Orthopaedics Flashcards
1
Q
What are the 3 stages of fracture management?
A
Reduce
Hold
Rehabilitate
2
Q
What are the principles for reduction in fracture management?
A
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.
3
Q
What are the principles for hold stage of fracture management?
A
Immobilising fracture.
Common methods - simple splints or plaster casts.
4
Q
What are the principles for rehabilitate stage of fracture management?
A
Intensive period of physiotherapy.
Essential for successful recovery.
5
Q
What is the classification system for open fractures and what are the different grades?
A
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)
6
Q
Initial management of fractures
A
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.
7
Q
Risk factors for osteoarthritis
A
No obvious cause Trauma Infiltrative disease Connective tissue disease Obesity Advancing age Female gender Manual labour occupations
8
Q
Features of OA
A
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.
9
Q
Investigations of OA
A
Clinical diagnosis X-ray - Loss of joint space Osteophytes Subchondral cysts Sunchondral sclerosis
10
Q
Management of OA - conservative
A
Advice on joint protection Strengthening and exercise. Weight loss. Local heat and ice packs Joint support Physiotherapy
11
Q
Management of OA - medical
A
Simple analgesics and topical NSAIDs
Intra-articular steroid injections
12
Q
Management of OA - surgical
A
Osteotomy Arthrodesis (joint fusion) Arthroplasty (joint replacement)
13
Q
Complications of total hip replacement?
Reasons for revision of total hip replacement?
A
Venous thromboembolism
Intraoperative fracture
Nerve injury
Aseptic loosening (most common)
Pain
Dislocation
Infection
14
Q
Post-operative recovery advice of total hip replacement
A
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.
15
Q
Most common sites for open fractures
A
Tibial Phalangeal Forearm Ankle Metacarpal
16
Q
Features of compartment syndrome
A
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
17
Q
Diagnosis of compartment syndrome
A
Measure intracompartmental pressure - >20mmHg abnormal
>40mmHg diagnostic
No pathology on x-ray
18
Q
Treatment of compartment syndrome
A
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.
19
Q
Most common organisms for septic arthritis
A
Most common - staph aureus
Young sexually active - consider neisseria gonorrhoea
20
Q
Most common location of septic arthritis
A
Knee
21
Q
What is the criteria for diagnosis of septic arthritis called and what are the key points
A
Kocher criteria Fever >38.5 Non-weight bearing Raised ESR Raised WCC
22
Q
Management of septic arthritis
A
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.
23
Q
Risk factors for septic arthritis
A
Age >80 Pre-existing joint disease DM Chronic renal failure Hip or knee joint prosthesis IVDU
24
Q
Complications of septic arthritis
A
Osteoarthritis
Osteomyelitis
25
Most common cause for osteomyelitis
Staph aureaus
| Sickle cell - salmonella species
26
Risk factors for osteomyelitis
```
DM
Sickle cell anaemia
IVDU
Immunosuppresion due to either medication or HIV
Alcohol excess
```
27
Investigations of osteomyelitis
Bloods - FBC, CRP, ESR, blood cultures
| MRI
28
Management of osteomyelitis
Flucloxacillin for 6 weeks
| Clindamycin if pen-allergic
29
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
30
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.
31
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
32
Complications of clavicle fractures
Non-union
Neurovascular injury
Puncture injury - haemothorax, pneumothorax
Healing time is 4-6 weeks.
33
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)
34
What are the 4 muscles of the rotator cuff?
Supraspinatous - abduction
Infraspinatous - external rotation
Teres minor - external rotation
Subscapularis - internal rotation
35
Risk factors for rotator cuff tears
```
Age
Trauma
Overuse
Repetitive overhead shoulder motions
Smoking, DM, high BMI
```
36
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
37
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.
38
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.
39
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.
40
Complications of rotator cuff tears?
Adhesive capsulitis
41
Types of shoulder dislocations?
Anterior dislocation - 95%
| Posterior dislocation - due to seizures, electrocution, trauma
42
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.
43
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.
