Orthopaedics Flashcards
What are the different types of bone?
Woven - Disorganised bone that forms calluses
Lamellar - Mature bone which takes one of two forms:
Cortical: Dense outer layer
Trabecular: Porous central layer
By which method do most bones form?
Endochondral ossification (mesenchyme -> cartilage -> bone)
What are the phases and timings of fracture healing?
Reactive phase (0-48hrs): Haematoma forms and local inflammation leads to granulation tissue formation
Reparative phase (2d-2w): Proliferaiton of osteoblasts and fibroblasts which form cartilage and woven bone, which is then consolidated into lamellar bone
Remodelling phase (1wk-7y): Remodelling of lamellar bone to cope with mechanical forces according to Wolff's Law
What is the difference between a stress fracture and a pathological fracture?
Stress fractures are due to bone fatigue due to repetitive strain, e.g. marathon runners feet
Pathological fractures are due to normal forces applied to diseased bone
When radiographing a fracture, what images must be requested?
AP and lateral film of the fracture site, as well as images of the joint above and below the #
How would you describe a fracture?
PAIDS
Pattern; transverse, oblique, spiral, multifragmentary, crush, greenstick, avulsion
Anatomical location
Intra/extra articular, dislocation or subluxation
Deformity (distal relative to proximal); Translation, angulation, rotation, impaction
Soft tissues; open or closed, neurovascular status, compartment syndrome
What are the four ‘R’s of fracture management?
Resuscitate
Reduction
Restriction
Rehabilitation
What are the principles of ‘Resuscitation’ in # management?
ATLS # usually in 2ary survey Assess neurovascular status Consider reduction and splinting before imaging Manage pain and bleeding
What are the 6As of open fracture management?
Analgesia: M+M Assess: NIV status, soft tissues Antisepsis: wound swab, irrigation, dressing Alignment Anti-tetanus - check status Abx: Fluclox + Benpen
What is the most concerning complication of an open fracture?
C. perfringens infection
What are the methods of fracture reduction?
Manipulation/Closed reduction: under local/regional anaesthesia, use traction to disimpact and manipulation to align
What are the principles of fracture restriction?
The interfragmentary strain hypothesis dictates that tissue formed at the # site depends on the strain it experiences. Fixation also reduces pain and increases functionality
What are the different methods of fracture restriction?
Non rigid - slings, elastic supports
Plaster
Functional bracing - joints free to move but bone shafts supported in cast segments
Continuous traction - e.g. collar and cuff
External fixation - useful in open #s, burns and tissue loss
Internal fixation - pins, plates, screws, IM nails. Perfect anatomical alignment which improve stability and aid early mobilisation
What are the methods of # rehabilitation?
Physio
OT
Social services
What are the possible complications following #?
General vs specific
General:
Tissue damage (haemorrhage, infection, rhabdomyolysis)
Anaesthesia (anaphylaxis, aspiration)
Bed rest (infections, pressure sores, muscle wasting, DVTs, reduced BMD)
Specific:
Immediate (NV damage, visceral damage)
Early (Compartment syndrome, infection, fat embolism ->ARDS)
Late (malunion, AVN, growth disturbance, post traumatic osteoarthritis, Complex regional pain syndrome, myositis ossificans)
How might an axillary nerve palsy form and present?
Following anterior shoulder dislocation -> Numb regimental badge area, weak abduction
How might a radial nerve palsy form and present?
Following # humeral shaft ->waiters tip
How might an ulnar nerve palsy form and present?
Elbow dislocation-> Claw hand
How might a sciatic nerve palsy form and present?
Hip dislocation -> foot drop
How might a fibular nerve palsy form and present?
neck of fibula or knee dislocation -> foot drop
How does compartment syndrome present and how is it treated?
Pain on passive muscle stretching of a warm, erythematous, swollen limb with weak pulses
Rx by elevation, removal of bandage/cast and fasciotomy
What are the causes of delayed/non-union?
5Is
Ischaemia Infection Interfragmentary strain Interposition of tissue between fracments Intercurrent disease
What are the different types of non-union?
Hypertrophic - rounded, dense bone
Atrophic - osteopoenic ends
What is myositis ossificans?
