Orthopaedics 2 Flashcards
How long after a hip fracture should surgery take place?
<36 hours
What measures and drug is used to stop life threatening bleeding in someone with a high INR?
Stop warfarin
Vitamin K
Prothrombin complex concentrate
or
FFP if PCC not available
*this is usually indicated in patients with INR >8
If someone presents with a hip fracture, what important thing should be done if they are on warfarin?
It should be withheld and vitamin K started
What is the most common cause if a locked knee?
Meniscal tear
What test is conducted for an ACL tear? and for a PCL?
Lachman’s test - ACL: femur over the tibia
Anterior drawer test - PCL: Tibia over femur
What will be a defining features seen on an x-ray of a knee following a tibial plateau fracture?
lipohaemoarthrosis
- fat and blood from bone marrow in the joint. Highly indicative of a tibial plateau fracture or distal femur fracture.
Following an injury to the knee which began to swell and was extremely painful - what things do you want to ask?
Position of knee at injury and rotation it moved
Was foot planted
How quickly did the swelling appear
ROM, is there a mechanical block
Pain, any specific site
In the setting of a knee injury which is acutely painful and unable to move due to swelling, - what procedure can be done in the clinical to improve this? Also outwith a fracture what is blood in the joint a very strong suggestive factor for?
Knee joint aspiration
- allows for movement
- reduces pain
hemarthrosis out with a fracture is very suggestive of an ACL
Name two significant differences in the radiological appearance of a patella tendon rupture and quadricep tendon rupture:
Patella tendon: Patella Alta
- proximal high patella
Quadriceps tendon: Patella Baja
- Low riding patella due to unopposed pull
What is the best imaging modality for assessing intra-articular fractures?
CT
What is the definition of a fracture:
Loss of continuity of the cortex bone
How should neurological damage in spinal damage be documented?
ASIA chart
What are you checking for when logrolling someone?
Tenderness
Boggyness
If you are unable to attain a CT scan for the cervical neck, what x-rays should you request?
AP
Lateral
Peg view
What muscle does the palmer aponeurosis come off?
Palmaris longus
What muscle tendons join into the PIPJs and which to the DIPJs?
PIPJs - flexor digitorum superficialis
DIPJs - flexor digitorum profundus
What structures are found within the carpel tunnel?
Tendons of:
- flexor digitorum profundus
- Flexor digitorum superfiscialias
Tendon of:
- Flexor pollocis longus
Median nerve
What is the anatomical line used to guide incisions on the hand to avoid the blood supply?
Kaplan’s cardial line
- should incise proximal to it
Which muscle tendons make up the De Quervains?
Abductor pollocis longus
Extensor policis brevis
The radial nerve branches to become what nerve, and what muscle is not supplied by this?
Posterior interosseous nerve
- Extensor carpi radials is not supplied by the PIN. it is supplied directly of the radius nerve.
- Brachioradiulus is also supplied by the PIN
What muscle does the ulnar nerve pass through at the cubital fossa? and what motor branches does it through off in the forearm?
Flexor carpi ulnaris
throws off branches to the flexor digitorum profundus for the digits 4 and 5.
What muscles in the hand does ulnar supply?
Hypothenar muscles
Lumbricals 4&5
Adductor pollicis
Interossie Muscles - via the deep branch
What must you think if there is excessive pain on passive stretching following a fracture? and what area is most associated with this?
Compartment syndrome
Supracondylar fractures
What is the imaging modality most utilised to diagnose a Achilles tendon rupture? What is the diagnostic test done?
Ultrasound initially used
MRI is used for further investigation into partial tendon rupture
Diagnostic test:
- Simmonds’s triad
Which mononeuropathy are steroid injections not recommended for?
Cubital tunnel syndrome
What are the top differentials for a prolonged painful shoulder in a 50 year old male?
OA of the glenohumoural joint OA of the AC joint Impingement syndrome Adhesive capsulitis Rotator cuff injury Referred pain from neck
What are the symptoms of impingement syndrome?
Pain associated with overhead activity
Pain perceived on the lateral aspect of the shoulder
Pain at night when lying on the shoulder
What are the key symptoms of adhesive capsulitis?
Pain and stiffness in all active and passive movements but especially true for external rotation and to a lesser degree internal rotation
History of:
- trauma
- diabetes
What are the main diagnostic tests for impingement syndrome?
Neer’s test
- pain on passive forward flexion within an arc of 60-120 degrees whilst arm is pronated
Painful arc
- pain on passive abduction from 60-120 degrees
Empty can test
What would weakness supraspinatus suggest? and what investigations would you consider to diagnosis this?
tear or damage to the tendon of it
Ultrasound can usually identify a tear but not much more.
MRI is more sensitive and gives more details around other structures
- MRI is therefore usually the preferred choice
How is degeneration of the supraspinatus muscle treated?