44
Management of shoulder dislocation
Analgesia
Reduction, immobilisation, rehabilitation.
Assess NV status pre and post reduction.
Place arm in broad-arm sling - 2 weeks.
45
Risk factors for humeral shaft fractures
Osteoporosis
Increasing age
Previous fractures
46
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.
47
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
48
Risk factors for adhesive capsulitis
DM
| Female
49
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.
50
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.
51
What are the contents of the subacromal space?
Rotator cuff tendons
Long head of biceps tendon
Coraco-acromial ligament
Subacromial bursa
52
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.
53
Investigations for SAIS
MRI
54
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
55
What pathologies does SAIS encompass?
Rotator cuff tendonitis
Subacromial bursitis
Calcific tendinitis
56
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.
```
57
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
58
What is the classification of supracondylar humeral fractures?
Gartland classification system
1 - undisplaced
2 - displaced with intact posterior cortex
3 - displaced in two or three planes
4 - displaced with complete periosteal disruption
59
Management of supracondylar humeral fracture?
If NV compromise - immediate closed reduction, then secure in theatre with K-wire.
Type 1 or some type 2 can be managed with above elbow cast in 90 degrees flexion.
Type 2, 3 and 4 nearly always require closed reduction and percutaneous K-wire fixation.
Open fractures - open reduction with percutaneous pinning.
60
Complications of supracondylar humeral fracture?
Nerve palsies - anterior interosseous nerve most commonly affected.
Malunion
Volkmann's contracture - ischaemia and subsequent necrosis of flexor muscles of forearm eventually begin to fibrose and form a contracture. Results in wrist and hand to be held in permanent flexion, as a claw-like deformity.
61
Features of olecranon fracture
Due to sudden pull of triceps.
Outstretched hand, elbow pain, swelling and lack of mobility.
Tenderness of posterior elbow.
62
Investigations of olecranon fracture
Bloods - G+S and clotting screen.
| AP and lateral x-rays.
63
Management of olecranon fracture
Analgesia
Non-surgical - displacement <2mm, immobilisation in 60-90 degrees of below flexion and early introduction of range of motion at 1-2 weeks. Also for >75 years of age.
Surgical - displacement >2mm.
Tension band wiring (if fracture proximal to coranoid process)
Olecranon plating (if at level of or distal to coranoid process.
64
Features of radial head fracture
FOOSH
Tenderness on palpation over lateral aspect of elbow and radial head, with pain and crepitation on supination and pronation.
65
Investigations of radial head fracture
Bloods - G+S and clotting
AP and lateral radiographs.
Sail sign - elbow effusion on lateral projection
CT scan for associated ligament damage.
66
Classification of radial head fracture
Mason classification
1 - non-displaced or minimally displaced fracture <2mm
2 - partial articular fracture with displacement >2mm or angulation
3 - comminuted fracture and displacement (a complete articular fracture)
67
Management of radial head fracture
Analgesia
Check presence of NV compromise
Type 1 - non-operative, sling <1 week and then early mobilisation.
Type 2 - If no mechanical block, treat as type 1. If mechanical block, may need surgery - ORIF
Type 3 - surgical intervention - ORIF or radial head excision or replacement.
68
Elbow dislocation features
high-energy fall
Painful and deformed elbow, swelling and decreased function.
NV examination - ulnar nerve, check cap refill
69
Investigations of elbow dislocation
Plain film radiograph - AP and lateral.
70
Management of elbow dislocation
Closed reduction.
Analgesia and sedation if appropriate.
Apply elbow backslab once reduced to keep elbow at 90 degrees - immobilisation for 5-14 days. Early rehabilitation.
If dislocation complicated by fracture - operative fixation required - ORIF.
71
What is involved in the terrible triad?
Elbow dislocation with -
Lateral collateral ligament injury
Radial head fracture
Coronoid fracture
72
Causes of olecranon bursitis
Repetitive flexion-extension movements at the elbow, causing irritation of the bursa.
