Orthopaedics Flashcards
summarise the entire process of describing a fracture radiogarph
Describing a fracture: PAID • Radiographs must be orthogonal: request AP and lat. films. • Need images of joint above and joint below #. • Demographics § Pt. details § Date radiograph taken § Orientation and content of image • Pattern • Transverse • Oblique • Spiral • Multifragmentary • Crush • Greenstick • Avulsion • Anatomical Location • Intra- / extra-articular • Dislocation or subluxation • Deformity (distal relative to proximal) § Translation § Angulation or tilt § Rotation § Impaction (→shortening) • Soft Tissues § Open or closed § Neurovascular status § Compartment syndrome • ? Specific # classification/type § Salter-Harris § Garden § Colles’, Smith’s, Galeazzi, Monteggia
fracture healing process
Reactive Phase (injury – 48hrs) Reparative Phase (2 days – 2 wks) • Consolidation (endochondral ossification) of woven bone → lamellar bone Remodelling Phase (1wk – 7yrs) • Remodelling of lamellar bone to cope ¯c mechanical forces applied to it (Wolff’s Law: “form follows function”)
classifying cause of fracture
Classification • Traumatic # § Direct: e.g. assault ¯c metal bar § Indirect: e.g. FOOSH → clavicle # § Avulsion • Stress # § Bone fatigue due to repetitive strain § E.g. foot #s in marathon runners • Pathological # § Normal forces but diseased bone - Local: tumours - General: osteoporosis, Cushing’s, Paget’
open fracture managemetn
Open fractures require urgent attention: 6As
• Analgesia: M+M
• Assess: NV status, soft tissues, photograph
• Antisepsis: wound swab, copious irrigation, cover with
betadine-soaked dressing.
• Alignment: align # and splint
• Anti-tetanus: check status (booster lasts 10yrs)
• Abx
§ Fluclox 500mg IV/IM + benpen 600mg IV/IM
§ Or, augmentin 1.2g IV
Mx: debridement and fixation in theatre
open # classify and complications
Gustillo Classification of Open #s
• Wound <1cm in length
• Wound ≥1cm ¯c minimal soft tissue damage
• Extensive soft tissue damage
Clostridium perfringes • Most dangerous complication of open # • Wound infections and gas gangrene • ± shock and renal failure • Rx: debride, benpen + clindamycin
4 steps in fracture management
resus
reduce
restrict
rehab
open reduction and internal fixation indications
Open reduction (and internal fixation) § Accurate reduction vs. risks of surgery § Intra-articular #s § Open #s § 2 #s in 1 limb § Failed conservative Rx § Bilat identical #s
rehab after fracture key points
Principles
• Immobility → ↓ muscle and bone mass, joint stiffness
• Need to maximise mobility of uninjured limbs
• Quick return to function ↓s later morbidity
Methods
• Physiotherapy: exercises to improve mobility
• OT: splints, mobility aids, home modification
• Social services: meals on wheels, home help
general fracture compolications
General Complications Tissue Damage • Haemorrhage and shock • Infection • Muscle damage → rhabdomyolysis Anaesthesia • Anaphylaxis • Damage to teeth • Aspiration Prolonged Bed Rest • Chest infection, UTI • Pressure sores and muscle wasting • DVT, PE • ↓ BMD
specific fracture complications`
Immediate • Neurovascular damage • Visceral damage Early • Compartment syn. • Infection (worse if assoc. ¯c metalwork) • Fat embolism → ARDS Late • Problems ¯c union • AVN • Growth disturbance • Post-traumatic osteoarthritis • Complex regional pain syndromes
common nerve palsies assoc with #
rarely get nerve damage with # but if they do…
Ant. shoulder dislocation
Humeral surgical neck
Axillary N. Numb chevron
Weak abduction
humeral shaft Radial N. Waiter’s tip
Elbow dislocation Ulnar N. Claw hand#
Hip dislocation Sciatic N. Foot drop
neck of fibula /
Knee dislocation
Fibular N.
