Orthopaedics Flashcards
What are the 3 types of joint?
- Fibrous - connected by dense connective tissue, no joint cavity eg skull sutures
- Fibrocartilagenous - where the body of one bone meets the body of another (aka symphysis), found in vertebral column and pubic symphysis
- Synovial - connected with a fibrous cavity filled with synovial fluid eg. ball and socket joints (hip), hinge joints (interphalangeal)
What is a Bennett’s fracture?
- Intraarticular two part fracture of the base of the first metacarpal
What is a Rolando fracture?
- Three part/comminuted intra-articular fracture-dislocation of the 1st metacarpal
What is mallet finger?
- Injury to the externsor mechanism of the finger at the DIP
- Most prevalent finger tendon injury in sport
- Will often have triangular avulsion fraction at insertion of the common extensor tendon on dorsel aspect of distal phalynx at DIP joint
What is Gamekeeper’s thumb?
- aka Skiers thumb
- Avulsion of rupture of the ulnar collateral ligament of the first metacarpophalangeal joint
What is a Boxer’s fracture?
- Minimally comminuted, transverse fracture of the 5th metacarpal neck
- Most common metacarpal fracture
- Often treated conservatively with closed reduction and splintage +/- K-wire
What is contained in the extracellular matrix?
Collagens
Elastins
Glycoproteins/proteoglycans
What is an oblique fracture?
Angled
What is a segmental fracture?
A fracture composed of at least two fracture lines that isolate a segment of bone
What is an incomplete fracture?
A fracture in which the bone doesn’t break completely - often occurs in the long bones of paediatric patients
What is a greenstick fracture? What is the usually mechanism of injury?
Incomplete fracture of the long bones - usually during infancy and childhood due to a child falling
What is a compression fracture?
aka Crush fracture
A fracture of the vertebrae (cancellous spongy bone), often due to osteoporosis
What is an intra-articular fracture?
A fracture in which the break crosses into the surface of a joint causing cartilage damage - may cause secondary OA
What is a stress fracture? Where is it commonly found?
Tiny fractures formed through repetitive overuse - common in runners and soldiers in the tibia, metatarsals, fibula and navicular bones.
V common in 2nd metatarsal!!!
What is a pathological fracture?
Fracture due to disease, such as osteoporosis, osteomalacia, Paget’s, osteitis and malignancy
What are the requirements for bone healing?
- Viability (intact blood supply)
- Mechanical rest (immobilisation)
- Absence of infection
What are the 2 mechanisms of bone healing?
PRIMARY - healing without formation of callus, bone ends must be touching, osteoclasts traverse line and form lamellar bone to form a compression plate (high risk)
SECONDARY - healing with callus formation and remodelling triggered by responses in periosteum and external soft tissues (low risk)
When assessing a patient with a fracture, what injuries may be identified?
Bones - fractures, pain
Skin - open fractures, devolving injuries, ischaemic necrosis
Muscles - crush and compartment syndromes
Blood vessels - vasospasm, arterial laceration
Nerves - nerve laceration, neuropraxia
Ligaments - joint instability ad dislocation
What investigations should be done in a fracture patient?
BEDSIDE: Obs, ECG
BLOODS: FBC, ESR, U&E, bone profile, myeloma screen
IMAGING: x-rays (2 views, 2 joints), MRI, CT, bone scan, US
(may need to investigate cause of fall)
What are the 3 principles of fracture management?
- Reduce (open or closed)
- Hold (external or internal)
- Rehabilitation
What are the indications for closed reduction?
- Extra-articular features
- Closed fractures
- Simple fractures
- Stable configuration
- Children
What are the indications for open reduction?
- Failed closed reduction
- Displaced intra-articular fractures
- Open fractures
- Nerve/vessel injuries
- Multiple injuries
- Pathological fractures
What are some methods of external fixation?
- Plaster
- Traction (steady, pulling action, often preliminary)
- Brace
- Percutaneous wires
- External fixator
What are some methods of internal fixation?
- Extra-medullary (plates, screws)
- Intra-medullary (nails)
How do you manage an open fracture?
- Inspect, clean and cover wound
- Give immediate IV co-amoxiclav/cefuroxime
- Give tetanus prophylaxis
- Operate within 6 hours (excise wound edges and dead tissue, irrigate, stabilise)
What are some early local complications of fractures?
- Visceral/vascular injury
- Compartment syndrome
- Nerve injury
- Haemarthrosis
- Infection
- Plaster sores
What are some late local complications of fractures?
