Orthopaedics Flashcards
1
Q
What are the 3 concepts of fracture management?
A
Reduce
- usually performed closed
- requires analgesia or a short period of conscious sedation
Hold = immobilise the fracture
- simple splints or plaster casts
- thromboprophylaxis if patient is non-weightbearing and immobilised
- adivse patients on the symptoms of compartment syndrome
Rehabilitate
- intensive period of physiotherapy following management
2
Q
What are the main causative organisms of septic arthritis?
A
S aureus (adults)
Streptococcus spp
Gonorrhoea (sexual active patients)
Salmonella (especially in those with sickle cell)
3
Q
How does septic arthritis present?
A
Hx = pre-exisiting joint disease, DM or immunosuppression, Chronic Renal Failure, hip or knee joint prosthesis, IVDU
- a single swollen joint causing SEVERE pain
- red, swollen, warm joint on examination
- Pain on passive and active movements. Sometimes the joint is so rigid it doesnt tolerate any passive movement at all
- Unable to weight bare
- Effusion sometimes
- pyrexia in 60% so don’t rule it out just becuase they dont have a fever!
- symptoms are more obvious in native joints, may be more subtle signs in prosthetic joint infections
4
Q
How would you investigate septic arthritis?
A
- FBC, CRP, ESR, Urate, blood cultures
-
Joint aspiration before antibiotics
- joint fluid analysis = Gram stain, leucocyte count, polarising microscopy, fluid culture
-
XRay of affected joint
- no signs early on.
- Later on may have soft tissue swelling, fat pad shift, joint space widening
- Ultrasound to guide joint aspiration and drainage
- Radionuclide scans useful for identifying septic arthritis in isolated joints eg. sacroiliac joint
5
Q
How would you manage septic arthritis?
A
-
empirical antibiotic treatment for 4-6 weeks (IV for first 2 weeks)
- Flucloxacillin
- MRSA = vancomycin
- Gonococcal = ceftriaxone
- Infected native joints require surgical irrigation and debridement in theatre
- In a prosthetic joint, washout is required but revision surgery is typically also needed
6
Q
A patient comes in with compartment syndrome. How does he present and what is in his history that makes you think this
A
Hx = high energy trauma, crush injury, tight casts or splints, DVT, post-reperfusion swelling, iatrogenic vascular injury, etc
- developed hours after insult
- severe pain disproportionate to injury
- Pain doesnt improve with analgesia, elevation to the level of the heart, or splitting the tight cast
- Pain is made worse by passively stretching the muscle bellies
- Paraesthesia distally
- Affected compartment feels tense compared to other side though may not be swollen
- If you leave it long enough, signs of acute arterial insufficiency will develop:
- 5Ps = palor, pain, perishingly cold, paralysis, pulselessness
7
Q
Describe how compartment syndrome happens
A
- fascial compartments can’t distend as they are closed. Therefore any fluid that is deposited in them causes an increase in intracompartmental pressure
- As pressure increases, veins are compressed.
- This increases venous hydrostatic pressure, causing fluid to move down its gradient out of veins into the compartment. This further increases the intracompartmental pressure.
- Then, traversing nerves are compressed causing sensory/motor deficit distally. (presents as distal paraesthesia)
- Finally, as intracompartmental pressure reaches diastolic blood pressure, arterial flow is compromised = ischaemia (pale, pulseless, paralysed distal limb)
8
Q
How would you diagnose compartment syndrome?
A
- clinical diagnosis!
- intra-compartmental pressure monitor
- Creatine kinase level is elevated
9
Q
How would you manage compartment syndrome?
A
- keep the limb at a neutral level
- Give High flow oxygen
- give bolus of IV crystalloid fluids (improves perfusion of affected limb)
- remove all dressings, splints, casts down to the skin
- IV opioid analgesia
-
fasciotomies
- leave skin incisions open and re-look in 24-48 hours for any dead tissue to debride.
- Monitor renal function due to rhabdomyolysis or reperfusion injury
10
Q
Describe a vague pathophysiology of OA
A
- The balance between damage and repairing bone is lost!!!!