Formation of bone within muscle/soft tissue
What is the presentation of complex regional pain syndrome type 1?
Presents weeks - months after injury in a neighbouring area to the #site Hyperalgia, lancing pain, allodynia Vasomotor Fx Skin is swollen or atrophic neuromuscular features
What are the grades of growth plate injury according to the Salter Harris Classification?
SALT CRUSH
Straight across Above Lower Through CRUSH
What are the risk factors for osteoporosis?
AGE + SHATTERED
Steroids Hyperpara/thyroidism Alcohol & cigarettes Thin Testosterone low Early menopause Renal/liver failure Erosive bone disesae Dietary calcium deficiency
What questions should you ask in a hip fracture pt?
Mechanism Osteo RFs Premorbid mobility Premorbid independence Comorbidities MMSE
How would you manage a hip fracture pt?
Resuscitate
Analgesia
NV status
Image
Prep for theatre: ABCDEFG Anaesthetist Bloods CXR DVT prophylaxis ECG Films Get consent
What are the different types of hip fracture?
Intercapsular: Subcapital, transcervical, basicervical
Extracapsular: Intertrochanteric/subtrochanteric
What is the Garden classification?
Used for intracapsular fractures (incomplete undisplaced, complete undisplaced, complete partially displaced, complete completely displaced)
What is the difference between a hemiarthroplasty and a total hip replacement/
Hemiarthroplasty involves only replacing the femoral head, while total hip replacement also replaces the acetabulum (/part of it)
What is the surgical management of intracapsular hip fractures?
<55 yos: ORIF
55-75yos: total hip replacement
>75: hemiarthroplasty
What is the surgical management of extracapsular hip fractuers?
ORIF with dynamic hip screw
What is the prognosis following hip fracture?
30% mortality in 1 year
50% never gain full function
Majority will have some residual pain/disability
What are the radiographic features of Colle’s fracture?
Extra articular # of distal radius
Dorsal displacement and angulation of distal fragment
+-impaction
What are the specific complications of a Colle’s fracture?
Median nerve injury Adhesive capsulitis Tendon rupture Carpal tunnel syndrome non/malunion Sudek's atrophy
What are the radiological features of a Smith’s fracture?
Distal radius fracture with volar displacement and angulation of the distal fragment
If clinical Hx and exam suggest scaphoid fracture but X-ray normal, what should you do?
Treat anyway as #may only show after 10 days
Plaster cast
What is a Monteggia fracture?
of proximal 3rd of ulna shaft
What is a Galleazzi fracture?
of radial shaft between mid and distal 3rds
When might you see a posterior shoulder dislocation?
Direct trauma
Epileptic seizures
What is a Bankart lesion?
Damage to anteroinferior glenoid labrum
What is a Hill Sachs lesion?
Cortical depression of the posterolateral part of the humeral head following impaction against the anteroinferior glenoid rim.
V common
What is the rate of dislocation recurrence following traumatic dislocation?
90% in 20 years
What is the pathology of Impingement syndrome/Painful arc?
Entrapment of the supraspinatus tendon and subacromial bursa between the acromion and greater tuberosity of the humerus
How does Impingement Syndrome present?
Painful arc between 60-120 degrees
Weakness
Reduced range of movement
What is the management of a painful arc?
Supportive - rest, physio
Medical - NSAIDs, steroid injection
Surgical - Arthroscopic acromioplasty
What is the presentation of adhesive capsulitis?
Progressive impairment of active and passive ROM
Significantly reduced external rotation
Shoulder pain esp at night
What is the classic sign of a rotator cuff tear?
Able to abduct actively following possive abduction to 90 degrees. Lowering past this point leads to a sudden drop
What structure is most commonly damaged in a supracondylar fracture?
Brachial artery
What demographic are supracondylar fractures most commonly seen in?
Children after FOOSH
What specific complications might occur following a supracondylar fracture?
Neurovascular injury to brachial artery, radial nerve, median nerve
Compartment syndrome
Gunstock deformity
How much blood should be Xmatched for the following fractures?
Tibial
Femoral
Tibial - 2 units
Femoral - 4 units
What are the specific complications following lower limb long bone fractures?