- Delayed/non/mal union
- Joint stiffness
- Avascular necrosis
- Complex regional pain syndrome
- Osteoarthritis
- UTI/LRTI
What are some general complications of fractures?
- Shock
- ARDS
- Fat embolism
- Crush syndrome
- Tetanus
- Gas gangrene
What is compartment syndrome?
High pressure within a closed fascial space which reduces capillary blood supply so that there is an insufficient level to support tissue –> tissue death
Presents in early stage as passive stretch pain, late stage as numbness and loss of pulses
Diagnosis is pressure >40mmHg
How is compartment syndrome managed?
Occlusive dressing and urgent fasciotomy to decompress muscle compartment - prevents ischaemia and rhabdomyolysis
Requires aggressive IV fluids as risk of myoglobinuria and renal failur after fasciotomy
They will need morphine!!
What is a Colle’s fracture?
Complete fracture of the radius, causing posterior displacement of the radius (looks like a fork) - common in elderly female patients from falling on an outstretched hand
NB - this is equivalent to a greenstick fracture in children
How is a Colle’s fracture managed?
Internal/external fixation - usually 6 weeks in a cast
May need prior reduction if poor bone alignment
What is a Smiths fracture?
- Fracture of the distal radius after falling onto a flexed wrist or due to a direct blow to the back of the wrist
- Reverse Colles fracture
- Causes volar angulation
What is a Barton’s fracture?
- Intraarticular distal radius fracture with dislocation of the radiocarpal joint
Describe the Garden classification of NOFs?
THIS IS A CLASSIFICATION FOR INTRACAPSULAR HIP FRACTURES
Stage 1 - undisplaced, incomplete
Stage 2 - undisplaced, complete
Stage 3 - incompletely displaced (some continuity between fracture ends), complete
Stage 4 - completely displaced, complete
How are NOFs managed?
INTRACAPSULAR:
- Internal fixation with a DHS (if undisplaced/extracapsular)
- Replacement arthroplasty (total/hemi - if displaced)
Also give analgesia, nerve block, thromboprophyalxis, antibiotics, MDT involvement
EXTRACAPSULAR:
- Stable > DHS
- Reverse oblique, transver or subtrochanteric > intramedullary device
What is a Thomas splint?
A splint applied in A&E that keeps the leg still if broken before surgical management
What is ORIF?
Open reduction internal fixation - procedure to realign bone in the case of a severe fracture
What are the complications of a NOF?
- Leg deformity, mobility issues
- Avascular necrosis of the femoral head and collapse (more likely in intracapsular garden 3/4)
How is avascular necrosis of the hip managed?
- Do MRI to look at extent of AVN
- Core decompression (drill holes into femoral head)
- Osteochondral grafting
- Total arthroplasty (if collapse has already occurred)
What are the symptoms of a scaphoid fracture?
Pain and swelling in the anatomical snuffbox
What is the main complication of a scaphoid fracture?
Avacular necrosis of the scaphoid - may need a vascularized bone graft
How is a scaphoid fracture managed?
Immobilisation in a thumb cast for 8-12 weeks
If displaced may need surgical reduction and fixation
What are osteporotic spinal compression fractures? How are they managed?
Isolated failure of anterior spinal column - usually stable flexion fractures and heal conservatively with bracing for 8-12 weeks and rehab. Maybe have lordosis and kyphosis.
Usually in postmenopausal women and those on long term corticosteroids. Exclude malignancy!
What are the different types of pelvic fracture?
- Stable - only one break in pelvic ring, bones line up adequately
- Unstable - multiple breaks with displacement. high energy event
What is a ganglion cyst?
Smooth, soft benign non-tender mass located on the wrist with one or more communicating stalks into the wrist joint or surrounding structures.
What are the RF for a ganglion cyst?
Female
Age 10-30 years
Trauma
Scapholunate instability
How should a ganglion cyst be managed?
Without neurovascular compromise:
- Observe (often resolve spontaneously)
- Cyst aspiration and steroid injection
- Surgical resection
With neurovascular compromise:
1. Surgical resection
What is tenosynovitis tendonopathy?
Inflammation of the extrinsic tendons of the hand and wrist, manifesting as:
- Trigger fingers
- De Quervains disease
Result from overuse of hand and degeneration
What are the symptoms of trigger finger?
Pain, stiffness and locking when you bend or straighten finger. Tendon can catch in the tendon sheath causing characteristic appearance.