- Chondrocytes proliferate in the articular cartialge and become overactive
- Cartilage is degraded and bone is remodelled at a high rate however this cartilage is oedematous
- Inflammatory cells in surrounding tissues release enzymes which break down collagen and proteoglycans, destroying the articular cartilage
- This exposes underlyling subchondral bone which leads to sclerosis
- Reactive remodelling changes result in osteophyte and subchondral bone cysts formation
- Joint space is progressively lost
11
Q
When would you suspect OA as opposed to another joint condition?
A
- Most commonly affected are the small joints of hands and feet, hip, knee
- Pain and stiffness worsened with activity, relieved by rest
- Pain worsens throughout the day, stiffness improves
- Deformity such as Bouchard nodes (PIPJs), Herberden nodes (DIPJs), flexion or varus malignment in the knees
- Reduced range of movement
12
Q
What are the XRay features of OA?
A
- Loss of joint space
- Osteophytes
- Subchondral cysts
- Subchondral Sclerosis
13
Q
When woudl you suspect a meniscal tear? (Hx and presentation)
A
Hx = traumatic twisting of knee whilst flexed and weight bearing, results in a “tearing” sensation and intense sudden onset pain
- knee swells slowly over 6-12 hours
- In longitudinal “bucket handle” tears where the tear can result in a free body within the knee, knee can be locked in flexion
- Joint line tenderness on exam
- significant joint effusion
- limited knee flexion
- McMurrays test and Apley’s Grind test
14
Q
What’s your gold standard meniscal tear investigation?
A
MRI Scan
Xray to exclude a fracture
15
Q
How would you manage a meniscal tear?
A
- rest and elvation with compression and ice
- <1cm meniscal tears can initially swell but pain will subside and heal
- For larger/symptomatic tears = arthroscopic surgery
- Risk of DVT or damage to saphenous vein/nerve, peroneal nerve, popliteal vessels
16
Q
How would hallux valgus present?
A
- a bunion!
- deformity of the first Metatarsophalangeal joint (medial deviation of 1st metatarsal and lateral deviation of hallux. associated joint subluxation)
- presents as a painful medial prominence that hurts on walking, weight bearing, narrow toed shoes
- May be able to see contracture of extensor hallucis longus tendon in longstanding joing subluxation or excessive keratosis on foot
17
Q
How would you investigate and manage hallux valgus
A
- Xray to assess degree of severity
- Measure angle between 1st metatarsal and 1st proximal phalanx. Angle >15 degrees is positive
- Give analgesia, advise them to adjust their footwear, and suggest physiotherapy such as stretching exercises and gait re-education
- Surgery = Chevron procedure, scarf procedure, lapidus procedure, keller procedure
18
Q
How would a talar fracture present?
A
- Hx = high impact trauma where ankle is forced into dorsiflexion. immediate pain and swelling around the ankle
- in dislocation = clear deformity
- Unable to dorsiflex or plantarflex ankle
- Check of overlying skin is white/non-blanching/tethered as it could be “threatened” and about to become an open injury
*
19
Q
How would you manage and investigate a suspected talar fracture?
A
- Antero-posterior and lateral Xray.
- Lateral should be taken in dorsiflexion and plantarflexion to differentiate between type 1 and 2 (plantarflexion reduces any subluxation present)
Management:
-
Hawkins classification to determine risk of avascular necrosis due to predominantly extraosseus arterial supply
- 1 = conservatively in a plaster + non-weightbearing crutches for 3 months. Then assess union and AVN in fracture clinic.
- 2-4 = closed reduction in ED. Cast placed then repeat XRays to ensure correct position. Definitive surgical fixation required then an extended period of non-weight bearing post-op.
20
Q
Describe the anatomy of the ankle
A
- talus bone articulates with mortise
- Mortise = tibial plafond and medial malleolus (distal tibia) and lateral malleolus (distal fibula)
- Tibia and fibula join at syndesmosis:
- consists of Anterior Inferior Tibiofibular Ligament, Posterior Inferior Tibiofibular Ligament, Intraosseous Membrane
21
Q
How are ankle fractures classified?
