Orthopaedics Flashcards
What are the 3 stages of fracture management?
Reduce
Hold
Rehabilitate
What are the principles for reduction in fracture management?
Restores anatomical alignment of fracture or dislocation.
Tamponade of bleeding at fracture site.
Reduction in traction of soft tissue, reducing swelling.
Reduction in traction of traversing nerves.
Reduction of pressures of traversing blood vessels.
Can be closed reduction or open reduction or intra-operatively.
What are the principles for hold stage of fracture management?
Immobilising fracture.
Common methods - simple splints or plaster casts.
What are the principles for rehabilitate stage of fracture management?
Intensive period of physiotherapy.
Essential for successful recovery.
What is the classification system for open fractures and what are the different grades?
Gustilo and Anderson classification system.
1 - low energy wound <1cm
2 - >1cm wound with moderate soft tissue damage
3 - >1cm high energy wound with extensive soft tissue damage
3A - adequate soft tissue coverage (ortho alone)
3B - inadequate soft tissue coverage (plastics input)
3C - associated arterial injury (vascular input)
Initial management of fractures
Immobilise fracture - including proximal and distal joints.
Monitor and document neuromuscular status, particularly following reduction and immobilisation.
Manage infection including tetanus prophylaxis.
IV broad spectrum abx for open injuries.
Open fractures should be thoroughly debrided.
Open fractures are an emergency and should be debrided and lavaged within 6 hours of injury.
Risk factors for osteoarthritis
No obvious cause Trauma Infiltrative disease Connective tissue disease Obesity Advancing age Female gender Manual labour occupations
Features of OA
Common joints are small joints of hands and feet, hip and knee.
Pain and stiffness
Worse with activity, relieved by rest.
Pain worse throughout the day, stiffness tends to improve.
Reduced ROM.
Bouchard nodes - swelling of PIPJ
Heberden nodes - swelling of DIPJ
Fixed flexion deformity or varus malalignment of knees.
Crepitus during ROM.
Investigations of OA
Clinical diagnosis X-ray - Loss of joint space Osteophytes Subchondral cysts Sunchondral sclerosis
Management of OA - conservative
Advice on joint protection Strengthening and exercise. Weight loss. Local heat and ice packs Joint support Physiotherapy
Management of OA - medical
Simple analgesics and topical NSAIDs
Intra-articular steroid injections
Management of OA - surgical
Osteotomy Arthrodesis (joint fusion) Arthroplasty (joint replacement)
Complications of total hip replacement?
Reasons for revision of total hip replacement?
Venous thromboembolism
Intraoperative fracture
Nerve injury
Aseptic loosening (most common)
Pain
Dislocation
Infection
Post-operative recovery advice of total hip replacement
Physiotherapy and course of home-exercises.
Walking sticks or crutches for up to 6 weeks after hip or knee replacement surgery.
Avoid flexing hip >90 degrees
Avoid low chairs
Do not cross legs
Sleep on back for first 6 weeks.
Most common sites for open fractures
Tibial Phalangeal Forearm Ankle Metacarpal
Features of compartment syndrome
Pain - especially on movement Parasthesiae Pallor may be present Arterial pulsation may still be felt as necrosis occurs as result of microvascular compromise Paralysis of muscle group
Diagnosis of compartment syndrome
Measure intracompartmental pressure - >20mmHg abnormal
>40mmHg diagnostic
No pathology on x-ray
Treatment of compartment syndrome
Prompt and extensive fasciotomies
Myoglobulinuria may occur following fasciotomy and result in renal failure - so give aggressive IV fluids
Necrotic tissue - debridement and amputation considered
Death of muscle groups occur within 4-6 hours.
Most common organisms for septic arthritis
Most common - staph aureus
Young sexually active - consider neisseria gonorrhoea
Most common location of septic arthritis
Knee
What is the criteria for diagnosis of septic arthritis called and what are the key points
Kocher criteria Fever >38.5 Non-weight bearing Raised ESR Raised WCC
Management of septic arthritis
Synovial fluid should be obtained before treatment.
IV abx - flucloxacillin or clindamycin if pen allergic
Abx given for 6-12 weeks
Needle aspiration to decompress joint
Arthroscopic lavage may be required.
Risk factors for septic arthritis
Age >80 Pre-existing joint disease DM Chronic renal failure Hip or knee joint prosthesis IVDU
Complications of septic arthritis
Osteoarthritis
Osteomyelitis
Most common cause for osteomyelitis
Staph aureaus
Sickle cell - salmonella species
Risk factors for osteomyelitis
DM Sickle cell anaemia IVDU Immunosuppresion due to either medication or HIV Alcohol excess
Investigations of osteomyelitis
Bloods - FBC, CRP, ESR, blood cultures
MRI
Management of osteomyelitis
Flucloxacillin for 6 weeks
Clindamycin if pen-allergic
What are the 3 types of clavicle fractures?
Type 1 - most common
Fracture of middle third of clavicle
Type 2 - lateral third of clavicle fracture - unstable if displaced
Type 3 - medial third of clavicle fracture - associated with multi-system polytrauma
How to do medical and lateral fragments usually displace in a clavicle fracture and why?
Medial fragment displaces superiorly due to SCM muscle
Lateral fragment displaces inferiorly from weight of arm.
Management of clavicle fracture
Sling and early movement of shoulder joint to prevent frozen shoulder development.
Open fractures - surgical management.
