Orthopaedics Flashcards
How are paediatric fractures involving the growth plate classified?
Salter-Harris System
I: Fracture through the physis only (x-ray often normal)
II: Fracture through the physis and metaphysis
III: Fracture through the physis and epiphyisis to include the joint
IV: Fracture involving the physis, metaphysis and epiphysis
V: Crush injury involving the physis (x-ray may resemble TI and appear normal)
In paediatric fractures, what is a complete fracture?
Both sides of the cortex are breached
In paediatric fractures, what is a toddlers fracture?
Oblique tibial fracture in infants
In paediatric fractures, what is a plastic deformity?
Stress on bone resulting in deformity without cortical disruption
In paediatric fractures, what is a greenstick fracture?
Unilateral cortical breach only
In paediatric fractures, what is a buckle fracture?
Incomplete cortical disruption resulting in periosteal haemotoma only
What types of salter-harris fractures will usually require surgery?
Which are often associated with disruption to growth?
Surgery: Types III, IV and V
Disruption to growth: Type V
What nerve root is the triceps reflex?
Radial C7
What palsy results in wrist drop?
Radial (C5-8)
What is meralgia paraesthetica?
Burning sensation over antero-lateral aspect of thigh due to compression of the lateral cutaneous nerve of thigh
What features of leg pain might make you suspect a prolapsed lumbar disk?
Clear dermatomal pain and neurological deficits
Leg pain worse than back
Pain often worse when sitting
What features would you expect in L3 nerve compression?
Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test (Mackiewicz sign) - patient lies prone, the knee is passively flexed to the thigh and the hip is passively extended ; the test is positive if the patient experiences anterior thigh pain.
What features would you expect in L4 nerve compression?
Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
What features would you expect in L5 nerve compression?
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test (straight leg raise until pain in buttocks/thigh/calf, dorsiflex foot at this point of discomfort - test is positive if additional pain results)
What features would you expect in S1 nerve 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
What is the most common causative organism in osteomyelitis?
What is the patient has sickle-cell anaemia?
Staph aureus
If sickle, then salmonella more common
What conditions predispose to osteomyelitis?
- DM
- Sickle cell
- IVDU
- Immunosuppression
- XS EtOH
What is the Ix of osteomyelitis?
MRI (90-100% sensitivity)
What is the Mx of osteomyelitis?
Flucloxacillin for 6 weeks
Clindamycin if penicillin allergic
What is Parsonage-Turner syndrome?
A rare peripheral neuropathy typically involving the shoulder/arm.
Rapid onset of severe pain in the shoulder and arm, followed by wasting and weakness.
May complicate viral illness and usually resolves spontaneously.
What is calcific tendonitis?
Calcium crystals (apatite crystals) deposit in tendons, causing sudden attacks of painful inflammation.
- Painful swelling around the joint (most commonly shoulder)
- Bulging tendons due to crystal deposits
- Redness and tenderness around the joint.
What is impingement syndrome? What causes it?
Narrowing of the subacromial space (between anterior edge of the acromion and humeral head). Impinges the supraspinatus tendon -> inflammation.
Anything narrowing gap can cause:
- Subacromial spurs (bony projections from the acromion)
- Osteoarthritic spurs on the acromioclavicular joint
- Thickening or calcification of the coracoacromial ligament
- LOF of the rotator cuff muscles (injury or wasting) may cause the humerus to move superiorly, resulting in impingement.
- Inflammation and subsequent thickening of the subacromial bursa
What is Leriche syndrome?
What is the classic triad of symptoms?
What is the Ix?
Atherosclerotic disease of AA +/- iliac, compromising blood flow to the pelvic viscera.
- Claudication of the buttocks and thighs
- Atrophy of the leg muscles
- Impotence (L1 paralysis)
Ix: Angiography (+ angioplasty/stenting as Mx)
What is a Colles’ fracture?
Commonly after FOOSH
- Transverse fracture of the radius
- 1 inch proximal to the radio-carpal joint
- Dorsal displacement and angulation
What is a Smith’s fracture?
= Reverse Colles’ fracture, caused by direct blow to the dorsal forearm or falling onto flexed wrists.
Volar angulation of distal radius fragment
What is a Bennett’s fracture?
Intra-articular fracture of the 1st carpometacarpal joint (thumb)
Impact on flexed metacarpal, typically after fist fight
Triangular fragment at ulcer base of metacarpal on x-ray
What is a Monteggia’s fracture?
Dislocation of the proximal radioulnar joint in association with an ulnar fracture
Caused by FOOSH with forced pronation
Needs prompt diagnosis to avoid disability
What is a Galezzi fracture?
Radial shaft fracture with association dislocation of the distal radioulnar joint.
Caused by a direct blow.
What is a Pott’s fracture?
Bimalleolar ankle fracture, with forced foot eversion.
What is a Barton’s fracture?
Distal radius fracture (Colles’/Smith’s) with associated radoiocarpal dislocation.
Fall onto extended and pronated wrist.
What is the most common type of shoulder dislocation?
Glenohumeral. Anterior.
NB. Check neuromuscular status pre and post reduction (Axillary - regimental badge)
What is a Bankart lesion?
Complication of anterior shoulder dislocation.
Detachment of the anterior inferior labrum (torn capsule and labrum) from the underlying glenoid. Creates a pocket for the humeral head to dislocate into. Suspect if recurrent dislocation.
Labral only = “soft Bankart”, Bony glenoid margin (impaction fracture) = “bony Bankart”.
Soft Bankart lesions are more common.
What is fat embolism syndrome?
Features? - Resp, Derm, CNS
Systemic response to fat emboli released by mechanical insult of major trauma.
