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.
- 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 displaced, transcervical (Garden type IV) fracture of his right NoF?
Thus in this scenario, a hemi hip-arthroplasty would be the most suitable treatment or conservative.
- A fractured neck of femur (#NoF) is a common problem that presents to orthopaedic surgeons. What is the prognosis of patients who present with a fractured neck of femur?
Mortality rate is 8.1% at 30 days, 25-30% at 1 year.
Predictors of mortality is:
· Pre injury mobility
· CKD – mortality rises to 45% at 2 years
- What is an open fracture?
An open fracture exists when there is a fractured bone and a breach of the dermis in the same limb segment.
Treatment:
· Immediate IVA antibiotics – Cephazolin for S. Aureus and S. pyogenes
· Urgent irrigation and debridement
· Tetanus prophylaxis
· Operative – likely
o Definitive reconstruction and fracture fixation and tissue coverage once adequate sterility is achieved ideally within 6 hrs of injury
o Large dirty wounds should be left open and closed by delayed primary suture after 5 days
· Non – operative – extremity stabilisation and dressing
- What is a closed fracture?
Closed fracture is when the fractured bone does not involve the dermis. Risks of major complications lower but internal bleeding, nerve damage and some soft tisse damage risk still present.
- What is a ‘pathological’ fracture?
A pathological fracture classically results from a normal force acting on an abnormal bone. There are number of possible pathologies including osteoporosis (fragility fracture) as swell as osteomalacia, Paget’s disease and osteogenesis imperfecta. However, it is important to identify pathological fractures arising from bone tumours.
- What is a ‘fracture’?
Fracture is any break in the continuity of a bone. Fractures are described in terms of a number of characteristics:
Traumatic fracture – injuries are caused by direct or indirect violence; they are the effect of an abnormal force applied to normal bone
· Pathological fracture – fractures occurring in diseased bone often caused by low energy. Can be localised ex: tumour or generalised ex: osteoporosis or osteomalacia
· Insufficiency fractures – most common type of pathological fractures – often occurs as a result due to osteoporosis – characterised by decrease BMD and deterioration in bone microarchitecture. Common sites: osteoporotic fractures are hip, wrist, proximal humerus and spine. Osteomalacia is bone softening due to defective mineralisation of matrix – vitamin D deficiency.
· Fatigue or stress fractures – results of a cyclical application of normal forces to normal bone with excessive frequency following change in level or intensity of activity. Fracture usually linear and incomplete. Entirely undisplaced fracture – infraction.
- What is a greenstick fracture?
A greenstick fracture is an incomplete fracture in which there is a disrupted periosteum and cortex only on one side.
This fracture pattern seen more in young children as bone Is more flexible and usually occur after angulated longitudinal forces from FOOSH or direct blow.
Management: casting and reagulation/reduction for 4-6 weeks.
- What are the phases of fracture healing?
- Inflammation – haematoma and local inflammation. Influx of neutrophil, macrophage, fibroblast and granulation tissue formation.
- Soft callus formation – fracture ends die back and an undispalced fracture more evident. Granulation gradually replaced with fibrous connective tissue and caritalge.fracute ends become ‘sticky’ and movement iss reduced. Resist shortening but not angulation.
- Hard callus – bone formation begining within soft callus where strain is lowest. Bone can be formed in 2 ways: intramembranous ossification and endochondral ossification. Progresses centrally across fracture gap, gradually reducing movement and strain. Calcium laid in matrix and callus becomes visible on radiography. Rigid with this woven bone and united when no movement or crepitus at fracture site. Consolidated ocne completely healed with bridging bone.
- Remodelling – creeping substitution replaces woven bone with lamellar bone. Same process in routine skeleteal turnover as well as primary bone healing. Bone laid according to Wolff’s law [highest density of lamellar bone (and strength) restored where load is greatest]
- What are the principles of fracture management?