If fractures fail to unite, ORIF will be necessary 2-3 months post-injury
Complications of clavicle fractures
Non-union
Neurovascular injury
Puncture injury - haemothorax, pneumothorax
Healing time is 4-6 weeks.
What are rotator cuff tears classified in to?
Acute - <3 months
Chronic - >3 months
Partial thickness
Full thickness (small <1cm, medium 1-3cm, large 3-5cm, massive >5cm)
What are the 4 muscles of the rotator cuff?
Supraspinatous - abduction
Infraspinatous - external rotation
Teres minor - external rotation
Subscapularis - internal rotation
Risk factors for rotator cuff tears
Age Trauma Overuse Repetitive overhead shoulder motions Smoking, DM, high BMI
Rotator cuff tear features
Pain over lateral aspect of shoulder
Inability to abduct arm above 90 degrees
Tenderness over greater tuberosity and subacromial bursa
In massive rotator cuff tears - supraspinatus and infraspinatous atrophy
What are the specific tests to do in rotator cuff tear?
Jobe’s test - empty can test. Tests supraspinatus.
Gerber’s lift-off test - tests subscapularis. Internally rotate arm and place hands on lower back. Ask patient to lift hands away against resistance.
Posterior cuff test - tests infraspinatous and tires minor. Arm by patients side, elbow flexed to 90 degrees. Externally rotate arm against resistance.
Investigations of rotator cuff tear?
Urgent plain film radiograph to exclude fracture.
Ultrasonography - establishes presence and size of tear.
MRI imaging - detects size, characteristics and location of any tear.
Management of rotator cuff tear?
Conservative (within 2 weeks of injury) -
Analgesia and physiotherapy
Corticosteroid injections
Surgical (2 weeks since injury or remaining symptomatic despite conservative management) -
Rotator cuff repair.
Complications of rotator cuff tears?
Adhesive capsulitis
Types of shoulder dislocations?
Anterior dislocation - 95%
Posterior dislocation - due to seizures, electrocution, trauma
Features of shoulder dislocation?
Painful shoulder Reduced mobility Feeling of instability Loss of shoulder contours Anterior bulge Assess NV status
Anterior dislocation - external rotation and abduction
Associated injuries -
Bony bankart lesions - fracture of anterior inferior glenoid bone
Hill-Sachs defects - impaction injury to chondral surface of posterior and superior portions of humeral head
Fractures of greater tuberosity and surgical neck of humerus.
Investigation findings of shoulder dislocation
Plain radiographs - AP, Y-scapular and axial views.
Anterior dislocations - humeral head visibly out of glenoid fossa
Posterior dislocation - ‘light bulb’ sign as humerus is fixed in internal rotation.
Management of shoulder dislocation
Analgesia
Reduction, immobilisation, rehabilitation.
Assess NV status pre and post reduction.
Place arm in broad-arm sling - 2 weeks.
Risk factors for humeral shaft fractures
Osteoporosis
Increasing age
Previous fractures
Features of humeral shaft fracture.
What is Holstein-Lewis fracture?
Pain and deformity
Radial nerve involvement - reduced sensation over dorsal 1st webspace and weakness in wrist extension.
Assess NV status
Holstein-Lewis Fracture -
Fracture of distal third of humerus resulting in entrapment of radial nerve. Surgical management indicated in such cases.
Management of humeral shaft fracture
Re-alignment of limb and then functional humeral brace.
Most cases will go on to full union within 8-12 weeks.
Surgical management -
Open reduction and internal fixation with plate.
Intramedullary nailing if pathological fractures, polytrauma, or severely osteoporotic bones
Risk factors for adhesive capsulitis
DM
Female
Features of adhesive capsulitis
Generalised deep and constant pain, often disturbs sleep.
External rotation is affected more than internal rotation or abduction.
Active and passive movement are affected.
Three phases - painful phase, freezing phase, thawing phase.
Episodes typically last between 6 months and 2 years.
Management of adhesive capsulitis
Keep active Education Physiotherapy NSAIDs and paracetamol Corticosteroid injections
Surgical -
if no improvement after 3 months. Joint manipulation under GA to remove capsular adhesions to humorous, arthrogaphic distension or surgical release of glenohumeral joint capsule.
What are the contents of the subacromal space?
Rotator cuff tendons
Long head of biceps tendon
Coraco-acromial ligament
Subacromial bursa
Features of subacromial impingement syndrome (SAIS)
Progressive pain in anterior superior shoulder.
Pain exacerbated by abduction between 60 and 120 degrees
Neers impingement test - arm placed by side, fully internally rotated and passively flexed - pain in anterolateral shoulder
Hawkins test - shoulder and elbow flexed to 90 degrees. Stabilise humerus and passively internally rotate arm and test is positive if pain is in anterolateral aspect of shoulder.
Investigations for SAIS
MRI
Management of SAIS
Analgesia, physio
Corticosteroid injections
Surgical -
6 months without response to conservative management -
Surgical repair of muscular tears
Surgical removal of subacromial bursa - bursectomy
Surgical removal of section of acromion - acromioplasty
What pathologies does SAIS encompass?
Rotator cuff tendonitis
Subacromial bursitis
Calcific tendinitis
Features of supracondylar humeral fractures
Age 5-7 FOOSH Sudden-onset severe pain Swelling, deformity, limited ROM. Median nerve, anterior interosseous nerve, radial nerve and ulnar nerve damage. NV compromise.
Investigations for supracondylar humeral fractures
AP x-ray -
Posterior fat pad sign - lucency visible on lateral view
Displacement of anterior humeral line
CT for surgical planning