Gout
Rheumatoid arthritis
73
Features of olecranon bursitis
Pain and swelling
Erythema
ROM normal
Can get systemic symptoms - fever or lethargy.
74
Olecranon bursitis investigations
Bloods - FBC, CRP, serum urate
X-ray of elbow
Definitive diagnosis - aspiration of fluid for MC+S and presence of crystals.
75
Management of olecranon bursitis
Without infection - NSAIDs, rest, splinting of elbow may be required.
With infection - IV abx, surgical drainage. Bursectomy in some cases.
76
Features of lateral epicondylitis (tennis elbow)
Pain and tenderness localised to lateral epicondyle.
Pain worse on resisted wrist extension with elbow extended or supination of forearm with elbow extended.
Episodes last between 6 months and 2 years. Acute pain for 6-12 weeks.
77
Management of medial and lateral epicondylitis
Modify activities
Reduce repetitive actions
Simple analgesics alongside topical NSAIDs
Corticosteroid injections - repeated every 3-6 months.
Physiotherapy
Surgical - open or arthroscopic debridement of tendinitis and/or release or repair of any damaged tendon insertions may be required.
78
Features of medical epicondylitis
Pain and tenderness localised to medial epicondyle
Pain aggravated by wrist flexion and pronation
Symptoms may be accompanied by numbness/tingling in 4th and 5th finger due to ulnar nerve involvement.
79
Features of Colles' fracture
```
FOOSH
Described as dinner fork type deformity
Features of injury:
1. transverse fracture of radius
2. 1 inch proximal to radio-carpal joint
3. Dorsal displacement and angulation
```
80
Features of Smith's fracture
Volar angulation of distal radius fragment
| Caused by falling backwards onto palm of outstretched hand or falling with wrists flexed.
81
Features of Barton's fracture
Distal radius fracture (Colles/smiths) with associated radiocarpal dislocation
Fall onto extended and pronated wrist.
82
Risk factors for distal radial fractures
```
Age
Female gender
Early menopause
Smoking or alcohol excess
Prolonged steroid use.
```
83
Management of distal radial fractures
Closed reduction.
Place in below-elbow backslab case, then radiographs repeated after 1 week to check for displacement.
If significantly displaced or unstable, surgery required - ORIF, K-wire fixation or external fixation.
Physiotherapy.
84
Features of scaphoid fractures
Pain along radial aspect of wrist, at base of thumb.
Loss of grip/pinch strength.
- Point of maximal tenderness over the anatomical snuffbox. This is a highly sensitive, but poorly specific test in isolation.
- Wrist joint effusion. Hyper acute injuries (<4hrs old), and delayed presentations (>4days old) may not present with joint effusions.
- Pain elicited by telescoping of the thumb (pain on longitudinal compression)
- Tenderness of the scaphoid tubercle (on the volar aspect of the wrist)
[5] Pain on ulnar deviation of the wrist
85
Scaphoid fracture investigations
X-ray - AP and lateral view. and Scaphoid view.
Repeat 2 weeks later when scaphoid fracture diagnosed, or when initial radiographs inconclusive.
CT required for planning operative management.
MRI is definitive investigation to confirm or exclude diagnosis.
86
Management of scaphoid fractures
Undisplaced - immobile in plaster with thumb spica splint.
Displaced - percutaneous variable-pitched screw
87
Cubital tunnel syndrome:
Features
Investigations
Management
Compression of ulnar nerve as it passes through cubital tunnel
Tingling and numbness of 4th and 5th finger
Weakness and muscle wasting
Pain worse on leaning on affected elbow
History of OA or prior trauma to area
Ix - clinical dx.
```
Management -
avoid aggravating activity
Physiotherapy
steroid injections
surgery in resistant cases
```
88
Features of carpal tunnel syndrome
Compression of median nerve in carpal tunnel.
Pain/pins and needles in thumb, index and middle finger.
Patient shakes hands to obtain relief, classically at night.
Weakness of thumb abduction (abductor pollicis brevis)
Wasting of thenar eminence
Tinel's sign - tapping causes paraesthesia
Phalen's sign - flexion of wrist causes symptoms.
