Orthopaedics Flashcards
Clavicle fractures - types, incidence and referral criteria
Class A - middle third - 85%
Class B - lateral third - 12%
Class C - medial third - 3%
Non-union 10-15%
Refer if:
-open or tented skin
-NV compromise
-lateral third fracture with displacement
-any fracture with significant displacement eg 100% displacement or 2cm shortening
ACJ injury assessment, Rockwood classification and management
Get bilateral zanca views
Type I - no separation
Type II - clavicle elevated but not superior to acromion
Type III - clavicle elevated above acromion border up to 100% displacement. Surgical treatment if labourer, athlete, cosmetic requirement or not healing
Type IV - posterior displacement to trapezius. surgical fix
Type V - >100% superior displacement. surgical fix
Type VI - rare. Inferior displacement. Surgical fix
SCJ dislocation
If anterior will be pain and swelling. Treat with NSAIDs, ice, rest, physio, sling
If posterior can lead to dysphagia, limb paraesthesia, SOB and stridor/tachypnoea - worse when lying flat. Refer immediately for this
Rotator cuff exam
Supraspinatus - Jobe’s test - empty can position then raise arm against resistance
Infraspinatus - external rotation
Subscapularis - lift-off
Teres minor - stop/hornblowers sign
Test impingement with Hawkins test - internal rotation of shoulder after flexion of shoulder and elbow to 90’
Biceps rupture signs and treatment
Proximal rupture - Popeye sign
Usually not repaired as short head remains intact but refer if young, active.
Distal rupture - impalpable tendon in ACF. Positive squeeze test. Often repaired.
Nerve injury in supracondylar fracture and how to assess
Anterior interosseous branch of median nerve most common. Check OK sign, sensation in palmar first 3.5 digits
Radial nerve. Thumbs up
Ulnar nerve association with flexion injury (less common). Cross fingers.
Complications of supracondylar fracture
Vascular injury - brachial artery
Nerve injury - medial most likley
Volkman’s contracture
Non-union
Chronic deformity
Myositis ossificans
Compartment syndrome
Most common adult elbow fracture?
Radial head
Radial head fracture management
Joint aspiration + LA injection
Sling immobilisation for 3-7/7 then early ROM for low grade injuries
What is the terrible triad of elbow injuries?
Dislocation
Radial head/neck fracture
Coronoid fracture
What is a Monteggia fracture
Proximal 1/3 ulna fracture with radial head dislocation at elbow
Check for posterior interosseous neuropathy by assessing wrist and digit extension
May be associated with “terrible triad” of elbow
Galeazzi fracture
Distal 1/3 radial fracture with ulnar dislocation (anterior/posterior) or DRUJ injury at wrist (best seen on lateral), can be seen as shortening of the radius cf the ulna
Can also see ulnar styloid fracture and widening of DRUJ
Indication for manipulation of Colles
> 5mm shortening
20’ dorsal angulation
Displacement >2/3 of radius width
Carpal tunnel risk factors, signs and referral
Flick test most sensitive and specific (waking in night and shaking hands to restore feeling)
Median nerve compression (hold for 30s)
Phalen’s (flexion)
Tinel’s (tapping)
Hypoalgesia - decreased pain palmar index cf little
Square wrist
Hypothyroid, DM, obesity, repetitive strain, pregnancy, RA
Refer if:
sensory loss
muscle wasting
no improvement after 6/12 conservative tx
De Quervain’s tenosynovitis
Stenosing tenosynovitis of canal which houses Abductor Pollicus Longus and EPB in lateral distal radius
Due to repetitive strain, commonly from lifting babies
Tender here, also hitchhikers sign and Finkelstein’s sign - pain with enclosing thumb in fist + ulnar deviation
Tx with rest, NSAIDs, splinting, hand therapy
TFCC tear
(Triangular fibro-cartilage complex of the wrist)
FOOSH
Pain in wrist esp ulnar/pisiform area
Difficulties with ADLs
Tender ulnar/pisiform area
Decreased wrist power
Pain and weakness with lifting in supination
MRI diagnostic
Splint, rest, hand therapy
Why are scaphoid fractures prone to avascular necrosis in the proximal portion?
Blood supply runs distal to proximal by radial artery branch
Scaphoid fracture exam and management
65% waist
25% prox pole
10% distal pole
Tenderness at ASB/scaphoid tuberble
Pain on resisted pronation
Pain on axial loading
FU in 2/52
If displaced or proximal pole FU in 1/52 with ortho
Canadian CT C-spine criteria
Age >65
Extremity paraesthesias
Dangerous mechanism:
Fall >3 feet/5 stairs
High speed MVA/rollover/ejection
Axial load
Bicycle collision
Motorised RV
Low risk factors:
Simple rear-end MVC
Ambulatory at any time
Sitting in ED
No midline tenderness
Delayed neck pain
Able to actively rotate 45’ L+R
What % of sacral fractures are seen on XR?
