Orthopaedics Flashcards
- You are an Intern in the Emergency Department. Gary is a 35yo male who presented to the emergency department after coming off his motorbike. He is complaining if right thigh and knee pain. The primary survey is done, and the only injury of any consequence is pain and deformation of his left thigh. Prompt provided – Photo A
What is the likely diagnosis? What other structures in the leg must you examine while assessing this injury? If your examination findings of this structure were abnormal, what would you do? If you did this, and your examination findings remained abnormal, what investigation should the patient have and how soon?
The likely diagnosis is compound distal fracture
Other structures to examine are skin, neurovascular system.
Skin
- Check whether open or threatened (tethered, white, non-blanching)
- The proximal fragment is invariably pulled into flexion and external rotation (by iliopsoas and gluteus medius & minimus, respectively
- Femoral shaft fracture results in great amount of blood loss (~1500mL), hence check for haematoma (tense, swollen thigh), may be double if open fracture
Neurovascular
- Check distal neurovascular status (motor, sensation, pulses, especially popliteal pulse)
- Distal part of superficial femoral artery is most likely to be damaged
- If pulse is absent, reduction should be done and re checked.
- If still abnormal, CT angiogram should be done
If examination is abnormal:
· Assess haemodynamic stability
· Take thorogh history
· Bloods – FBC, CRP, UEC, LFT, VBG, Coag, Group and Hold
· Obtain bedside X ray + CT of both legs.
· Consult orthopaedic and vascular surgeons
· Open fracture – clean, debride, reduce and splint (esp if neurovascular compromise)
· Antibiotics
· Monitor for compartment syndrome
If still abnormal – perform CT angiogram and refer to vascular and orthopaedic surgeons
- You are an Intern in the Emergency Department. Gary is a 35yo male who presented to the emergency department after coming off his motorbike. He is complaining if right thigh and knee pain. The primary survey is done, and the only injury of any consequence is pain and deformation of his left thigh. Prompt provided – Photo A
- What is the likely diagnosis.
- What investigations are required to confirm this diagnosis?
Prompt provided – X- Ray A Note – this is not the same patient as this is the x-ray of a right leg.
- Describe this x – ray as you would to a consultant orthopaedic surgeon if you were contacting them with the result of this x-ray from the Emergency Department
The likely diagnosis is a fracture of the femur.
To confirm the diagnosis, an X-ray is needed.
The X-ray shows spiral open fracture of the distal femoral shaft.
- You are an Intern in the Emergency Department. Gary is a 35yo male who presented to the emergency department after coming off his motorbike. He is complaining if right thigh and knee pain. The primary survey is done, and the only injury of any consequence is pain and deformation of his left thigh. Prompt provided – Photo A.
- What is the likely diagnosis.
- What investigations are required to confirm this diagnosis?
Prompt provided – X- Ray A Note – this is not the same patient as this is the x-ray of a right leg.
- Describe the different ways that this injury might be managed.
Likely diagnosis – open comminuted femoral fracture
Investigations: Bedside X ray or CT, Doppler ultrasound for vascular injury
Management:
· Reduction of femur under sedation and analgesia or a femoral nerve block by realigning limb using gentle manual traction from end of table and apply splint -> improve distal blood supply
· Referral to orthopaedics
o Non-operative – skin or skeletal traction, Thomas splint traction
o Operative – intramedullary nailing, not often used are external fixation and plating due to infection risk and soft tissue dissection.
- You are an Intern in the Emergency Department. Gary is a 35yo male who presented to the emergency department after coming off his motorbike. He is complaining if right thigh and knee pain. The primary survey is done, and the only injury of any consequence is pain and deformation of his left thigh. Prompt provided – Photo A.
- What is the likely diagnosis.
- What investigations are required to confirm this diagnosis?
Prompt provided – X- Ray A Note – this is not the same patient as this is the x-ray of a right leg.
- Describe the important complications that might arise from this injury in the first 4 - 6 hours after the injury has occurred.
Likely diagnosis – open comminuted femoral fracture
Investigations: Bedside X ray or CT, Doppler ultrasound for vascular injury
Complications in first 4-6 hrs after injury
· Compartment syndrome · Neurovascular injury · Fat embolism · Haemorrhage · Hypovolemia
- You are an Intern in the Emergency Department. Gary is a 35yo male who presented to the emergency department after coming off his motorbike. He is complaining if right thigh and knee pain. The primary survey is done, and the only injury of any consequence is pain and deformation of his left thigh. Prompt provided – Photo A.
- What is the likely diagnosis.
- What investigations are required to confirm this diagnosis?
- Describe the important complications specific to the limb repair that might arise from this injury in the early post fixation phase of recovery ( 2 hours to 1 week after surgical fixation)
Likely diagnosis: Comminuted femoral fracture (left – compound)
Investigations: Bedside X ray or CT, Doppler ultrasound for vascular injury
Complications (2 hrs – 1 week) after fixation
· Malunion
· Rotational malalignent
· Infection + hospital acquired infection
· DVT + PE
· Pudendal nerve injury – paraesthesia, neuropathic pain, impotence, urinary urgency
· Femoral artery/nerve injury
- You are an Intern in the Emergency Department. Gary is a 35yo male who presented to the emergency department after coming off his motorbike. He is complaining if right thigh and knee pain. The primary survey is done, and the only injury of any consequence is pain and deformation of his left thigh.
Q1. what is the likely diagnosis? What investigations are required to confirm this diagnosis.