Most commonly affects ring finger (4th)
Manage with steroid injection and finger splint
What are the symptoms of De Quervains disease?
- Pain, stiffness and locking of tendons on the THUMB side of the wrist.
- Due to inflammation of the sheath containing the extensor pollicis brevis and abductor pollicis longus
Positive Finkelstein test - pain on ulnar deviation
How should tenosynovitis be investigated and managed?
1st line - high res USS shows effusion, tendon sheath thickening and hyperaemia (excess blood vessels)
Manage with NSAIDS, splinting, steroid injection and surgery if necessary - in trigger finger incise the A pulley and DQ incise the first dorsal compartment
Describe the sensory supply to the hand
ULNAR - half of fourth digit and entire fifth digit on dorsal and palmar aspects
MEDIAN - tips of first second and third digits and half of the fourth digit
RADIAL - remaining dorsal surface of these digits, extending proximally to the wrist
What is Dupytrens contracture, what are the risk factors and how is it managed?
Inherited disease involving progressive fibrous tissue contracture of the palmar fascia. May have contracture of 4th/5th digits. May have Garrods nodes and involvement of penis.
More common in men, northern europe, smokers/alcohol. Phenytoin use. Autosomal dominant.
Diagnose with US, give steroids. If significant MCP/PIP joint contracture (over 30 degrees), give collagenase injection, needle aponeurotomy and percutaneous fasciotomy
High rate of recurrence.
What spinal nerve roots supply the brachial plexus?
C5, C6, C7, C8, T1
Which nerves come off the brachial plexus?
Musculocutanous (C5,C6,C7) Axillary (C5, C6) Radial (all) Median (all) Ulnar (C8, T1)
What is Dupytrens contracture, what are the risk factors and how is it managed?
Inherited disease involving progressive fibrous tissue contracture of the palmar fascia and aponeuroses. May cause flexion of proximal and middle phalanx on ring and little finger. May have Garrods nodes and involvement of penis.
More common in men, northern europe, smokers/alcohol. Autosomal dominant.
Diagnose with US, give steroids. If significant MCP/PIP joint contracture (over 30 degrees), give collagenase injection, needle aponeurotomy and percutaneous fasciotomy
High rate of recurrence.
Describe the sensory supply to the hand
ULNAR - half of fourth digit and entire fifth digit on dorsal and palmar aspects
MEDIAN - tips of first second and third digits and half of the fourth digit
RADIAL - remaining dorsal surface of these digits, extending proximally to the wrist
What are the clinical features of radial nerve palsy?
- Numbness over posterior arm, forearm and radial hand distribution
- Wrist drop (weak extensor muscles)
- Absent triceps, supinator reflexes
What might cause injury to the radial nerve?
- Humeral/radial fracture
- Stab wounds to antecubital fossa, forearm, wrist
- Crutch palsy
- Saturday night palsy
- Honeymoon palsy
What are the clinical features of medial nerve palsy?
- Sensory loss over thenar eminence and tips of fingers
- HAND OF BENEDICTION (1/2/3 digits remain upright when trying to make a fist)
What might cause injury to the medial nerve?
- Supracondylar fracture (just above elbow) of humerus
- Stab wounds to antecubital fossa, forearm, wrist
- Self harm
- Carpal tunnel syndrome
What are the clinical features of an ulnar nerve palsy?
- Sensory loss over hypothenar eminance and ulnar side of hand
- CLAW HAND (patient cannot extend IPJs of ring or little fingers causing fixed flexion of IPJs and hyperextension of CMPJs, at REST)
What are the clinical features of medial nerve palsy?
- Sensory loss over thenar eminence and tips of fingers
- HAND OF BENEDICTION (1/2/3 digits remain upright when trying to make a fist)
- Positive froments sign (reduced functionality of pincer grip)
What is cubital tunnel syndrome?
- Compression of the ulnar nerve
- Presents as tingling and numbess of 4th and 5th fingers
- May develop weakness and muscle wasting over time
- Pain worse on leaning on affected elbow
How is cubital tunnel syndrome managed?
- Usually a clinical diagnosis but may use NCS
- Manage conservatively with physio
- Steroid injections + surgery if refractory
What is the flexor retinaculum?
Thick connective tissue that forms the roof of the carpal tunnel
What is carpal tunnel syndrome?