Foot drop
compartment syndrome presentation and mx
Pain > clinical findings • Pain on passive muscle stretching • Warm, erythematous, swollen limb • ↑ CRT and weak/absent peripheral pulses Rx • Elevate limb • Remove all bandages and split/remove cast • Fasciotomy
problems with bone union and reasons
Delayed Union: union takes longer than expected
Non-union: # fails to unite
Causative Factors: 5 Is
• Ischaemia: poor blood supply or AVN
• Infection
• ↑ interfragmentary strain
• Interposition of tissue between fragments
• Intercurrent disease: e.g. malignancy or malnutrition
non bone union classify
Non-union Classification • Hypertrophic § Bone end is rounded, dense and sclerotic • Atrophic § Bone looks osteopenic
management non union
Management
• Optimise biology: infection, blood supply, bone
graft, BMPs
• Optimise mechanics: ORIF
define malunion
Malunion: # healed in an imperfect position
• Poor appearance and/or function
avascular necrosis where etc
Death of bone due to deficient blood supply.
• Sites: femoral head, scaphoid, talus
• Consequence: bone becomes soft and deformed →
pain, stiffness and OA.
• X-ray: sclerosis and deformity
myositis ossificans just FYI
Myositis Ossificans • Heterotopic ossification of muscle @ sites of
haematoma formation
• → restricted, painful movement
• Commonly affects the elbow and quadriceps
• Can be excised surgically
complex regional pain syndrome
Definition
• Complex disorder of pain, sensory abnormalities,
abnormal blood flow, sweating and trophic changes in
superficial or deep tissues.
• No evidence of nerve injury.
Causes
• Injury: #s, carpal tunnel release, ops for Dupuytren’s
• Zoster, MI, Idiopathic
Presentation
• Wks – months after injury
• NOT traumatised area that is affected: affects a
NEIGHBOURING area.
• Lancing pain, hyperalgesia or allodynia
• Vasomotor: hot and sweaty or cold and cyanosed
• Skin: swollen or atrophic and shiny.
• NM: weakness, hyper-reflexia, dystonia, contractures
salter harris fractures
5 types Straight across • Above • Lower • Through • CRUSH
look up pics
risk of arrested growth increases with the numbers
risk factors for osteoporosis
Steroids • Hyper- para/thyroidism • Alcohol and Cigarettes • Thin (BMI<22) • Testosterone low • Early Menopause • Renal / liver failure • Erosive / inflame bone disease (e.g. RA, myeloma) • Dietary Ca low / malabsorption, DM
presentation of NOF and key Qs to ask
• O/E: shortened and externally rotated • Key Qs: § Mechanism § RFs for osteoporosis / pathological # § Premorbid mobility § Premorbid independence § Comorbidities § MMSE
initial management of NOF#
Resuscitate: dehydration, hypothermia • Analgesia: morphine, fascia iliaca block • Assess neurovascular status of limb • Imaging: AP and lateral films • Prep for theatre § Inform Anaesthetist and book theatre § Bloods: FBC, U+E, clotting, X-match (2u) § CXR § DVT prophylaxis: TEDS, LMWH § ECG § Films: orthogonal X-rays § Get consent
NOF# imaging
- Ask for AP and lateral film
- Look @ Shenton’s lines
- Intra- or extra-capsular?
- Displaced or non-displaced
- Osteopaenic?
