Orthopaedics Flashcards
Compartment syndrome
A: Occurs when pressure in muscle compartment exceeds that of capillary blood supply. Eventually leading to muscle oedema and ischaemia.
Usually from open/closed fracture (tibial most common), crush injury, burns, penetrating injury, vascular injury or iatrogenic (dressings, IM injection)
S: Pain out of proportion with the injury, Paraesthesia and diminished pulses are late signs.
D: Clinical, but compartment pressure can be measured with an external probe.
T: Remove dressings, immediate fasciotomy and decompression
Cauda equina syndrome
A: Spinal cord terminates at L1-L2, the cauda equina extends below this and can become compressed.
Central disc prolapse, tumour, trauma (spinal anaesthesia, fractures, penetrating injury), spinal stenosis, spinal inflammatory conditions.
S: Reduced lower limb power, reduced anal tone, reduced/absent reflexes, saddle anaesthesia, bilateral leg pain, incontinence, urinary retention.
D: Urgent MRI lumbar spine.
T: Surgical decompression within 48 hours of symptom onset.
Median nerve injury (carpel tunnel)
S: Loss of thumb abduction and opposition. Loss of sensation in thumb, index finger, middle finger and radial aspect of ring finger.
D: Phalen’s test (inverted prayer sign), Tinel’s sign (tapping over wirst), nerve conduction studies.
T: Rest, splinting, steroid injection, carpel tunnel decompression.
Ulna nerve injury
A: Usually compressed at medial epicondyle as it passes the elbow.
S: Ulna claw hand (little and ring fingers), loss of sensation in little finger and in medial half of ring finger and on corresponding palm below.
D: Forment’s sign (paper held between thumb and forefinger, when trying to pull paper away the thumb has to flex due to muscle weakness).
T: Rest, fix fracture, surgical decompression.
Radial nerve injury
A: Usually mid-shaft humeral fractures.
S: Wrist drop, loss of sensation over anatomical snuff box (below thumb tendon)
D: Nerve conduction studies.
T: Splinting, physio.
Bachial plexus injury
A: Shoulder trauma, tumours and inflammation.
S: Erb’s palsy - “waiter’s tip” position (c5-c6)
Klumpke’s palsy - claw hand, paralysis of intrinsic hand muscles (c8-t1)
D: NCS
T: Physio, nerve transfer if severe.
Lateral cutaneous nerve of thigh injury
A: Injured by entrapment or compression as it passes between the ilium and inguinal ligament near the ASIS. Known as meralgia paraesthetica.
Compressed by seatbelts, tight clothing, obesity.
S: Pain, loss of sensation over outer thigh
D: NCS
T: Analgesia, weight loss, nerve decompression if severe.
Sciatic nerve
A: Arises from L4-S3. Compression can be from lumbar disc herniation, lumbar spinal stenosis, piriformis syndrome.
S: Pain, altered sensation, weakness in lower back radiating down buttox, posterior thigh and leg.
D: Lasegue test (straight leg raise) positive if sciatic pain produced between 30-70 degrees.
MRI spine.
T: Underlying cause, analgesia, discectomy.
Common peroneal nerve injury
A: Damaged as it winds around the neck of the fibula.
S: Foot drop, sensory loss to dorsal surface of foot.
D: Clinical.
T: Rest, fix fracture.
Colles’ fracture
A: Extra-articular distal third radius fracture with displacement dorsally.
Fall onto outstretched hand, elderly population.
S: Pain, “dinner-fork” deformity (ie arm curved upwards)
D: XR
T: Closed reduction in A & E with application of backslab.
Open reduction and internal fixation (ORIF).
Smith’s fracture
A: Extra-articular distal third radius fracture with voral (downwards) displacement.
Fall onto flexed wrist (ie back of hand), elderly population.
S: Garden spade/reverse dinner fork defomity, pain.
D: XR
T: Closed reduction in A & E with application of backslab.
ORIF.
Barton’s fracture
A: Intra-articular distal third radial fracture with dislocation of radiocarpal joint - may be volar or dorsal.
S: Pain, deformity.
D: XR
T: ORIF
Galleazzi fracture
A: Middle to distal third radius fracture associated with an intact ulna and disruption of the distal radio-ulna joint.
Fall onto outstretched hand, peak incidence 9-12 years.