A
A fracture of any malleolus (latera, medial, or posterior) with or without disruption to the syndesmosis.
They can be isiolated lateral malleolar fractures, isolated medial malleolar fractures, bimalleolar fractures (medial + lateral), or trimalleolar fractures.
Weber classification for lateral malleolus fractures!!!
- A = below syndesmosis
- B = at level of syndesmosis
- C = above syndesmosis (the more proximal, the more unstable the ankle is so C always needs surgical fixation)
22
Q
How would you diagnose and manage an ankle fracture?
A
- Xray AP/Lateral
- Ensure ankle is in full dorsiflexion as the talus can appear translated within the mortise when the ankle is plantarflexed
- check joint space for uniformity, ensuring no evidence of talar shift
- Can use CT for surgical planning in more severe disease
Manage:
- Immediate fracture reduction under sedation to realign fracture to anatomical allignment
- Place in below knee back slab and then repeat xray and neurovascular exam
- Conservative = non-displaced medial malleolar, Weber A, Weber B without talar shift, those unfit for surgery
- Surgery (ORIF eg. using plates and screws) = Displaced bimalleolar and trimalleolar, Weber C, Weber B with talar shift, Open fractures
- SE of orif = surgical site infection, DVT, PE, neurovascular injury, non-union, metalwork prominence
23
Q
What’s the fracture most at risk of compartment syndrome?
A
Tibial shaft fracture
24
Q
How would a tibial shaft fracture present?
A
- Hx of trauma
- inability to weight bear
- severe pain in lower leg (assess for out of proportion pain for compartment syndrome!!!)
- Significant swelling and bruising
- sometimes a deformity like angulation or malrotation
*
25
How woudl you investigate a tibial shaft fracture?
* ATLS protocol for major trauma!
* Urgent bloods, group and save
* Full length antero-posterior and lateral Xray of tiba and fibula which should include knee and ankle
* typically can present with an _associated fibula fracture_ (In high energy mechanisms, typically at same level as tibia. Low energy fractures can present with one at a different level)
* CT imaging in...
* potential intra-articular extension
* if a spiral fracture of distal tibia is suspected
* to assess fracture of posterior malleolus
26
How do you manage a tibial fracture?
* realign it under analgesia or conscious sedation! (try and bring to approx length and rotation)
* After reduction, put in **above knee backslab**
* put it in **slight flexion at the knee and neutral dorsiflexion at the ankle** to control rotation
* Limb must be **elevated and monitored for compartment syndrome**
* Neurovascular exam and Xray after manipulation
Conservative = **Sarmiento cast** in closed stable tibial fractures
Surgery =
* **Intramedullary nailing** (minimally invasive, high success, patients can fully weight bear immediately after)
* In really proximal or distal fractures (especially those that extend into joint) = **ORIF with locking plates**
* In those with multiple injuries = **temporary external fixation** if they are unstable
* In associated fibular fractures, leave them be as they heal well after the tibial fracture has been stabilised
27
What 4 things tend to result in a femoral shaft fracture? (remembers its a massive bone)
* high energy trauma
* fragility fractures in elderly (low traum)
* pathological fractures eg. metastatic deposits, osteomalacia
* Bisphosphonate-related fractures
28
How would a femoral shaft fracture present?
* pain in the thigh
* Sometimes hip/knee pain
* Unable to weight bear
* In severe cases you'll see a deformity
* Assess the skin as the proximal fragment is pulled into flexion/external rotation by iliopsoas and Glut Med/Min, so tent the skin
* Can be loads of bleeding as the femur is highly vascularised due to its role in haematopoesis and the fact its supplied by the profunda femoris artery.
29
How would you classify femoral fractures?
**Winquist and Hansen Classification**
0 = no comminution
1 = insignificant amount of comminution
2 = greater than 50% cortical contact
3 = less than 50% cortical contact
4 = segmental fracture with no contact between proximal and distal fragment
30
How would you investigate a femoral fracture?
* major traumas should always be investigated using ATLS protocol
* Bloods, coag, group and save, serum calcium, etc
* Xray (AP and lateral of entire femur including hip and knee)
* CT if polytrauma, femoral neck or intra-articular damage is suspected
31
How would you manage a femoral shaft fracture?
