts
OA management
(conservative/medical/surgical)
Conservative:
- Losing weight
- Physiotherapy
- Walking aids etc. (occupational therapy)
Medical:
- analgesia; paracetamol WHO pain ladder
- Steroid injections
Surgical:
- Arthroscopy +/- cartilage excision/remove loose bodies
- Arthroplasty
- Arthrodesis (palliative)
- Realignment osteotomy (biomechanics, younger)
Special Tests!
●Spine
●Shoulder
●Elbow
●Hand and wrist
●Hip
●Knee
●Foot and ankle
●Spine – Schober’s, Straight leg raise
●Shoulder – rotator cuff (Supra, Infra, Teres m, Subscap)
●Elbow – medial and lateral epicondylitis
●Hand and wrist – Tinel’s (c. tunnel) Finkelstein’s (tenosynovitis)
●Hip – Thomas’s test, Trendelenberg’s
●Knee – Cruciate, Collateral and Cartilage (Mcmurray’s)
●Foot and ankle – Simmond’s (Achilles’ rupture)
What is Trendelenburg’s test
Trendelenburg’s test of hip abductor strength. Weak muscle on the contralateral side that the pelvis drops as it fails to abduct and keep pelvis stable when foot is lifted off the floor.
‘Sound side sags’
Hip related Gaits (define and likely cause)
Antalgic
Trendelenburg
Circumduction
Antalgic;
- chronic hip pain rsults in avoidance of use and stiffness. classic ‘limp’
- likely causes= OA (other’ bursitis, musculoligamentous strain, femoroacetabular impingement)
Trendelenburg
- weakening of hip abductors causes pelvic instability. The patient corrects this by lurching their body towards the side of the weakness.
- Likely cause = Gluteus medius strain. Superior gluteal nerve lesion (compression, inflammation, trauma).
Circumduction
- Gait seen in hemiplegia/hemiparesis. With a lack of knee and hip flexion the affected foot is dragged in front of the body in a semicircle during the swing phase
- likely cause: stroke most common. Other neuro conditions.
What is Thomas test?
Thomas’s test
- Place hand under patient’s spine.
- Passively flex both legs (hips/knees) as far as you are able to.
- Your hand should detect the lumbar lordosis is obliterated.
- Ask patient to fully extend the hip you are assessing.
- Failure to flatten leg shows a fixed flexion deformity.
Causes of a fixed flexion deformity:
- Osteoarthritis of knee or hip.
- Other causes depend on the structure involved:
- Skin – burns and scar tissue cause contractures
- Muscles – hamstring contracture
- Joint – intra-articular fractures, septic arthritis.
Define: True and Apparent hip lengths
Causes of discrepancy (>2cm) in true leg length (and therefore apparent leg length):
x3
Causes of discrepancy (>2cm) in apparent leg length with equal true leg lengths:
x2
True = ASIS to medial malleoulus
Apparent = Midline point (xiphisternum/umbilicus) to medial malleolus
Significant difference = 2cm
Causes of discrepancy in true leg length (and therefore apparent leg length):
- Congenital
- Fracture (NOF acutely, chronically after growth plate fracture)
- Post total hip replacement
Causes of discrepancy in apparent leg length with equal true leg lengths:
- Spinal pathology e.g. scoliosis
- Pelvic pathology e.g. hip abduction/adduction contracture
Finding on Ex of hip OA
Gait/look/feel/move/special
GAIT – Antalgic if severe. Walking aids.
Look – ?arthroplasty/arthroscopy scars
Feel – May have pain on palpation of greater trochanter.
Move – Reduced range of active and passive movement.
Special test’s – Thomas’ positive. Fixed flexion deformity.
Hip arthroplasty scars
and potential injuries!