Hypovolaemic shock
Neurovascular (sciatic nerve, superficial femoral artery)
Compartment syndrome
PE/ARDS from Fat emboli
What might the following features of a knee injury indicate?
i) Swelling
ii) Pain
iii) Locking
iv) Giving way
i) Haemarthrosis due to fracture or torn cruciates (80% ACL)
ii) Meniscal or collateral tear
iii) Meniscal tear
iv) Ligament injury
What is the Unhappy triad of O’donoghue?
ACL tear
Medial collateral tear
Medial meniscus tear
What is the management of a ruptured ACL?
Conservative - Rest, physio strengthening quads and hammies
Surgical - Autograft repair using semitendinosus +-gracilis held in place with screws
What is the definition of osteoarthritis?
Degenerative joint disorder where there is progressive loss of hyaline cartilage and new bone formation at the joint surface and its margin
What are the two main risk factors for OA?
Age
Obesity
Which joints does OA typically affect?
Hips Knees DIPS PIPS Thumb CMC
What are the symptoms and signs of OA?
Pain at end of day Stiffness after rest Joint deformity Reduced ROM Pouchards and Heberdips Fixed flexion deformity
What Xray changes are associated with OA?
Subchondral sclerosis Loss of joint space Osteophytes Deformity Subchondral cysts
What is the management of OA?
Supportive - Physio, weight loss, walking aids/home mods
Medical - Para, NSAIDs, Tramadol, joint injections
Surgical - Arthroscopic washout, arthroplasty
What is the presentation of the most common disc prolapse?
Most commonly affecting the L5 and S1 nerve roots, presenting with lumbago and sciatica.
Signs include limited flexion/extension with free lateral flexion, pain on straight leg raise.
What does S1 root compression cause??
Weak plantarflexion and eversion with loss of ankle jerk and reduced sensation over sole of foot and back of calf
What is the commonest surgical procedure for disc prolapse?
Lumbar microdiscectomy
What is spondylolisthesis and where does it commonly affect?
Displacement of one lumbar vertebra over another, usually anterior displacement of L5 over S1.
What are the common causes of spondylolisthesis?
congenital malformation
Spondylosis
Osteoarthritis
How does spoondylolisthesis commonly present?
Usual onset in adolescence with pain worse on standing +- sciatica
What is the presentation of spinal stenosis?
Spinal claudication - aching buttoch and lower limb pain on walking usually rapid onset +-parasthesia. Pain eased by sitting forwards and worsened by spine extension.
What is the presentation of acute cord compression (Neurosurgical emergency)
Bilateral back and radicular pain
LMN signs at compression level
UMN signs at sensory level and below compression
Sphincter disturbance
What is the presentation of acute cauda equina?
Radicular leg pain
Saddle anaesthesia
Loss of anal tone
Bladder +-bowel incontinence
What is the management of acute cord/cauda equina compression?
Large prolapse - laminectomy/discectomy
Tumour - Radiotherapy and steroids
Abscesses - decompression and Abx
What is osteochondritis?
Idiopathic temporary softening of bone centre in adolescents due to necrosis followed by rehardening of bone in deformed position.
What are some examples of osteochondritic disorders?
Seheuermann's disease Kohler's disease Friedberg's disease Panners sidsease Perthe's disese
What are some examples of traction apophysitis?
Osgood Schlatter’s
Siding Larsen’s disease (tibia)
Sever’s disease (Calcaneal)
What is osteochondritis dissecans, how does it present and what is the management?
When a piece of articular bone breaks off into the joint space.
As well as pain and swelling, locking is a classical feature.
Mx: Arthroscopic removal
How would you investigate and manage an acute osteomyelitis?
Ix: ESR/CRP, WCC, cultures, Xray (changes take 2 weeks to develop), MRI is sensitive and specific
Mx: Vanc + cef empiriaclly, drainage, analgesia
What additional investigation might you for a septic arthritis that you wouldnt do for an osteomyelitis?
Joint aspirate MCnS
What are the complications of septic arthritis/
Osteomyelitis
Post infective arthritis
Ankylosis (fusion)
What are the commonest tumours which metastasise to the bone?