* ATLS guidelines to stabilise patient
* pain relief = opioids and regional blockade (**fascia iliaca block**)
* Open fractures:
* *tetanus vaccine, photograph and remove gross debris, dress in saline soaked gauze, then surgical debridement, wash out in theatre with saline, ensure skeletal stabilisation*
* Otherwise, **immediate reduction using in-line traction** to ensure appropriate haematoma formation and reduces pain
* **Traction splinting (a Kendrick traction splint)** is used in mid-shaft femur fractures
* contraindicated in hip/pelvic fractures, supracondylar fractures, ankle/foot fractures
Conservative = **long-leg casts** in undisplaced or those not suitable for surgery
Surgery =
* fixed within 24-48 hours, sooner if open.
* **Antegrade intramedullary nail.** (retrograde intramedullary nail if concurrent lower limbs fractured or if patient has hip replacement in situ)
* External fixation used in unstable polytrauma or open fractures just to ensure the patient is stable before definitive fixation
32
What is the most common mechanism of a supracondylar (distal) humeral fracture?
Falling on an outstretched hand with the elbow in extension
Most common in kids 5-7 years old
33
How would a supracondylar fracture present? (including what nerves might be affected)
* Hx of a fall or trauma followed by sudden onset severe pain and a reluctance to move that arm
* **Ecchymosis of the anterior cubital fossa** on examination
* gross deformity, swelling, limited range of elbow movement
* Potentially damage to **median nerve, anterior interosseus nerve, radial nerve, ulnar nerve**
34
How woudl you investigate a supracondylar fracture?
* AP and lateral xray of elbow
* **posterior fat pad sign**
* **displacement of the anterior humeral line**
* CT for comminuted fractures or where you suspect intraarticular damage
35
How would you classify and manage a supracondylar humeral fracture?
**Gartland Classification** to aid management!
1 = undisplaced
2 = displaced with an intact posterior cortex
3 = displaced in 2 or 3 planes
4 = displaced with complete periosteal disruption
Management:
* immediate closed reduction with K-wire fixation
* Conservative = Type 1, minimally displaced Type 2
* **above elbow cast in 90 degrees flexion**
* Surgery = Type 2,3,4
* **closed reduction and percutaneous K wire fixation**
* Open fractures need **open reduction with percutaneous pinning**
36
What are some complications for supracondylar fractures?
* Nerve palsys
* most commonly the **anterior interosseous nerve during injury**
* **ulnar nerve palsy is common post-op** due to insertion of the _medial k-wire_
* _Malunion_ resulting in a **cubtius varus deformity** (gunstock deformity)
* **Volkmann's contracture** following vascular compromise (ischaemia and necrosis of flexor muscles of the forearm causes them to fibrose and contract)
37
How would a humeral shaft fracture present?
* Hx of falling onto the outstretched limb or laterally onto the adducted limb
* pain and deformity!
* **Reduced sensation over 1st dorsal webspace** and **weakness on wrist extension** = _radial nerve involvement_
* radial nerve runs _within the spiral groove_ so is a high risk of involvement
* **Holstein-Lewis fractures** present with **loss of sensation in radial nerve distrubtion** and **wrist drop deformity**
* This is due to a fracture in the _distal third of the humerus_ resulting in _entrapment of the radial nerve_
38
How would you investigate and manage a humeral fracture?
* Xray ap and lateral of the humerus (including elbow and shoulder)
* CT for pre-op planning in severely comminuted cases
Conservative Management:
* **functional humeral brace** to realign the limb (or U-slab if not available)
* Fractures that are \<20 degrees anterior angulation, \<30 degrees varus or valgus angulation and \<3cm shortening are suitable for conservative
* follow up with repeated xray imaging
Surgical management:
* **ORIF with a plate**
* **Intramedullary nailing** for pathological fractures, polytrauma or severely osteoporotic bones
39
When woudl you suspect a radial head fracture?