Treatment of any fracture comprises 3 main consideration – Is fracture position acceptable or does it require reduction. Is fracture stable or does it need to heal. When can patient begin to use and move the limb.
Reduce – acceptability of fracture position is dependent on location of fracture, degree of displacement and functional demands of the patient [open or closed reduction].
· Direct – surgical exposure, visualisation and anatomical reduction
· Indirect – closed with traction and manipulation
Hold – degree of stability
· Stable – will not displace under physiological loading due to fracture configuration or regional anatomy – require support only for comfort and treated with removable splint
· Unstable – will displace with loading and require stabilisation
o Non surgical – splintage or plaster
o Surgical – plates, screw, nails and external fixation
Move
· Timing of rehab is compromise between protection of fracture reduction through immobilisation and avoid load bearing vs avoiding joint stiffness, muscle wasting and impaired function through early movement.
- This is the pelvic x.ray of a 72 year of age man who has presented to emergency with a 2 day history of increasing right groin pain.
On examination, his leg is aligned normally, he has restricted range of movement in all directions, due to pain, in his right hip, but he can weight bear.
Q1. 1. What abnormalities can you see in the bones on this X-ray?
Q2. 2. What are the possible causes (differential diagnoses) for these abnormalities
Q3. 3. What treatment does he need for the bones, specifically (not for the potential causative processes)
Abnormality seen is multiple cystic lesions in pelvis, femur and spine and right neck of femur fracture. Most likely a pathological fracture as there is localised pathology to one part of the bone.
Causes include metastatic spread (prostate, thyroid, lung, renal, breast).
Other causes include: solitary bone cyst, aneurysmal bone cyst, fibrous dysplasia, chondroma, chondromyxoid fibroma, chondroblastoma, brown tumour hyperparathyroidism, hyatid cyst, intraosseous ganglion, epidermoid cyst, giant cell tumour, fibrous cortical defect.
Examination of primary sites, routine blood test – FBC, CRP, UEC, LFT, Coag, tumour markers.
Referral for oncologist for chemotherapy and radiation and consider:
Non operative – bisphosphonate
Operative – cemented hemiarthroplasty or THR if acetabular involvement then post-operative radiation.
- This is a shoulder and upper arm x ray of a previously fit 72 year of age lady who fell while gardening at home.
Q1. What abnormalities can you see on the image; describe them, please.
Q2. What would be the usual initial management of this problem (first 24 hours)
Q3. What would be the usual longer term management of this problem (from day 3 to 4-6 weeks post presentation)
Left proximal humerus dislocation and fracture [describe fracture]
Majority of proximal humerus can be treated non-operatively but if there is severe comminution or instability of in high demand, a surgical approach may be beneficial.
As fracture-dislocation, urgent surgery due to neurovascular compromise (axillary nerve and artery):
· ORIF – most common
· Intramedullary nail
· Arthroplasty if highly comminuted or bone stock poor
Longer term management:
Shoulder movement pendular movements for 6 weeks.. Full movement at elbow down. No lifting till union. Until union, passive physiotherapy and minimal activity.
- This is the X – ray of a 72 yoa lady who has fallen, sustained an injury to her arm, and had an operation to treat it. Two weeks after treatment the lady returns with a history of a sudden increase in pain in the affected shoulder. This is the x ray taken at this time.
Q1. What has happened
Q2. How can this be managed?
Failed internal fixation – separation from bone
Management
· Re-operation with larger or stable implant
· Instruction + care of fracture - likely cause of failure
- This is an x-ray of the right shoulder of a 22 yoa man injured in a high speed motorcycle accident. This is his only injury
Q1. How should this usually be managed?
Q2. Is this the only option for managing this problem
Fracture – clavicle, usually presents with:
· shortening and depression of lateral fragment with proximal displacement of medial.
· Pain, crepitus
· Support elbow with other hand
Central 3/5ths usually affected (80% of time).