Hip arthroplasty scars, incisional approach:
Anterior/lateral/posterior
Anterolateral approach: Femoral nerve damage. Abductor weakness. Increased risk of infection
Posterior approach: Sciatic nerve damage. Increased risk of dislocation
Also consider femoral diaphyseal #
Reasons for hip arthroplasty
Reasons for arthroplasty:
- Fracture repair in an individual unlikely to heal with fixation alone
- Erosion of the hip joint such that a replacement will improve quality of life e.g. osteoarthritis.
Hip # types
- Intracapsular; subcapital, transcervical, basicervical
- Extracapsular
- intertrochanteric
- subtrochanteric
Why does it matter?
Intracapsular fractures are at risk of avascular necrosis of the femoral head.
What is Garden classification
Garden classification of intracapsular fractures.
Higher grade = higher risk of AVN.
- incomplete #
- Complete # (-displacement)
- Complete # + Partial Displacement
- Complete # + Full Discplacement
Femoral head blood supply
Three main supplies:
- Retinacular vessels, originating from the medial circumflex artery from femora profundis
- Nutrient arteries from bone
- Artery to ligamentum teres (very small amount and variable)
Intracapsular fracture disrupts 2/3, with increasing displacement = increased disruption and risk of AVN
NOF# Management
A-E.
Analgesia; paracetamol, opiodis (NOT NSAIDS)
Assess: MMTS/VTE risk
Surgery within 36 hours proven to improve outcomes.
Surgical management:
- Undisplaced #
- ORIF with cannulated screws.
- Displaced #:
- Inter-trochanteric = dynamic hip screw
- Subtrochanteric = intramedullary nail + screws if needed.
- Intracapsular. Consider Garden classification, patient’s pre-admission mobility and comorbid status.
- Total hip replacement = good mobility, cognition, few medical comorbidities
- Hemiarthroplasty = non-ambulatory, severe cognitive impairment, high operative risk, fracture is very old.
Rehabilitate
MDT rehabilitation w/early mobilisation (on day after surgery). Early supported discharge home/to intermediate care
Should be incorporated into a formal “Hip Fracture Programme”: orthogeriatric input, optimisation for surgery more generally, discharge planning
Dynamic Hip Screw
- The idea behind the dynamic compression is that the femoral head component is allowed to move along one plane; since bone responds to dynamic stresses, the native femur may undergo primary healing: cells join along boundaries, resulting in a robust joint requiring no remodeling.*
- -Used for ORIF of Intertrochanteric #*
ORIF-screws
Hemiarthroplasty Hip
Total hip replacement
Knee sweep test
explain
Sweep test
- Can detect very small effusions if done correctly.
- Start medially > superiorly > laterally.
- Watching the medial groove of the knee joint all the time for a bulge.
Knee ‘special tests’
Special tests – THINK CCC – CRUCIATES, COLLATERALS, CARTILAGE
Cruciates (remember to anchor the foot)
- Anterior drawer – ACL tear
- Posterior drawer – PCL tear
Collaterals – practice the technique on your friends. Obvious when not well versed.
- Medial collateral – apply force to lateral aspect
- Lateral collateral – apply force to medial aspect
Cartilage – medial and lateral menisci. Likely not done in PACES
McMurray’s test.
Knee OA findings
Gait/look/feel/move/special
GAIT – Antalgic if severe. Walking aids.
Look – ?arthroplasty/arthroscopy scars
Feel – May have pain on palpation of medial aspect.
Move – Reduced range of active and passive movement.
Special tests – Normal.
Knee OA tends to affect medial compartment of knee first. Patients often present with pain specifically medial to patella.
OA Knee Mx
Conservative and medical
Surgical:
- Realignment osteotomy (biomechanics). In young patients with abnormal biomechanics or deformity resulting in accelerated osteoarthritis.
- Partial or unicompartmental knee replacement
- Total knee replacement
?Partial knee replacement:
factors affecting suitability
Advantages
Disadvantages
Factors increasing suitability:
- Unicompartmental disease
- Normal BMI
- Good activity levels and ROM pre-surgery.