89
Causes of carpal tunnel syndrome
```
Idiopathic
Pregnancy
Oedema, eg HF
Lunate fracture
RA
```
90
Treatment of carpal tunnel syndrome
```
Corticosteroid injection
Wrist splints at night
Surgical decompression (flexor retinaculum division)
```
91
Features of dupuytren's contracture
Male
Family history
Ring finger and little finger are most commonly affected
92
Risk factors for dupuytren's contractures
```
Smoking
Alcoholic liver cirrhosis
DM
Use of vibration tools or heavy manual work
Phenytoin treatment
```
93
Management of dupuytren's contractures
Conservative -
Hand threapy
Injectable collagenase clostridium histolyticum
Surgical -
Excision of diseased fascia
Indicated in functional impairment, MCP joint contracture >30 degrees, any PIP contracture, rapidly progressive disease.
Fasciectomy - regional, segmental or dermofasciectomy.
94
Features of De Quervain's tenosynovitis
Sheath containing extensor pollicis brevis and abductor pollicis longs tendons are inflamed.
Affects females aged 30-50.
Pain on radial side of wrist
Tenderness over radial styloid process
Abduction of thumb against resistance is painful
Finkelstein's test - pull thumb of patient in ulnar deviation and longitudinal traction. In a patient with tenosynovitis this causes pain.
95
Management of De Quervain's tenosynovitis
Analgesia
Steroid injection
Immobilisation with thumb splint
Surgical treatment
96
Features of ganglionic cysts
Smooth spherical painless lump
Lump transilluminates
RFs - female, OA, previous joint or tendon injury
97
Management of ganglionic cysts
Monitor, disappears spontaneously
| If causes pain or limits ROM - aspirate or cyst excision
98
Trigger finger:
Risk factors
Features
Management
Women, RA, DM
Associated with abnormal flexion of digits. Disparity between size of tendon and pulleys through which they pass. Tendon becomes stuck and cannot pass smoothly through pulley.
More common in thumb, middle or ring finger.
Stiffness and snapping when extending flexed digit.
Steroid injection is usually successful.
Finger splint may be applied afterwards.
Surgery for patients who don't respond to steroids.
99
Features of Erb's palsy
Damage of upper trunk of brachial plexus - C5, C6
May be secondary to dystocia during child birth.
Arm hangs by side and is internally rotated, elbow extended
Waiters tip
100
Klumpke Injury
Damage of lower trunk of brachial plexus - C8, T1
Sudden upward jerk of hand.
Associated with Horner's syndrome.
101
What determines whether a fracture is intra-capsular or extra-capsular?
Intra-capsular - subcapital region of femoral head to basocervical region of femoral neck.
Extra-capsular:
Inter-trochanteric - between greater trochanter and lesser trochanter
Sub-trochanteric - from lesser trochanter to 5cm distal to this point.
102
What is the blood supply to the femoral neck?
Retrograde - medial circumflex femoral artery, which lies directly on intra-capsular femoral neck
103
How to classify intracapsular fractures?
```
Garden Classification:
1 - non-displaced, incomplete
2 - non-displaced, complete fracture
3 - partially displaced, complete fracture.
4 - fully displaced, complete fracture.
```
104
Features of neck of femur fracture?
Pain in groin, thigh, or referred to knee. Inability to weight bear.
leg is shortened and externally rotated due to pull of short external rotators.
105
Investigations of neck of femur fracture?
X-ray - AP and lateral views.
Also obtain full length femoral x-rays.
Bloods - FBC, U&Es, coagulation screen, G+S, CK (for any rhabdomyolysis).
106
Management of neck of femur fracture?
Intracapsular -
Undisplaced - internal fixation or hemiarthroplasy if unfit
Displaced - young and fit - reduction and internal fixation. Older and reduced mobility - hemiarthroplasty or total hip replacement.
Extracapsular -
Dynamic hip screw
If revere oblique, transverse or subtrochanteric - intramedullary device.