30%
SUFE
Posterior and inferior displacement
Obesity #1 risk factor
M>F
L>R, 25% bilateral
Also: endocrine disorders (esp hypothyroid), trisomy 21, renal disorders, prior radiation
Age 10-16
O/E:
Groin/hip/thigh/knee pain. Limp
Pain and reduced ROM on internal rotation
Loss of abduction and flexion
Trendelenburg (drop of contralateral hip on standing phase of gait cycle) or waddling gait
Obligatory external rotation with passive hip flexion
Thigh weakness and atrophy
Grade 1 = 0-33’ slippage “mild”
Grade 2 = 34-50’ slippage “moderate”
Grade 3 = >50’ slippage “severe”
Trendelenburg gait
Drop of contralateral hip on standing on affected side or during standing phase of gait cycle
Due to weak hip aBductors eg gluteus maximus and medius
Can be due to affected superior gluteal nerve esp after hip replacement
Compensation may occur where the individual leans to the affected side to balance hips
Waddling gait is a bilateral weakness of hip aBductors causing bilateral trendelenburg gait and therefore a waddling appearance
Knee dislocation
50% self-reduce
High energy (low energy + obesity also possible)
Dashboard injury is classic
Anterior most common (hyperextension) - 30-50%
Posterior (dashboard) 30-40%
Lateral 13% Medial 3% Rotational 4% - usually irreducible
0.02% Ortho presentations
Neurovascular injuries common. Popliteal artery, vein and perineal nerve (25%) (esp with anterior) are common injuries. Tibial nerve less common
Check ABPI - if <0.9 needs angiography
Needs immediate surgical exploration if pulses remain absent/diminished after reduction. Imaging contraindicated if will result in surgical delay
Femoral fracture
Blood loss if closed can be up to 1500ml, double that if open
Check lower limb pulses, consider ABPI
Possible popliteal injury if distal fracture
Ottawa Knee Rules
ANY of:
Age >55
Pain over patella or fibular head
Not able tot take 4 steps at time of injury AND in ED (limping is ok)
Inability to flex to 90’
Risk factors for quads tendon ruptures
Renal disease/dialysis
DM
Hyperparathyroidism
Lupus
RA
Connective tissue disorders
Obesity
CKD
Gout
Hypercholesterolaemia
Iatrogenic: PO steroids, fluroquinolones, steroid injections (20-33% risk)
Patella fractures
Direct blow
Loss of SLR indicative
Can brace only if vertical (rare) and SLR intact. Early WBAT
Surgical treatment required if articular step, displaced, unable to SLR, horizontal.
Non-union in 1-5%
Osteonecrosis usually spontaneously resolves
OA common
Patella sleeve fracture
> 50% of patella fractures in children but 1% of orthopaedic injuries in children
8-12
M:F 5:1
Patella separates from ligament, sometimes with avulsion fragment
Indirect injury
Painful knee, non-weight bearing
Palpable defect inferiorly (usually) to patella (can be superior)
Difficult/unable SLR
Treat with cylinder cast
Risk factors for patella instability
10-17yo
Ehler’s-Danlos
Acute injury - twisting with planted foot
Bony malalignment with increased Q angle
Q angle
ASIS to centre of patella and centre of patella to tibial tuberosity
Knee soft tissue injuries referral
MCL - physio
Meniscal tear - physio
ACL/PCL - physio and specialist
Posterolateral corner injury - specialist
Locked knee due to meniscal tear - specialist
Meniscal injury tests
McMurrays - sens 60, spec 95%
Thessaly’s - sens 90%, spec 95%
Apley’s - sens 40% spec 90%
Joint line tenderness - sens 85% spec 70%
Achilles tendon rupture
Rupture occurs 4-6cm above insertion
Causes include weekend warriors, local steroid injections, fluoroquinolones, males 30-40yo
High risk of DVT with this - can use TRIP score to determine need for anticoagulation
Operative management suggested if:
-presentation >72 hours post injury
-laceration injury
-competitive athlete
At-risk of compartment syndrome
Leg anterior compartment, forearm flexor compartment
Fracture to limb - esp high energy to tibia, radius or ulna
Crush injury to limb
Circumferential burn
Reperfusion injury
Constrictive casts or splints
DVT
Male
<30
Vascular injuries
Heat stroke
Extravasation injuries
Electrical injuries
Criteria for Maisonneuvre fracture
Spiral prox fibular fracture AND
medial malleolar fracture OR
medial malleolar tenderness OR
syndesmosis tenderness OR
talar shift
Calcaneal fractures