* Hx of FOOSH followed by elbow pain, swelling and bruising at the elbow
* On examination there is tenderness on palpation over **lateral aspect of the elbow and radial head**
* **Pain and crepitation** on supination and pronation
* Elbow **effusion**
* Limited supination and pronation
* Potential shoulder and wrist injuries too
*
40
How would you investigate a radial head fracture?
* routine bloods, clotting, group and save
* AP and lateral Xray of elbow (+ joints above and below)
* **elbow effusion seen on lateral** = **"Sail sign"** = **elevation of anterior fat pad**
* MRI for suspected ligament injuries
* CT for complciations
41
How would you manage a radial head fracture?
* analgesia
* check for neurovascular compromise and any mechanical block of elbow motion (can flex, extend, supinate, pronate)
**Mason classification** = Degree of displacement and intraarticular movement
* Mason Type 1 = non displaced or minimally displaced fractuer (\<2mm)
* Conservative treatment = **\<1 week immobilisation with a sling** followed by **early mobilisation**
* Mason Type 2 = partial articular fracture with displacement \>2mm or angulation
* If no mechanical block, then treat as Type 1
* If mechanical block then treat with ORIF
* Mason Type 3 = Comminuted fracture and displacement (complete articular fracture)
* **ORIF or radial head excision/replacement**
42
Describe how the elbow is stabilised?
Static + Dynamic stabilisers
Primary Static = humeroulnar joint, medial and lateral collatearl ligaments
Secondary static = radiocapetellar joint, joint capsule, common flexor and extensor origin tendons
Dynamic = anconeus, brachialis, triceps brachii
43
How would an elbow dislocation present?
* Hx of a high energy fall
* painful and deformed, swelled joint with decreased function
* Neuropraxia of **ulnar nerve** is common = deficit in this territory
44
How would you investigate a suspected elbow dislocation?
* Assess neurovascular status and do ATLS
* Any _concern over the pulse_ should warrent **Doppler ultra sound**, as even in arterial injury there tends to remain a good cap refill time (elbow has a rich collateral circulation)
* **Ulnar nerve** affected
* Xray of elbow Ap and lateral
* you will see a **loss of radiocapitellar and ulnotrochlea congruence**
45
How would you manage an elbow dislocation?
* **Closed reduction under analgesia** then Xray and re-assess neurovascular status
* Apply an **above elbow backslab** once reduced to **keep elbow at 90 degrees**
* Post-reduction, soft tissue damage will dictate the stable position
* if _lateral collateral ligament_ is damaged, elbow will be more stable in _pronation_
* if _medial collatearl ligament_ is disrupted, elbow will be more stable in _supination_
* If no fracture, **immobilise for 5-13 days** then early rehab with **supervised range of motion exercises in the stable arc**
* If fracture or open = ORIF and soft tissue repair
46
What is the terrible triad?
Elbow dislocation with **Lateral collateral ligament** injury, **radial head fracture** and **coronoid fracture** = Very unstable elbow!!!
This is usually a **posterolateral dislocation.**
Complications = recurrent problems with instability, stiffness, arthrosis
Management = ORIF of radial head or arthroplasty with LCL reconstruction and coronoid ORIF
47
Describe how a distal radius fracture occurs?
* a fracture through the distal metaphysis of the radius.
* Mechanism = FOOSH
* increased risk in osteoporosis (fragility fractures)
48
When would you suspect a Colle's fracture?
* Extra-articular fracture of the distal radius with **dorsal angulation and dorsal displacement**
* Usually is a _fragility fracture_
* Mechanism = person falls forward and plants outstratched hand infront of them. **Wrist is forced into supination**
49
What is a Smith's fracture?
* volar angulation of the distal fragment of an extra-articular fracture of the distal radius
* Mechanism = falling backwards and planting outstretched hand behind the body, causing **forced pronation**
* less common than colles
50
What is Barton's fracture?
* **intraarticular fracture of the distal radius** with associated **dislocation of the radio-carpal joint**
* It can be volar (more common) or dorsal (less common)
51
What are the clinical features of a distal radius fracture?