Emboli occlude microvasculature, triggering an inflammatory response:
Resp:
- Tachycardia
- Tachypnoea, dyspnoea, hypoxia usually 72 hours following injury
- Pyrexia
Derm:
- Red/brown petechial rash (in 25-50%)
- Subconjunctival and oral haemorrhage/petechiae
CNS:
- Confusion and agitation
- Retinal haemorrhages and intra-arterial fat globules on fundoscopy
What nerves can be damaged in forceps delivery?
Femoral
Lumbosacral
Sciatic
Obturator
How do Scaphoid fractures usually occur?
What physical signs would you expect?
Direct hard blow to palm or FOOSH
- Swelling and tenderness in anatomical snuff box
- Pain on wrist movements and longitudinal compression of the thumb
How do radial head fractures usually occur?
What physical signs would you expect?
Common in young adults, usually by FOOSH
- Local tenderness over the head of the radius
- Impaired movements at the elbow
- Sharp pain on lateral side of the elbow at extremes of pronation and supination
What is talipes equinovarus?
What % are bilateral?
Club foot.
Inverted and plantar flexed foot. Not passively correctable.
50% are bilateral.
What are the features of lateral epicondylitis (tennis elbow)?
Pain and tenderness localised to the lateral epicondyle
Pain worse on:
- resisted wrist extension with elbow extended
- supination of the forearm with elbow extended
What are the features of medial epicondylitis (golfer’s elbow)?
Pain and tenderness localised to medial epicondyle
Pain worse on wrist flexion and pronation
May be accompanied by numbness/tingling in the 4th and 5th finger due to ulnar nerve involvement
Back pain relieved by sitting down, leaning forwards and crouching down would be typical of what?
Spinal stenosis
How is a diagnosis of spinal stenosis confirmed?
MRI
What is syringomyelia? Which tracts does it affect?
Cystic cavity forms within the spinal cord.
Selectively affects the spinothalamic tracts, bilaterally. (pain and temperature)
What is a Morton’s neuroma?
A benign neuroma affecting the intermetatarsal plantar nerve, most commonly in the third inter-metatarsophalangeal space.
4x more common in females
What are the features of a Morton’s neuroma?
Forefoot pain, most commonly in third inter-metatarsophalengeal space
Pain worse on walking - may feel like a pebble in shoe
What is a Baker’s cyst?
A fluctuant swelling in the popliteal space = synovial fluid herniating between the two heads of the gastrocnemius.
Becomes tense on knee extension = Foucher’s sign.
More likely in patients with gout or arthritis, following a minor knee trauma.
What fracture fixation most commonly leads to compartment syndrome?
Tibial fractures, following fixation with intra-meduallary devices
What are the symptoms and signs of compartment syndrome?
- Pain, especially on movement (even passive)
- Parasthesiae
- Pallor
- Arterial pulsation may still be felt as the necrosis occurs as a result of microvascular compromise
- Paralysis of the muscle group
How is compartment syndrome diagnosed?
Intracompartmental pressure measurements. Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic.
What is the treatment of compartment syndrome?
Prompt, extensive fasciotomy
What is a complication of fasciotomy for compartment syndrome?
Myoglobinuria -> Renal failure.
Give aggressive IV fluids.
What clinical prediction tools can be used to assess a patients 10 year fracture risk?
- FRAX
- QFracture
What is the treatment of clubfoot?
Ponseti method.
= Manipulation and progressive casting which starts soon after birth. The deformity is usually corrected after 6-10 weeks. An Achilles tenotomy is required in around 85% of cases but this can usually be done under local anaesthetic.
Night-time braces should be applied until the child is 4.
How do you treat a undisplaced intracapsular hip fracture?
- No comorbidities
- With comorbidities
If no co-morbidities: Internal fixation (especially if young)
If major illness or advanced specific organ disease: Hemiarthroplasty
How do you treat a displaced intracapsular hip fracture?
- <70
- > 70
- Major comorb/illness
<70: Internal fixation
>70: Total hip arthroplasty
Major comorbidities/immobile: Hemiarthroplasty
How do you treat an extracapsular hip fracture (non-special type)?
Dynamic hip screw
How do you treat an extracapsular hip fracture (reverse oblique, transverse or sub-trochanteric)?
Intramedullary device
What is the Garden classification system?
I?
II?
III?
IV:
When is blood supply typically disrupted?
Type I: Stable fracture with impaction in valgus.
Type II: Complete fracture but undisplaced.
Type III: Displaced fracture, usually rotated and angulated, but still has bony contact.
Type IV: Complete bony disruption.
Blood supply disruption is most common following Types III and IV.
What is a Hill-Sachs lesion?
When the cartilage surface of the humerus is in contact with the rim of the glenoid. Occurs in about 50% of anterior glenohumeral dislocations.
What is a buckle fracture?
Incomplete fracture of a long bone, characterised by bulging of the cortex. Typically in children 5-10 years old.
What is Freiberg’s disease?
What are the x-ray findings?
Anterior metatarsalgia affecting the head of the second metarsal, typically occurring in the pubertal growth spurt.
On x-ray:
- Joint space widening
- Formation of bony spurs
- Sclerosis and flattening of the metatarsal head
What is cubital tunnel syndrome? What are its features?
Compression of the ulnar nerve near the medial epicondyle.
Features:
- 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
What is osteopetrosis?
A rare autosomal recessive condition, commonest in young adults. = marble bone disease, Albers-Schönberg disease.
Bones become more dense and brittle, with a lack of differentiation between the cortex and the medulla.
May also present with features of anaemia or thrombocytopenia due to decreased marrow space.
What is the commonest reason for revision of a total hip replacements?
Aseptic loosening of the implant.
Less common: pain, dislocation, infection