Management
· Closed reduction not recommended due to risk of damage to adjacent structures and lack of position maintenance; same with figure 8 bandages or strapping.
· Provide sling that will give support to elbow
· gentle ROM exercises 2-4 weeks and strengthening at 6-10 weeks
· Majority heal with conservative management.
Referral
· Significant tenting
· Skin compromise
· Neurovascular compromise
Surgery – open, impending skin tenting, severe shortening, severe comminution, symptomatic non-union (late). – mainly OR with plate fixation. Intramedullary nail has been used sometimes.
- Q1. Do all clavicle fractures need to be managed with open reduction and internal fixation (ORIF)?
Q2. What are the complications that can occur from ORIF to the clavicle, that are directly the result of the actual operation (not generic operative risks, not generic orthopaedic bone healing risks)?
Management:
Attempts at closed reduction not recommended due to position not being able to be maintained and danger to damage adjacent neurovascular structures. Similarly no benefit from strapping.
Immobilisation – provide sling to give support to the elbow. No formal immobilisation needed.
Inpatient referral if significant tenting, skin compromise and neurovascular compromise.
Orthopaedic management (indications: open fracture, impending skin breakdown/tenting, severe shortening, severe comminution, symptomatic non-union) · Majority heal with conservative treatment · Only minority require intervention – symptomatic non-union, symptomatic malunion and cosmetic appearance.
- Please look at this photograph of the left leg of a 25 yo man injured in a motorcycle accident.
Describe the injury you can see
Distorted knee and lower limbs, skin breaks.
Possibel open knee dislocation
Fracture dislocation of knee/femur or tibia.
Knee dislocation (tibiofemoral) commonly associated with neurovascular injury
- Please look at this photograph of the left leg of a 25 yoa man injured in a motorcycle accident
What is the immediate and early management of this patient?
Management:
· Primary survey through ABCDE
· Obtain detailed history and examination – MSK (lower limb)
· Knee – AP + lateral (knee, hip and ankle), Doppler ultrasound if concern about vascular compromise
· Bloods – FBC, UEC, LFT, VBG, Coag, Group and Hold
· Admit for inpatient referral – orthopaedics, plastics, vascular, anaesthetic team.
· If possible and dislocated/fracture not open -> perform reduction via gentle but firm traction with pressure over displaced proximal tibia then splint.
· Monitor neurovascular after reduction.
· Concern for compartment syndrome – monitor. Perform fasciotomy if indicated.
Admit and refer inpatient
If neurovascular compromise, surgery
· Repair of collateral ligament
· Reconstruction of cruciate
Emergency surgery if open and contaminated or critical ischaemia. Must debride and give antibiotics.
- This 38 year old male was involved in a low speed accident at a farm stock yard. His foot was caught between a piece of machinery and a block wall. This is an isolated injury and his secondary survey is otherwise unremarkable. He cannot recall his last Tetanus booster.
Q1. What prophylactic measures would you institute to protect against infection?
Q2. What structures may be injured?
Q3. How would you manage this injury over the next 24 hours?
Tetanus booster – takes months for effect, immunoglobulin if unsure about vaccination status. Bacterial infection: debride + irrigate, antibiotics and relevant anaesthetic for surgery Apply pad, bandage and aim for secondary closure or delayed primary closure.
Structures that can be involved: · Skin · Ligament · Tendon · Muscles · Bone (tibia, fibula, ankle bones, foot bones) · Blood vessels – Post tibial art, ant tibial art, dorsalis pedis) · Nerves – fibular and tibula
Management:
Bloods: FBC, UEC, LFT, Group and Hold, Coag. Provide analgesia.
Imaging – X ray of foot (2 views) + other joints (knee, hip)
If open – prepare for surgery for washout, debridement and antibiotics.
Reduce and splint if fracture, check for neurovascular status – if compromise (surgery). Monitor for compartment syndrome.
If only ligamentous injury -> RICE + analgesia.
