Orthopaedics Flashcards
How do you manage an open fracture?
6 A’s:
- Analgesia
- Assess: NV status, soft tissues, photograph
- Antisepsis: wound swab, copious irrigation, cover with betadine soaked dressing
- Alignment (and splint)
- Anti-tetanus: check status (booster lasts 10 years)
- Antibiotics
- Fluclox 500mg IV/IM + benpen 600mg IV/IM
- Or augmentin 1.2g IV
How do you classify open fractures?
Gustillo:
- Wound <1cm in length
- Wound ≥1cm with minimal soft tissue damage
- Extensive soft tissue damage
Which organism causes gas gangrene?
Clostridium perfringens
How do you manage gas gangrene?
Debride, ben pen, clindamycin
What are the indications for open reduction of fractures?
- Intra articular fractures
- Open fractures
- 2 fractures in one limb
- Failed conservative treatment
- Bilateral identical fractures
What are the complications of fractures?
- Immediate
- Neurovascular damage
- Visceral damage
- Early
- Compartment syndrome
- Infection (worse if associated with metalwork)
- Fat embolism -> ARDS
- Late
- Problems with union
- AVN
- Growth disturbance
- Post traumatic osteoarthritis
- Complex regional pain syndromes
- Myositis ossificans
How do you classify neurological complications of fractures?
Seddon classification:
- Neuropraxia = temporary interruption of conduction without loss of axonal continuity
- Axonotmesis = disruption of nerve axon with distal Wallerian degeneration
- Connective tissue framework of nerve preserved
- Regeneration occurs and recovery is possible
- Neurotmesis = disruption of entire nerve fibre
- Surgery usually required and recovery not usually complete
What are the causative factors of problems with union?
5 I’s:
- Ischaemia: poor blood supply or AVN
- Infection
- Increased interfragmentary strain
- Interposition of tissue between fragments
- Intercurrent disease: e.g. malignancy or malnutrition
What is Pellegrini-Stieda disease?
Form of myositis ossificans where there is calcification of the superior attachment of MCL at the knee following traumatic injury
How do you classify intracapsular #NOFs?
Garden Classification:
- Incomplete #, undisplaced
- Complete #, undisplaced
- Complete #, partially displaced
- Complete #, completely displaced
How do you manage an intracapsular #NOF?
- Garden 1, 2: ORIF with cancellous screws
- Garden 3, 4:
- <55: ORIF with screws, follow up in OPD and arthroplasty if AVN develops (30%)
- 55-75: total hip replacement
- >75: hemiarthroplasty
- Mobilises: cemented Thompsons
- Non mobiliser: uncemented Austin Moore
What is a Colles’ fracture?
Extra articular fracture of the distal radius with dorsal displacement and angulation of the distal fragment
What are the complications of a Colles’ fracture?
- Median nerve injury
- Frozen shoulder/adhesive capsulitis
- Tendon rupture especially EPL
- Carpal tunnel syndrome
- Mal-/non-union
- Sudek’s atrophy/CRPS
What is a Smith’s fracture?
Fracture of the distal radius with volar displacement and angulation of the distal fragment (fall onto back of flexed wrist)
What is a Barton’s fracture?
Oblique intra-articular fracture involving the dorsal aspect of distal radius and dislocation of the radio-carpal joint
What is a Monteggia fracture?
proximal 3rd of ulna shaft with anterior dislocation of radial head at the capitellum
What is a Galeazzi fracture?
radial shaft between the mid and distal 3rds with dislocation of the distal radio-ulnar joint
How do you classify extension supracondylar fractures of the humerus?
Gartland:
- Nondisplaced
- Angulated with intact posterior cortex
- Displaced with no cortical contact
What are the Ottawa Ankle rules?
X ray ankle if pain is in the malleolar zone + if any of:
- Tenderness along distal 6cm of posterior tib/fib including posterior tip of the malleoli
- Inability to bear weight both immediately and in ED
What is the Weber classification?
Ankle fractures: relation of fibula # to joint line:
- A: below joint line
- B: at joint line
- C: above joint line
- Weber’s B and C represent possible injury ot the syndesmotic ligaments between tib and fib -> instability
Causes of avascular necrosis
- # or dislocation
- SCD, thalassaemia
- SLE
- Gaucher’s
- Drugs: steroids, NSAIDs
What are buckle fractures?
incomplete fractures of the shaft of a long bone that is characterised by bulging of the cortex. They typically occur in children aged 5-10 years.
Features of chondromalacia patellae
- Softening of the cartilage of the patella
- Common in teenage girls
- Characteristically anterior knee pain on walking up and down stairs and rising from prolonged sitting
- Usually responds to physiotherapy
Features of common peroneal nerve lesion
The most characteristic feature of a common peroneal nerve lesion is foot drop
Other features include:
- weakness of foot dorsiflexion
- weakness of foot eversion
- weakness of extensor hallucis longus
- sensory loss over the dorsum of the foot and the lower lateral part of the leg
- wasting of the anterior tibial and peroneal muscles
Which nerve is saturday night palsy
Radial
Features of De Quervain’s tenosynovitis
- pain on the radial side of the wrist
- tenderness over the radial styloid process
- abduction of the thumb against resistance is painful
- Finkelstein’s test: with the thumb is flexed across the palm of the hand, pain is reproduced by movement of the wrist into flexion and ulnar deviation
Features of trochanteric bursitis
Due to repeated movement of the fibroelastic iliotibial band
Pain and tenderness over the lateral side of thigh
Most common in women aged 50-70 years
What are the features of osteochondritis dissecans
Pain after exercise
Intermittent swelling and locking
Features of L3 nerve root compression
Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
Features of L4 nerve root compression
Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
Features of L5 nerve root compression
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
Features of S1 nerve root compression
Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test
Features of cubital tunnel syndrome?
initially intermittent tingling in the 4th and 5th finger
may be worse when the elbow is resting on a firm surface or flexed for extended periods
later numbness in the 4th and 5th finger with associated weakness
Ulnar nerve compression
Features of frozen shoulder
external rotation is affected more than internal rotation or abduction
both active and passive movement are affected
patients typically have a painful freezing phase, an adhesive phase and a recovery phase
bilateral in up to 20% of patients
the episode typically lasts between 6 months and 2 years
Features of meralgia paraesthetica
Caused by compression of lateral cutaneous nerve of thigh
Typically burning sensation over antero-lateral aspect of thigh
features of referred lumbar spine pain
Femoral nerve compression may cause referred pain in the hip
Femoral nerve stretch test may be positive - lie the patient prone. Extend the hip joint with a straight leg then bend the knee. This stretches the femoral nerve and will cause pain if it is trapped
Features of morton’s neuroma
forefoot pain, most commonly in the third inter-metatarsophalangeal space
worse on walking. May be described as a shooting or burning pain. Patients may feel they have a pebble in their shoe
Mulder’s click: one hand tries to hold the neuroma between the finger and thumb. The other hand squeezes the metatarsals together. A click may be heard as the neuroma moves between the metatarsal heads
there may be loss of sensation distally in the toes
How do you interpret a DEXA?
<-1 is normal
- 0-2.5 is osteopaenia
- 5 and up is osteoporosis