S: Swelling about distal third of ulna.
D: XR
T: Closed reduction with arm held in supination by long arm cast. If closed reduction not possible, ORIF.
Monteggia fracture
A: Proximal third ulna fracture with associated dislocation of radial head.
Peak incidence 4-10 years. Either direct blow on back of upper forearm or fall onto outstretched hand in the hyperpronated position.
S: Elbow swelling and deformity, painful movement especially pronation/supination and crepitus.
D: XR
T: Conservative, ORIF.
Scaphoid fracture
A: Most common mechanism is fall onto an outstretched hand with forced dorsi-flexion.
S: Tenderness over anatomical snuffbox, positive scaphoid shift test positive, pain and swelling at the base of the thumb.
D: XR can be initially non-diagnostic in 25% of fractures, so follow up in 1-2 weeks may be needed. If still negative but suspected, CT/MRI can be used.
T: Immobilisation in a thumb spica cast or operative ORIF.
Bennett’s fracture
A: Fracture of base of first metacarpal extending into the carpo-meta-carpal joint. Often from axial load on thumb from either punching a hard object or falling onto the thumb.
S: Tenderness, swelling and bruising over the base of the thumb.
D: XR
T: All need to be immobilised in a thumb spica cast for 4-6 weeks, some need closed reduction or ORIF.
Boxer’s fracture
A: Transverse neck fracture of 5th metacarpal. Typically sustained when an inexperienced fighter throws a punch and sustains most of the force through the 5th knuckle.
S: Localised swelling and pain, loss of 5th knuckle contour.
D: XR
T: If minimal splinting in the Edinburgh position, may not operative reduction.
ACL tear
A: ACL stabilizes the knee when it is in extension. Caused by deceleration followed by sudden change in direction or twisting knee on landing.
S: Sudden pop, knee locks or buckles, pain bending knee.
D: Anterior drawer test positive.
MRI confirms
T: RICE, knee brace, arthroscopic repair.
PCL tear
A: Direct blow to the flexed knee displacing the tibia posterior to the femur (eg. hitting the dashboard).
S: Pain, instability.
D: Posterior drawer test positive,
MRI confirms
T: Arthroscopic repair.
Meniscal tear
A: Menisci are c-shaped pads of fibrocartilage between femoral condyles and tibial plateau.
Trauma due to twisting of a flexed knee.
S: Pain on loading, swelling, mechanical symptoms (locking, clicking, catching or giving way). Tender over joint line.
D: Mcmurray’s test positive, Thessaly’s test positive, MRI confirms.
T: Conservative - analgesia, quadriceps strengthening.
Surgical - arthroscopic repair or removal
Salter-Harris fractures
A: Epiphyseal injuries in immature bones.
I; Slipped - Seperation of physis (growth plate)
II; Above - fracture above physis (most common)
III; Lower - fracture below physis
IV; Through - fracture through the metaphysis, physis and epiphysis
V; Rammed - crushed physis
Elbow - supracondylar fracture
A: Common in 5-15 year olds, fall onto outstretched hand causing elbow hyperextension, fracture runs through distal humerus above epicondyles.
S: Pain, swelling, unable to move elbows.
D: XR - anterior sail sign and posterior fat pad sign due to effusion suggest a fracture.
T: Depending on severity - immoblisation for 2-3 weeks, closed reduction or ORIF.
Important to monitor neurovascular status as they are commonly affected by these types of fractures.
Osgood-Schlatter disease
A: Irritation of the patella tendon at the tibial tuberosity. Often in active children 9-16 years, coincides with growth spurts.
S: Knee pain exacerbated with exercise.
D: XR may show calcification over tibial tuberosity.
T: RICE - self limiting and resolves in 2-3 months.
Cervical spondylosis
A: Degeneration of the intervertebral discs causing compression of the cord and nerve roots as the neck is flexed/extended.
S: neck stiffness, crepitus on neck movement, arm/wrist movement, neurological symptoms.
D: MRI
T: Immobilisation in collar.
Baker’s cyst
A: Benign posterior bulge if knee joint capsule, can be secondary to osteoarthritis.
S: Painless swelling in popliteal fossa, non-pulsatile. Beware of popliteal aneurysm.
D: US
T: Not needed, analgesia can be given. Aspiration can reduce size.