High energy - often fall from height or MVA
Check spine for fractures (10%) and contralateral calcaneus (10%)
Diffuse heel and foot pain, swelling and bruising
Horseshoe bruise on plantar foot
Short, widened heel
Check pulses + achilles tendon + perineal nerve for associated injury
CT imaging modality of choice
Calcaneocuboid intra-articular extension 65%
Extra-articular only 25%
Use Sanders classification - based on number of fracture fragments with increasing severity
Calcaneal fractures indication for conservative management
Small (<1cm) extra-articular fracture with no TA injury and <2mm displacement
Sanders type I (non-displaced)
Anterior process fracture involving <25% of calcaneocuboid joint
Non-comorbid patient (no smoking/PVD/DM)
Will involve 10-12 weeks of casting and NWB
Calcaneal fracture complications and rate
40% complication rate, greater if:
-fall from height
-patient factors: smoker/PVD/DM
-early surgical fix
-lateral soft tissue trauma
Skin necrosis
Non-union
Avascular necrosis
NV injuries
Subtalar arthritis
Compartment syndrome (10%)
Lateral impingement with perineal nerve irritation
Calcaneal fractures on XR
Use AP, later, Broden (posterior facet) and Harris (tuberosity) views
Look for double density sign
Check for reduction in Bohler’s angle (angle between top of posterior facet, anterior process and top of superior tuberosity - normal is 20-40’ - represents collapse of posterior facet)
Calcaneal shortening
Various tuberosity deformity
Increased angle of Gissane (angle between line along lateral edge of posterior facet and line anterior to beak of calcaneus - normal is 120-145’ - represents collapse of posterior facet)
Tarsal fractures by frequency
Calcaneus
Tarsus
Tarsal fracture management
Get Canale views
Discuss all with orthopaedics
Chronic stress Navicular fractures
Beware navicular pain in athletes who run and jump
“scaphoid of the ankle” due to similar issues with blood supply and risk of avascular necrosis
Fractures may not be seen until bony resorption takes place
Tenderness in navicular in 81%
Get patient to hop - increased pain
Base of 5th fractures
Zone 1 = 75%
-best prognosis
-usually avulsion of peroneus brevis due to inversion type injury
Zone 2 - Jones = 20%
-metaphysis/diaphysis junction
-commonly caused by forefoot adduction injury
-poor blood supply and prone to malunion
Zone 3 - stress/march fractures = rare
-prox diaphysis
-poor blood supply, prone to malunion
Metatarsal fracture management
For zones 2 and 3 base of 5th and for intraarticular fractures place a NWB below knee cast and RV at fracture clinic in a week
If single, undisplayed fracture of other metatarsals or zone 1 fracture base of 5th can do stiff soled shoe
Where is the Lis-Franc ligament?
Between the medial cuneiform and the bae of the 2nd metatarsal on the plantar surface
What is the Lis-Franc joint complex
3 articulations:
-tarso-metatarso articulation, plantar and dorsal
-intermetatarsal articulation
-intertarsal or inter-cuneiform articulations
Lis-Franc Xray findings:
5 critical findings:
-widening of gap between base of 1st and 2nd metatarsals (may see fleck sign in first intermetatarsal space)
-non-continuity of line from medial aspect of 2nd metatarsal to medial aspect of middle cuneiform
-dorsal displacement of the base of the 1st or 2nd metatarsals
-dicontinuity of line from base of 4th metatarsal to medial side of cuboid
-disruption of medial column line (ie medial cuneiform moved medially)
Toe fracture management
Stable, non-displaced or reduced fractures:
-buddy strap
-rigid shoe
-3/52 or 4/52 if great toe
Toe fracture indications for referral
Great toe fractures that are:
-open
-displaced intra-articular
-dislocated
-unstable displaced
-non-displaced intra-articular >25% joint surface
-consider if other, displaced
-growth plate
Lesser toe fractures that are:
-open
-dislocated
-displaced intra-articular
-multiple
-difficult to reduce
-SH III or above
Acceptable metacarpal fracture angulation
Index and middle = 10-20%
Ring = 30%
Little = 40%
How many LIs Franc injuries are missed on X-ray? (%)
20%
Acceptable angulation in distal forearm fractures in children
0-5yo = <20’
5-10yo = <15’
10-15yo = <10’
Distance from wrist joint to require AEPOP
2.5-3cm