Advantages:
- Shorter operation with reduced blood loss
- Fewer complications
- Faster recovery to full ROM
- Better ROM gained
Disadvantages:
- Higher revision rate. Revisions often result in a step down in function
Partial: ACL and PCL intact
Total: Cruciates removed
How many compartments does the knee have
The knee has three compartments. They are:
- Medial
- Lateral
- Patellofemoral
Knee arthroscopy
Indications/uses?
Why is it performed?
- To allow surgical examination of the knee’s anatomy under direct vision
- To repair meniscal tears
- For cruciate repair/reconstruction
- For collateral repair/reconstruction
Hallux Valgus
Definition
RF
Presentation(Hx)
Diagnosis
Definition: abnormal deviation of the great toe away from the midline of the body, towards the other toes of the foot
Bunion = the swelling that develops on the first MTP. Occurs due to persistent rubbing of the prominence on shoes, stimulating proliferation of fibrous tissue and even bone growth.
Risk factors: Wearing tight shoes/high heels. Not seen in shoeless cultures.
Presentation: Pain over bunion area when walking or rubbing/knocking it.
Diagnosis: Clinical. XR to help quantify amount of bony deformity.
Management of Hallux Valgus
Management; nb PROGRESSIVE, main indication for surgery is PAIN
- Conservative: wear wide shoes, wide tow box and protective badding, bunion splints/braces, physiotherapy
- Medical: Paracetamol, NSAIDs, NSAID gel.
- Surgical: Realignment osteotomies; bunionectomy, soft tissue reconstruction, excisional arthroplasty (keller), fusion arthrodesis etc.
Compartment Syndrome
define/Sx/Ix/Mx
Compartment syndrome: Increased intracompartmental pressure in closed anatomical space, leading to microvascular compromise
Symptoms: Pain, pallor, parasthesiae
Ix: clinical diagnosis, aided by measuring of compartmental pressure (preferably close to # site).
BLOOD PRESSURE (Whiteside theory, development of a compartment syndrome depends not only on intra-compartment pressure but also depends on systemic blood pressure). Many surgeons assess the difference between diastolic BP & intracompartmental pressure and use <30mmHg as the cut off for performing a fasciotomy. Measurement aids inc. catheter (e.g. slit catheter) or needle (e.g. side port needle)-
Mx: <30mmHg intracompartmental pressure difference (DBP-CP) is often taken as absolute indication to operate (fasciotomy) Eventually delayed primary closure, ideally within 5 days
^Skin, superficial and deep fascia incised
scar differential!
Cubitus varus (gunstock deformity) – an example of malunion of humeral #
Myositis ossificans – heterotopic ossification. Elbow is common location. Can Mx operatively with resection if symptomatic once lesion has matured.
Monoblock, unipolar hemiarthroplasty. Exeter stem (an example of a ‘proven femoral stem’). Most commonly used stem in UK.
Metal-on-poly(ethylene) THR: tapered stem, femoral head (notice how SMALL it is compared to hemiarthroplasty) & acetabulum w/metal cup & polyethylene liner.
Meniscal tear management
(non-op/op)
Meniscal tear mx
- Non-operative (i.e. physiotherapy)
- Operative: repair or PARTIAL meniscectomy. Total meniscectomy now no longer indicated.
Meniscal damage can predispose to OA in approx. 20yrs time
Remember
- 4 XR findings OA;
- Valgus =
- Gen Mx of #;
- Knee has how many compartments?
- 4 XR findings OA; joint space narrowing, sclerosis, osteophytes, subchondral cysts
- Valgus = Lateral
- Gen Mx of #; “Neurovascular status (DP, PT & CRP in lower limb; RP & CRP in upper limb), joint above & below, AP & lateral wt bearing x-rays//Shoulder=AP, lateral and Axilla
- Knee has 3 compartments
How would you examine/describe this?
- Unilateral or bilateral
- Degree of valgus
- bunion? (prominence of medial aspect of first metatarsal head)
- Signs inflammation: dolor, rubor, calor, tumour
- Walk the patient, examine shoes, plain weight-bearing X ray
