Orthopaedics Flashcards
What are the 3 concepts of fracture management?
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
What are the main causative organisms of septic arthritis?
S aureus (adults)
Streptococcus spp
Gonorrhoea (sexual active patients)
Salmonella (especially in those with sickle cell)
How does septic arthritis present?
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
How would you investigate septic arthritis?
- 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
How would you manage septic arthritis?
-
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
A patient comes in with compartment syndrome. How does he present and what is in his history that makes you think this
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
Describe how compartment syndrome happens
- 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)
How would you diagnose compartment syndrome?
- clinical diagnosis!
- intra-compartmental pressure monitor
- Creatine kinase level is elevated
How would you manage compartment syndrome?
- 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
Describe a vague pathophysiology of OA
- 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
When would you suspect OA as opposed to another joint condition?
- 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
What are the XRay features of OA?
- Loss of joint space
- Osteophytes
- Subchondral cysts
- Subchondral Sclerosis
When woudl you suspect a meniscal tear? (Hx and presentation)
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
What’s your gold standard meniscal tear investigation?
MRI Scan
Xray to exclude a fracture
How would you manage a meniscal tear?
- 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
How would hallux valgus present?
- 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
How would you investigate and manage hallux valgus
- 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
How would a talar fracture present?
- 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
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How would you manage and investigate a suspected talar fracture?
- 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.
Describe the anatomy of the ankle
- 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
How are ankle fractures classified?
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)
How would you diagnose and manage an ankle fracture?
- 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
What’s the fracture most at risk of compartment syndrome?
Tibial shaft fracture
How would a tibial shaft fracture present?
- 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
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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
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
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
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.
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
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
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
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
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
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
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
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
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
Describe how a distal radius fracture occurs?
- a fracture through the distal metaphysis of the radius.
- Mechanism = FOOSH
- increased risk in osteoporosis (fragility fractures)
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
Describe the hand bones
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
Describe the anatomy of the carpal tunnel
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
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)
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
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