Q2. After prompt (X-Ray) provided. What are the late complications that might happen, specific to the surgical repair, more than one week after surgery
Likely diagnosis: Comminuted femoral fracture (left – compound)
Investigations: Bedside X ray or CT, Doppler ultrasound for vascular injury
Complications 1 week after surgery · Heterotropic ossification · Non-union · Late infection wound infection, pneumonia · DVT, PE · Weakness and loss of function · Arthritis of joint
- A fractured neck of femur (#NoF) is a common problem that presents to orthopaedic surgeons. What is the important anatomy of the neck of the femur that renders the head of femur vulnerable to avascular necrosis after a #NoF.
The vascular supply to the femoral head arises from 3 sources:
· Most important – lateral and medial circumflex arteries – branches of profunda femoris. Form vascular ring within capsule of hip joint. From this retinacular vessels penetrate head.
· Small contribution from medullary canal
· Thirdly negligible contribution from ligamentum teres in adults.
An intracaspular fracture can disrupt retinacular vessels and blood supply to the head is threatened and thus potentially causing AVN and bony collapse of the femoral head. Extracapsular fractures rarely affect this blood supply.
- A fractured neck of femur (#NoF) is a common problem that presents to orthopaedic surgeons. Describe the classification used to categorise these fractures.
intracapsular- subcapital, transcervical, basicervical
extracapsular- intertrochanteric and subtrochanteric
Gardens classification is used
- A fractured neck of femur (#NoF) is a common problem that presents to orthopaedic surgeons. Why are these fractures more common in the elderly?
Reasons:
· Poorer bone quality – osteoporosis (estrogn deficiency in feamles and androgen deficiency in males)
· Increase fall
o Decreased cognition, proprioception/balance, muscle mass, sarcopenia, vision
o Polypharmacy
o Higher rates of acute illness – UTI, pneumonia -> delirium
o Co-morbid conditions
- A fractured neck of femur (#NoF) is a common problem that presents to orthopaedic surgeons. What are the classical symptoms and signs of a fractured Neck of Femur?
Presentation – frail elderly fall with comorbidities and inter-current illnesses or high speed trauma for young people
· After a simple fall from standing position, 5% occur while upright often in course of stumble.
· Tenderness over groin, may radiate to hip or knee
· Lower limb shortened and externally rotated if displaced
· Bruising appears later
· Pain on passive rotation of limb
· Unable to preform straight leg raise
- A fractured neck of femur (#NoF) is a common problem that presents to orthopaedic surgeons. Risk is increased by osteoporosis. Apart from age, and female sex, what are the common non-pharmaceutical risk factors for osteoporosis?
Modifiable – low calcium intake, eating disorders, GI surgery, medical conditions – celiac disease, IBD, kidney or liver disease, cancer, lupus, multiple myeloma, RA, lifestyle changes – sedentary lifestyle, excessive alcohol and tobacco
Non modifiable - age, sex, race (white or Asian descent), family history, body frame size
- A fractured neck of femur (#NoF) is a common problem that presents to orthopaedic surgeons. Risk is increased by osteoporosis. Apart from age, and female sex, what are the common pharmaceutical risk factors for osteoporosis?
Common:
· Glucocorticoids – steroids – cortisone and prednisolone
· Phenytoin and phenobarbital
· Gonadotropin releasing hormone agonist
· Aromatase inhibitors
Other medications
· Antacids
· Chemotherapy
· Cyclosporine and tacrolimus
· Heparin
· Thyroxine – Usual dose for thyroid disorders don’t increase loss
· MTX
· Barbiturates
· Loop diuretics – furosemide and torsemide
· Medroxyprogesterone acetate – contraception
· Thiazolidinediones such as pioglitazone and rosiglitazone
- A fractured neck of femur (#NoF) is a common problem that presents to orthopaedic surgeons. What are the treatment options for an otherwise fit and active 75 year old man who has a minimally displaced, intracapsular (Garden type 1) fracture of his right NoF?
Conservative if physiologically compromised for anaesthesia and surgery
Surgical – most NOF. Surgical technique selected based on fracture pattern, age and physiological condition.
Undisplaced intracapsualr fracture – displaced and valgus impacted fracture most commonly fixed in situ with cannulated screw or dynamic hip screw. Contraindication to screw fixation is if bone quality is abnormal (RA, renal failure, osteomalacia) or in rare event if hip affected by symptomatic OA.
Displaced intracapsular in elderly patients – displaced hip fracture higher risk of AVN, non-union and construct failure after attempted fixation. In elderly definitive arthroplasty outweigh preservation of the head. High demand patients, cognitively intact and independently mobile and active benefit from total hip replacement. Less active and socially dependent and do not walk independently – hemi-arthoplasty – faster, simper and thus safer and more predictable operation with lower rate of dislocation.
Displaced intracapsular fracture in young patients, under 55, sustained high energy fracture, normally reduced and fixed due to limited life span of hip replacement. If perfect closed reduction not achieved by closed traction, may be necessary to open reduction. DHS usually put in.
Thus in this scenario, screw fixation would be the most suitable treatment.
- A fractured neck of femur (#NoF) is a common problem that presents to orthopaedic surgeons. What are the treatment options for a 75 year old man, with pre-existing poor mobility and end stage chronic kidney disease with no further treatment options, who has a minimally displaced, intracapsular (Garden type 1) fracture of his right NoF?
Thus in this scenario, conservative would be the most suitable treatment.
- A fractured neck of femur (#NoF) is a common problem that presents to orthopaedic surgeons. What are the treatment options for an otherwise fit and active 75 year old man who has a displaced, trans cervical (Garden type IV) fracture of his right NoF?
Thus in this scenario, a total hip-arthroplasty would be the most suitable treatment.