Conservative:
- Physiotherapy
- Steroid injections into the subacromial space
Surgical:
- arthroscopic subacromial decompression
What is the best management for a Weber A ankle fracture?
CAM boot
What are the complicating issues and lesions that can occur complicating an anterior dislocation of the shoulder?
Bankart lesion
- damage to the anterior labrum
Hill Sach’s defect
- a posterior-lateral fracture to the humeral head as it passes over the anterior labarum following an anterior dislocation
Axillary nerve damage
What sign may be seen posteriorly in supraspinatus injury?
Early scapular rotation
What are the stages of adhesive capsulitis and what investigations must you do into it? How is it going to be managed?
- painful and freezing stage (1 year)
- freezing stage but no pain
- thawing phase (1-3years)
MRI - if clinically unsure
HbA1c
TFTs
- very important to do blood glucose and TFTs as its highly associated with the syndrome
- both hyper and hypothyroidism are risk factors
Management:
- NSAIDs
- physiotherapy
- Corticosteroid injection
- <6 week course of steroids
Surgical:
- Arthroscopic arthrolysis (loosening of adhesions)
**reassurance of the phases
What does SLAP tear stand for, what is the diagnostic examination and how is it treated?
Superior Labrum tear from Anterior to Posterior
Examination:
- O’Briens test
Management:
- NSAIDs
- Physiotherapy
- Surgical repair
Other than the tendons of the flexor palmar superfiscialis and profundus what other tendon is present in the carpal tunnel? and what structure is near by but not in it?
Flexor Pollicis Longus
Flexor capri radials is near by but not part of the tunnel.
Define the different types of neuronal injuries which can occur:
Neurapraxia:
- Transient loss of conduction due to damage to the membrane
- Demyelination
Axonotmesis:
- Damage to axon with preservation to the endoneurium and perineurium
- Distal end undergoes Wallerian degeneration.
- recovery is possible
Neurotmesis:
- Complete transection through the axon with no sparing of endoneurium or perineurium
- recovery not possible without surgical intervention
What are three associated conditions of subacromial impingement and what clinical examinations can be done to diagnose subacromial impingement?
if you an order an x-ray what are you looking for?
Hooked shaped acromion
Glenohumoral instability
Greater tuberosity fracture - malunion
Examination:
- Painful arc test
- Neer’s test
- Hawkins test
X-ray:
- Type 3 hook
- ACJ osteoarthritis
- Sclerosis/ cystic changes to greater tuberosity
What are the surgical options for subacromial decompression?
Arthroscopic subacromial decompression
Acromioplasty
What are the risk factors for rotator cuff tear?
Age (grey hair = rotator cuff tear)
Hyperthyroidism
Hypercholesterolemia
Smoking
What are the maternal complications and fetal complications of multiple pregnancy (not including the specific twin complications)?
Maternal complications:
- Hyperemesis gravida
- Anaemia
- Pre-eclampsia
- Antepartum haemorrhage
- C-section (breech presentation)
Fetal:
- Chromosomal abnormalities
- Structural abnormalities (only in monozygotic)
- Premature birth (most go into labour 37 weeks)
- Fetal growth restriction
What is the management for multiple pregnancies?
Supervision under MDT
- specialist obstetrician
- Midwife
*early establishment of chronicity
Regular visits (every 2 weeks for monochorionic twins after 16 weeks)
(every 4 weeks for dichorionic from 16 weeks)
- mother monitored for complications
- Planned delivery (37 weeks dichorionic, 36 for mono chorionic)
What is the major complication of induction of labour and how is this managed?
Uterine hyperstimulation
- removal of PGE2 if possible
- Tocolytics to stop/ slow down uterine contraction
What is the intra-vaginal pessary used for induction of pregnancy?
Prostin - PGE2
Typically when is a spinal used in obstetrics, and where is this injected? when else may it be used? and where should it not be injected above?
C- section
Into the subarachnoid space
also used when:
- repairing 3rd/ 4th degree tears
- instrumental deliveries
- management complications of PPH
**should not be injected above T4 as this can cause bradycardia which on top of hypotension side effects can be dangerous
What peripheral nerve can be blocked during labour and how is it accessed?
Pudendal nerve
accessed via he sacrospinal ligament
What angle are episiotomies done at? and when are they indicated?
Right (sometimes left) posteriolateral angle
Indication:
- Rigid perineum preventing birth
- If large tear is likely
- instrumental delivery
- Fetal compromise
- shoulder dystocia
When is the fetal head said to be engaged during labour?
When less then 2/5ths of the head is palpable abdominally
Engagement can be measured by the depth of the fetal head to what structure and what may artificially make you think the baby is more engaged that what it is?
ischial spines
Caput succedaneum can make falsely make the baby is more engaged than what they are
What colour of meconium during labour is worrying, what does it suggest?
Pea soup colour
- suggests fetal distress
What are some side effects of epidurals?
Puncture of CSF causing spinal headaches
Hypotension
Urinary retention
Respiratory depression