107
Features of ACL tear
Rapid joint swelling, significant pain.
| Lachman test and Anterior Draw Test positive
108
Investigations of ACL tear
X-ray - AP and lateral
| MRI is gold-standard
109
Management of ACL tear
RICE
Surgical repair
Intense physio if unsuitable for surgery
110
Grades of MCL injury
1 - mild, minimally torn fibres, no loss of MCL integrity
2 - moderate injury, incomplete tear and increased laxity of MCL
3 - severe, complete tear, gross laxity of MCL
111
Management of MCL injury
Grade 1 - RICE and NSAIDs - 6 weeks recovery
Grade 2 - analgesia, knee brace and strength training. 10 weeks recovery
Grade 3 - analgesia, knee brace, crutches. Surgery. 12 weeks recovery
112
Features of meniscal tear
Pain worse on straightening knee
Knee may give way
Displaced meniscal tears may cause knee locking
Tenderness along joint line
Thessaly's test - weight bearing at 20 degrees of knee flexion, patient supported by doctor, positive if pain on twisting knee.
113
Management of meniscal tear
RICE
Arthroscopic surgery - if tear in outer third of meniscus (which has rich vascular supply), the tear is sutured back together.
If tear in inner third of meniscus it is often trimmed.
114
Features of unhappy triad
ACL
MCL
Medial meniscus
115
Features of tibial plateau fracture
```
History of trauma
Sudden onset pain in affected knee
Unable to weight bear
Swelling of knee
Ensure NV status
```
Varus deforming force - medial tibial plateau
Valgus deforming force - lateral tibial plateau
116
Investigations of tibial plateau
X-ray - AP and lateral views
Lipohaemarthrosis present
CT scan needed
117
Classification of tibial plateau fracture
```
Schatzker classification
1 - lateral split fracture
2 - lateral split - depressed fracture
3 - lateral pure depression fracture
4 - medial plateau fracture
5 - bicondylar fracture
6 - metaphyseal - diaphyseal disassociation
```
118
Management of tibial plateau fracture
Non-operative -
Hinged knee brace and non- or partial- weight bearing for around 8-12 weeks
Physio and analgesia
Operative -
ORIF
Hinged knee brace
Non-weight bearing for 8-12 weeks
119
Risk factors for iliotibial band syndrome (ITBS)
```
Repetitive flexion and extension of knee, commonly runners, weightlifters or cyclists.
Genu varum
Excessive internal tibial torsion
Foot pronation
Hip abductor weakness
```
120
Features of ITBS
Lateral knee pain
Exacerbated by exercise
Worse when running downhill
Nobles test - positive when pain felt at 30 degrees when ITB passes over lateral femoral condyle
Renne test - stands in front of affected knee, puts pressure on lateral epicondyle with patient then asked to squat. Positive when pain at 30 degrees of flexion.
121
Management of ITBS
Modify activity
Analgesia
Steroid injections
Physiotherapy
Surgery - release of iliotibial band from its attachments from patella
122
Classification on ankle fracture
Weber classification
Type A - below syndesmosis
Type B - level of syndesmosis
Type C - above level of syndesmosis
123
What rules are used to diagnose ankle fracture?
Ottawa ankle rules:
Any pain in malleolar zone and any one of:
bony tenderness at lateral malleolar zone
bony tenderness at medial malleolar zone
Inability to walk four weight bearing steps immediately after injury and in ED.
124
Management of ankle fractures
Immediate fracture reduction to realign fracture
Below knee back slab once reduced.
Repeat NV examination.
This is for non-displaced medial malleolus fracture, weber A and B fracture without talar shift and those unfit for surgery.
```
Surgery:
ORIF
For displaced bimalleolar or trimalleolar fractures
Weber C fractures
Weber B fractures with talar shift
Open fractures
```
125
Features of achilles tendinitis
Gradual onset of posterior heel pain, worse following activity
Morning pain and stiffness
Calf muscle eccentric exercises
RF - quinolone use or hypercholesterolaemia.