Breast, lung, prostate, thyroid, kidney
What is the typical presentation of fibrous dysplasia/
A young female presents with fractures of the long bones. Also affecting the ribs and skull.
What syndrome is fibrous dysplasia associated with, and what other features does it present with?
McCune Albright
Precocious puberty in females
Cafe au lait spots
When and where might you see a Shepherds crook deformity?
In a patient with fibrous dysplasia in the proximal femur
What is the commonest benign bone tumour and which joint does it typically affect?
Osteochondroma
Knee
What is the most common malignant cartilagenous neoplasm and how does it present?
Chondrosarchoma
Presents in older patients with a painful lump typically of the pelvis or axial skeleton
What are the Xray findings of a chondrosarcoma?
Popcorn calcification
Name three benign bone forming neoplasms
Osteoma
Osteoid osteoma
Osteoblastoma
Which benign bone neoplasm typically has pain which responds to aspirin?
Osteoid osteoma
Osteoblastomas are classically unresponsive to aspirin
What is the commonest primary malignant bone tumour and how does it typically presnet?
Osteosarcoma
Presents in male teenagers with warm painful bone typically at the knee
What are the Xray findings in osteosarcoma/
Pereosteal elevation leading to Codman’s triangle
What is the classical presentation of Ewing’s sarcoma/
<20 year old with a painful warm enlarging mass with systemic signs (Fever, anaemia, raised WCC) typically affecting long bone diaphysis
Ewings sarcoma X ray findings?
Onion skin periosteal reaction
Which nerve roots are affected in Erbs and Klumpkes palsies?
Erbs: C5,6
Klumpkes: C8, T1
What are the different presentations of a radial nerve injury?
at elbow/forearm: Loss of CMC extension, no sensory loss
at humeral shaft: wrist drop, loss of sensation to snuff box
Axilla (crutches/sat night palsy): paralysis of triceps and wrist drop
What are the features of an ulnar nerve palsy?
Intrinsic hand paralysis -> Claw hand
Weak finger ab/adduction due to interossei paralyss
Sensory loss over little finger
What is the ulnar paradox?
Lesions at the elbow cause less clawing than more distal lesions, as the flexor digitalis profundus is also denervated, meaning IP flexion is weakened.
What are the different presentations of median nerve injury?
Above ACF: Cant flex index IJPs, cant flex terminal thumb phalynx, loss of sensation in median distribution
Injury at wrist: Typically affects abductor pollicis brevis
CTS
What forms the carpal tunnel and what is its contents?
Formed by flexor retinaculum and carpal bones
Contents: Tendons of flexor digitalis profundus and superficialis, flexor pollicis lungus and the median nerve.
Which hand muscles does the median nerve supply?
LLOAF
Lateral lumbricals
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis
What are the causes of carpal tunnel syndrome?
Primary idiopathic Pregnancy Oedema Radial # RA Gout Soft tissue swelling DM EtOH
What are the featuers of CTS?
Painful parasthesia of lateral 3.5 fingers worse at night or after repeated actions
Relieved by shaking
Clumsiness
Reduced 2 point discrimination (irreversible damage)
Thenar eminence wasting
Tinels and Phalens +ve
What is the management of CTS?
Treat underlying pathology Wrist splints in neutral position Analgesia Steroid injections Surgical decompression by division of flexor retinaculum
Risk of CTS surgery?
Hypertrophic scar formation actually worsens symptoms
What associated features might be seen in Dupuytrens contracture?
BAD FIBRES
Bent penis AIDS DM FH Idiopathic (commonest) Booze Epilepsy (phenytoin) Reidels thyroiditis Smoking
What is the anatomical cause of trigger finger?
Tendon nodule catching on the proximal side of a tendon sheath trigggering manual extension
What is a Baker’s Cyst and what is associated with?
Popliteal swelling between the medial head of gastrocnemius and semitendinosus muscle.
Usually 2ary to OA
May rupture causing calf pain and swelling
What is the commonest complication of hallux valgus/
Bunion at MTP
What is Morton’s metatarsalgia?
Pain from pressure on an interdigital neuroma between the metatarsals. Pain radiates to the medial side of one to and lateral side of another.