* trauma and then **immediate pain and deformity and swelling**
* Neurological damage:
* **Median**
* motor = abd thumb
* sensory = radial surface of distal 2nd digit
* **Anterior interosseus nerve**
* motor = opposition fo thumb and index finger (OK sign)
* **Ulnar**
* Motor = add thumb
* sensory = ulnar surface of distal 5th digit
* **Radial**
* motor = extension of IPJ of thumb
* sensory = dorsal surface of 1st webspace
52
How would you investigate a distal radial fracture?
* On an Xray look at...
* radial height (\<11mm)
* radial inclination (\<22 degrees)
* radial/volar tilt (\>11 degrees)
53
How would you manage a distal radial fracture?
* closed reduction
* ensure sufficient traction and manipulation under anaesthetic
* conscious sedation with a **haematoma block or biers block**
* Place in a **below-elbow backslab cast** then repeat xray after a week to check for displacement
* **Physiotherapy** once sufficient bone healing
Surgery:
* significantly displaced or unstable fractures
* **ORIF with plating**, or **K-wire fixation**
54
Describe the hand bones
55
Why is the scaphoid so prone to AVN?
* it is divided into proximal, waist and distal pole
* The blood supply is from **branches of the radial artery**
* The **dorsal branch** of the radial artery **enters in the distal pole** and travels in a **retrograde fashion** to the proximal pole
* Therefore _the more proximal the scaphoid fracture, the higher risk of AVN_
56
What are the clincial features of a scaphoid fracture?
* high energy trauma then **sudden onset wrist pain** or bruising
* **tenderness in the floor of the anatomical snuffbox**
* anatomical snuffbox = _abd poll longus, ext poll brev, ext poll long tendon_
* it contains the _radial artery, radial nerve, cephalic vein_
* **pain on palpating scaphoid tubercle**
* **pain on telescoping the thumb**
57
How would you investigate a suspected scaphoid fracture?
* A **scaphoid series** on xray (anteriorposterior, latera, oblique views)
* Not always detected on initial xrays though!!!
* if there is enough clinical suspicion, still **imobilise the wrist in a thumb splint and repeat xray in 10-14 days**
* If repeated xray is still negative, do an **MRI** scan of the wrist
58
How would you manage a scaphoid fracture?
* undisplaced = strict **immobilisation** in a **plaster with a thumb spica splint**
* Undisplaced of the proximal pole have a high risk fo AVN so suggest surgical
* Displaced = **percutaneous variable-pitched screw** to compress the fracture site
59
How does carpal tunnel syndrome happen and present?
Due to **compression of medial nerve** within the carpal tunnel of the wrist due to a raised pressure in this compartment.
Median nerve compression = pain, numbness, paraesthesia in lateral 3.5 digits
* palm usually spared as the palmar cutaneous branch of the median nerve branches proximal to the flexor retinaculum and passes over the carpal tunnel
* Symptoms generally **worse at night** and **relieved by hanging arm over side of the bed** or shaking it
* In later stages = **weakness of thumb abd** + **wasting of thenar eminence** due to denervation atrophy of thenar muscles
60
Describe the anatomy of the carpal tunnel
61
What are some risk factors of getting carpal tunnel?
* female
* old age
* pregnancy
* obesity
* DM, RA, hypothyroidism
* repetitive hand or wrist movements
62
How would you investigate carpal tunnel?
* **Tinels test** = percuss over the median nerve to produce sensory symptoms
* **Phalens test** = hold the wrist in full flexion for a minute to produce sensory symptoms
63
How would you manage carpal tunnel?
Conservative
* **wrist splint commonly worn at night** (prevents flexion so as to not exacerbate the tingling/pain)
* **physiotherapy** and training exercises
* **corticosteroid injections** can be administered directly into carpal tunnel to _reduce swelling and thus also symptoms_
Surgical
* **carpal tunnel release surgery** to decompress carpal tunnel
* Complications = persistent CTS symptoms, infection, scar formation, nerve damage, trigger thumb
64
What are dupuytrens contractures and how do they progress?