Numbness, tingling in the thumb and fingers and aching wrist due to COMPRESSION OF THE MEDIAN NERVE IN THE CARPAL TUNNEL
Symptoms are intermittent, gradual onset and worse at night time. Wasting of thenar eminence
What are the RF for carpal tunnel syndrome?
High BMI Female Age over 30 Smoking Pregnancy Diabetes, thyroid dysfunction, autoimmune, RA Occupational hazards
How is carpal tunnel syndrome investigated?
1st line - EMG (electromyogram), slowed nerve conduction (also phanlen and tinels test!)
2nd line - wrist US/MRI, if suspect space occupying lesion such as ganglion cyst
How is carpal tunnel syndrome managed?
- Wrist splint worn nightly and steroid injections
2. Surgical release through flexor retinaculum division (as risk of permanent nerve damage)
What are phalen and tinel tests?
PHALEN - flex wrists (backwards prayer) for 60s
TINEL - tap over transverse carpal ligaments
Positive test gives pain, anaesthesia and parasthesia
What is epicondylitis?
Tennis elbow (lateral epicondylitis) - lads play tennis:
- Pain worse on resisted wrist extension or supination of forearm with elbow extended
- Acute pain for 6-12 weeks
Golfers elbow (medial epicondylitis) - men play golf:
- Pain worse with wrist felexion and pronation
- May have parasthesia in 4/5 fingers due to ulnar involvemet
Describe the shoulder joint
Ball and socket - made up of humerus, scapula and clavicle.
Acromion and coracoid process of scapula exend laterally over the shoulder joint, forming the subacromial space.
Joint kept in place by rotator cuff muscles, with an underlying bursa allowing the tendons to glide freely on arm movement
What are the 4 rotator cuff muscles?
- Supraspinatus
- Infraspinatus
- Subscapularis
- Teres minor
What is the function of the supraspinatus muscle?
Elevates the shoulder joint out to the side
What is the function of the infraspinatus and teres minor muscle?
Externally rotate the shoulder joint
What is the function of the subscapularis muscle?
Allows the humerus t omove freely during arm elevation
What are some DDs for shoulder pathology?
- Shoulder impingement
- Subacromial bursitis
- Rotator cuff syndrome/tendonitis
- Trauma
- Adhesive capsulitis
What is subacromial impingement?
AKA impingement syndrome, painful arc syndrome
- Presents as shoulder pain worse on abduction
- Painful arc of abduction between 60 and 120 degrees
- Tenderness over anterioer acromion
What is a rotator cuff tear? How is it managed?
Pain, weakness and loss of ROM around the shoulder, due to trauma or attritional damage. Will usually have pain on initial 60 degrees of abduction
CONSERVATIVE: exercise, physio
MEDICAL: analgesia, subacromial steroid injection or nerve block (dont give more than 2 with 6 weeks in between as risk of tendon damage)
SURGICAL: open, arthroscopic repair (if no response after 6weeks medical therapy)
(nb - refer to secondary care if red flags, no benefit after 6 weeks or injury caused by trauma)
What is adhesive capsulitis? How is it caused?
Frozen shoulder - insidious, progressive severe restriction of active and passive shoulder motion. Initial pain but worsening stiffness.
Exact mechanism unknown, but may be due to scar tissue formation, causing thickening of joint capsule.
RF include age, DM/thyroid, prior hx, recent traumatic injury
What tests are done to diagnose adhesive capsulitis?
Coracoid pain test - pain elicited by direct pressure on coracoid
Shoulder shrug test - inability to abduct arm to 90 degrees in to plane of body
External rotation more affected than internal rotation or abduction
How is adhesive capsulitis managed?
The condition is generally self-limiting - should resolve within a year after passing through 3 phases (painful, stiff, recovery)
CONSERVATIVE - analgesia, activity modification, physiotherapy (sleeper stretch), hot packs
MEDICAL - glenohumeral steroid injection
How is acute shoulder dislocation managed?
- Do x-ray to confirm and exclude fracture
- Patients over 40 should have further US/MRA to look for rotator cuff tear
- Reduction under anaesthesia (abduction and external rotation and axial traction)
- Immobiliation in a sling for 3 weeks
- Repeat x-ray to exclude further iatrogenic fractures and confirm placement
What are the complications of joint dislocation?
- Soft tissue injury
- Articular surface injury
- Neurovascular compromise
What is a subluxtation and how is it managed?
Partial/incomplete dislocation. Treat with shoulder strengthening exercises, closed reduction and surgery if multiple occurences.