126
Management of achilles tendonitis
Stop precipitating exercise, ice the area, NSAIDs
| Rehab and physio
127
Features of achilles tendon rupture
Audible pop in ankle.
Sudden onset significant pain in calf or ankle
Inability to walk or continue playing sport.
Loss of power of ankle plantarflexion.
128
What is simmonds test
Used to assess achilles tendon rupture
Squeeze affected calf, if achilles tendon in continuity, foot will plantar flex. If plantarflexion absent then tendon is ruptured.
129
Management of achilles tendon rupture
Analgesia and immobilisation. Ankle splinted in a plaster in full equinus if presented <2 weeks post rupture.
Position held for 2 weeks.
Then ankle brought to semi-equinus and held for further 4 weeks.
Then ankle brought into neutral position and held for another 4 weeks.
If >2 weeks since rupture:
Surgical fixation with end-to-end tendon repair.
130
Features of hallux valgus
Deformity of first MTPJ.
Medial deviation of 1st metatarsal and lateral deviation +/- rotation of hallux with associated joint subluxation.
RF - female, CT disorders, hypermobility syndromes
131
Management of hallux valgus
Analgesia
Adjust footwear
Physiotherapy
Surgery - if impact on quality of life
Chevron procedure - V shaped osteotomy of distal first metatarsal, allowing first metatarsal to be shifted laterally back into normal alignment. Fixed by pins and screws.
Scarf procedure - longitudinal osteotomy made within shaft of first metatarsal, for distal portion to be moved laterally and fixed with two screws.
Lapidus procedure - fusion of first metatarsal and medial cuneiform
Keller procedure - if have severe arthritis of first MTPJ
132
Investigations of hallux valgus
Angle between first metatarsal and first proximal phalanx - >15 degrees is diagnostic.
Mild - 15-20 degrees
Moderate - 21-39 degrees
Severe - >40 degrees
133
Features and management of plantar fasciitis
Heel pain in adults. Pain usually worse around medial calcaneal tuberosity.
Rest feet where possible
Wear shoes with good arch support and cushioned heels
Insoles and heel pads may be helpful.
134
Monteggia's fracture features
Dislocation of proximal radioulnar joint in association with ulna fracture
135
Galeazzi fracture features
Radial shaft fracture with associated dislocation of distal radioulnar joint.
136
Growth plate fracture classification
```
Salter-Harris system:
1 - fracture though physis only
2 - physis and metaphysis
3 - physis and epiphysis
4 - physis, metaphysis and epiphysis
5 - crush injury involving physis
```
137
Risk factors for poor fracture healing
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Older age
Co-morbidities
Recent trauma
Smoker
osteoporosis
Corticosteroids
NSAIDs
Local complications to fracture
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138
Complications of fractures
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Fat embolus
Neurovascular injury
Infection
Delayed union
Non-union
Malunion
Thromboembolic events
Compartment syndrome
Complex regional pain syndromes
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139
Patella dislocation
- cause
- presentation
- management
Caused by twisting the lower leg, combined with contraction of the quadriceps
Often presents as a flexed knee with a lateral dislocation of the patella
Mx: firm medial pressure whilst extending the leg, then a period of immobilisation in a cast or posterior splint/ brace
140
Ankle ligament strain
Usually due to an inversion injury which injures the anterior talofibular part of the lateral ligament
Signs: stiffness, tenderness over the lateral ligament, pain on inversion
Mx: analgesia, ice, compression, elevation, rest.
If simple strain, gently exercise ankle early on
If severe strain, do below knee immobilisation for 10 days
141
Causes of lower back pain?
Facet joint
Spinal stenosis
Ankylosing spondylitis
Peripheral artery disease
142
Features of spinal stenosis?
```
Gradual onset
Unilateral or bilateral leg pain
Numbness
Weakness worse on walking
Pain relieved by sitting down, leaning forwards and crouching down.
```
143
Red flags for lower back pain?
```
Age <20 or >50 years
History of previous malignancy
Night pain
History of trauma
Systemically unwell eg weight loss, fever
```