* fibroplastic hyperplasia and altered collagen matrix of the palmar fascia which results in thickening and contraction of the palmar fascia
* starts as initial pitting and thickening of the palmar skin and underlying subcutaneous tissue, with loss of mobility of overlying skin
* firm painless nodule begins to form and become fixed to skin and deeper fascia
* a cord develops, resembling a tendon, which begins to contract
* contaction of the cord pulls on MCP and PIP joints, leading to progressive flexion deformity in fingers
65
What are some risk factors for dupuytrens?
* smoking
* alcoholic liver cirrhosis
* DM
* occupational exposures eg. vibration tools or heavy manual work
66
How does dupuytrens present clincially?
* reduced range of movement and nodular deformity through to complete loss of movement
* ring and little finger most comonly involved
* bilateral in 45%
* on examination = A thickened band or firm nodule adherent to skin
* skin blanching can occur on active extension of digits
* In later disease, MCP or PIP joints of the affected digit can be in a contracture
* Do **heuston's test** = lay their palm flat on the tabletop. if they can't, this is a positive test
67
How would you manage dupuytrens?
Conservative
* hand therapy and **stretching** exercises
* **injectable collagenase clostridium histolyticum** in early disease
Surgical
* excision of diseased fascia
* **Fasciectomy** under local/general anaesthetic (regional, segmental, dermofasciectomy) OR
* **closed fasciotomy** (good for people unsuitable for major surgery) OR
* finger amputation for severe cases
* usually in those with huge functional impairment, MCP joint contracture \>30 degrees, `PIP contracture, rapidly progressive disease
68
What are the different kinds of shoulder dislocation?
* most common is **anteroinferior (anterior)**
* usually trauma applied to an ext, abd, ext rotated humerus
* **Posterior**
* usually due to seizures, electorcution, or trauma
69
What are the clinical features of a shoulder dislocation?
* painful shoulder with reduced mobility and a feeling of instability
* Examination = **Asymmetry** with the contralateral side, loss of shoulder contours (**flattened deltoid**), **anterior bulge** from the head of the humerus
70
What are some associated injuries of shoulder dislocations?
Bony
* **Bony Bankart lesions** = fractures of the anterior inferior glenoid bone
* **Hill-Sachs defects** = impaction injuries to chondral surface of the posterior/superior portions of the humeral head (80% traumatic dislocations)
* Fractures of greater tuberosity and surgical neck of humerus can also occur
Labral, ligamentous, rotator cuff
* Soft bankart lesions = avulsions of the anterior labrum and inferior glenohumeral ligament
* Glenohumeral ligament avulsion
* Rotator cuff injuries occur frequently in anterior dislocations (in younger patients, around a third have at least one tear)
71
How would you investigate a shoulder dislocation?
* Trauma shoulder series on Xray = anterior-posterior, Y-scapular, axial views
* anterior dislocations = humeral head is visibly out of glenoid fossa on AP view, Y scapular view can confirm.
* Posterior dislocation = **"light bulb sign"** shows the humerus fixed in internal rotation.
* MRI if labral or rotator cuff injuries suspected
72
Management of a shoulder dislocation?
* A-E trauma assessment
* Reduction, immobilisation, rehabilitation
* Closed reduction
* assess the neurovascular status pre/post reduction
* Place arm in a **broad-arm sling** after reduction
* Physiotherapy to restore range of movement
*
73
How does degenerative disc disease occur?
Dysfunction
* Due to:
* progressive **dehydration of the nucleus pulposus**
* daily activities causing **tears in the annulus fibrosis**
* results in outer annular tears and separation of the endplate, cartilage destruction, facet synovial reaction
Instability
* disc resorption, loss of disc space height along with facet capsular laxity.
* leads to subluxation and spondylolisthesis
Restabilitation
* degenerative changes lead to osteophyte formation and canal stenosis
74
How would degenerative disc disease present?
* Early on = local spinal tenderness, contracted paraspinal muscles, hypomobility, painful extension of the back or neck
* When the disc degeneration causes instability, pain can become more severe and include radicular leg pain or paraesthesia
* **Lasegue sign** = positive sign of disc herniation is being able to _reproduce the pain by passively raising the extended leg_
75
What are some red flags of back pain??
* new onset **faecal incontinence or urinary**
* **saddle anaesthesia**
* immunosuppression
* chronic steroid use
* IV drug abuse
* unexplained fever
* significant trauma
* osteoporosis
* metabolic bone disease
* new onset after 50 years old
* history of malignancy
76
When is imaging warranted in suspected degenerative disc disease? What is the gold standard?
**MRI** is gold standard
Warranted if:
* red flags
* radiculopahty with pain for over 6 weeks
* evidence of spinal cord compression
* imaging would significantly alter management
77
How would you manage degenerative disc disease?
* pain relief
* encourage mobility and physiotherapy
* refer to pain clinic
* sometimes spinal fusion is suggested for chronic low back pain but no evidence
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What are some main symptoms diagnostic for Cauda equina
* back pain
* **bilateral** leg pain
* **saddle anaesthesia**
* impotence
* sensorimotor loss in lower extremity
* **neurogenic bladder dysfunction** (dysruption of bladder contraction and sensation = urinary retention then overflow incontinence)
* bowel dysfunction is rare
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How would you investigate and manage a cauda equina?
* **MRI** or CT myelography if MRI not available
Treatment
* urgent **surgical decompression** within 48 hours
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What are some causes of cauda equina?
space occcupying lesion in the lumbosacral canal eg.
* disc herniation (most common)
* spinal stenosis
* tumours
* trauma eg. retropulsion of fracture fragment
* spinal epidural haematoma
* epidural abscess
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Describe the anatomy of the neck of femur.
Ie. intracapsular, Extracapsular, Intertrochanteric, Subtrochanteric
* Intracapsular = from subcapital region of femoral head to basocervical region of femoral neck, immediately proximal to trochanters
* Intracapsular fractures = fractures of femoral head and neck
* Extracapsular = outside capsule
* Inter-trochanteric = between greater and lesser trochanter
* Subtrochanteric = from lesser trochanter to 5cm distal to here
* Extra capsular fractures = intertrochanteric fractures, subtrochanteric fractures, greater/lesser trochanteric fractures
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Describe the blood supply of the neck of femur
* It is **retrograde** (distal to prosimal from femoral neck to head)
* Via **medial circumflex femoral artery** which lies directly on the intracapsular femoral neck
* therefore displaced intra-capsular fractures disrupt blood supply to femoral head and it will undergo AVN
* \*\*\* in early life, there is blood supply from the **ligamentum arteriosum** too but this reduces later
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How are intracapsular fractures classified?
**Garden Classification**
* 1 = nondisplaced, incomplete fracture
* 2 = nondisplaced, complete fracture
* 3 = partially displaced, complete fracture
* 4 = fully displaced, complete fracture
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How would a neck of femur fracture present?
* following a low energy trauma
* pain felt in **groin, thigh, or referred to knee** in elderly
* **inability to weight bear**
* Examination = leg is **shortened and externally rotated**
* pain on pin-rolling the leg and axial loading
85
How would you investigate a neck of femur fracture?
* Xray AP and lateral of hip
* Xray AP pelvis (folow _Shentens line_)
* Xray full length femoral
* Routine bloods, FBC, U&Es, coag, group ad save, CK
* CXR, Urine dip, ECG to assess cause for fall in elderly
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How would you manage a neck of femur fracture?
* A-E
* opioid analgesia/ regional analgesia eg. **fascia-iliaca block**
Surgical
* \*\*\*displaced subcapital = **hip arthroplasty**
* \*\*\*intertrochanteric = **dynamic hip screw**
* non-displaced intracapsular = **cannulated hip screws**
* sub-trochanteric = **intramedullary femoral nail**
\*\*\* For the displaced _intracapsular fractures_ in a really _active well patient_, do a **Total Hip Replacement**
Medical
* DVT prophylaxis eg. enoxaparin, fondaparinux, heparin
* Mechanical DVT prophylaxis in nonaffected limb
* Analgesia
* Prophylactic antibiotics before surgery and 24 hours after surgical repair
Then early rehabilitation initiated on first post-op day, physiotherapists, occupational therapists
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