avn of femoral head
If retinacular vessels damaged there is risk of
AVN of the femoral head → pain, stiffness and OA
classify NOF’
Intracapsular: subcapital, transcervical, basicervical
• Extracapsular: Intertrochanteric, subtrochanteric
classify intracapsular #
Garden Classification of Intracapsular Fractures • Incomplete #, undisplaced • Complete #, undisplaced • Complete #, partially displaced • Complete #, completely displaced
summarise surgical management of neck of femur facture
Intracapsular • 1,2: ORIF ¯c cancellous screws • 3,4: § <55: ORIF ¯c screws. - f/up in OPD and do arthroplasty if AVN develops (in 30%) § 55-75: total hip replacement § >75: hemiarthroplasty - Mobilises: cemented Thompson’s - Non-mobiliser: uncemented Austin Moore Extracapsular • ORIF ¯c DHS
complications and prognosis NOF#
Specific Complications
• AVN of fem head in displaced #s (30%)
• Non / mal-union (10-30%)
• Infection
• Osteoarthritis
Prognosis
• 30% mortality @ 1yr
• 50% never regain pre-morbid functioning
• >10% unable to return to premorbid residence
• Majority will have some residual pain or disability
Colle’s fracture
Clinical Features • Fall onto an outstretched hand • Most common in elderly females ¯c osteoporosis • Dinner fork deformity Radiographic Features • Extra-articular # of dist. radius (w/i 1.5” of joint) • Dorsal displacement of distal fragment • Dorsal angulation of distal fragment § Normally 11 degrees volar tilt • ↓ radial height (norm =11mm) • ↓ radial inclination (norm =22O) • ± avulsion of ulna styloid • ± impaction
managemnet Colle’s
Examine for neurovascular injuries as median nerve and radial artery lie close. • If much displacement → reduction § Under haematoma block, IV regional anaesthesia (Bier’s block) or GA. § Disimpact and correct angulation. § Position: ulnar deviation + some wrist flexion § Apply dorsal backslab: provide 3-point pressure • Re X-Ray – satisfactory position? § No: ortho review and consider MUA ± K wires § Yes: home ¯c # clinic f/up w/i 48hrs for completion of POP • 6 wks in POP + physio • If comminuted, intra-articular or re-displaces: § Surgical fixation
complication of Colle’s fractur
Median N. injury • Frozen shoulder / adhesive capsulitis • Tendon rupture: esp. EPL • Carpal tunnel syn. • Mal- /non-union • Sudek’s atrophy / CRPS
scaphoid #
Clinical Features
• FOOSH
• Pain in anatomical snuffbox
• Pain on telescoping the thumb
management scaphoid fracture
Request scaphoid x-ray view
• If clinical hx and exam suggest a scaphoid #, it should
initially be treated even if the x-ray is normal.
§ # may become apparent after 10 days due to
localised decalcification.
• Place wrist in scaphoid plaster (beer glass position)
• If initial x-ray is negative, pt. returns to # clinic after 10
days for re-xray.
§ # visible → plaster for 6 wks
§ No visible # but clinically tender → plaster for 2
wks
§ # not visible and not clinically tender → no plaster
Specific Complications
• Main risk is AVN of the scaphoid as blood supply runs
distal to proximal.
§ → stiffness and pain at the wrist
classify radial and ulnar #
Classification
• Monteggia
§ # of proximal 3rd of ulna shaft
§ Anterior dislocation of radial head at capitellum
§ May → palsy of deep branch of radial nerve →
weak finger extension but no sensory loss
• Galleazzi
§ # of radial shaft between mid and distal 3rds
§ Dislocation of distal radio-ulna joint
manage radial and ulnar #
• Unstable fractures § Adults: ORIF § Children: MUA + above elbow plaster • Fractures of forearm should be plastered in most stable position: § Proximal #: supination § Distal #: pronation § Mid-shaft #: neutral
classify shoulder disloc
Classification • Anterior § 95% of shoulder dislocations. § Direct trauma or falling on hand § Humeral head dislocates antero-inferiorly • Posterior § Caused by direct trauma or muscle contraction (seen in epileptics).
presntation shoulder disloc
Presentation • Shoulder contour lost: appears square • Bulge in infraclavicular fossa: humeral head • Arm supported in opposite hand • Severe pain
disloc shouldr manage
Specific Management
• Assess for neurovascular deficit: esp. axillary N.
§ Sensation over “chevron” area before and
after reduction.
§ Occurs in 5%
• X-ray: AP and transcapular view
• Reduction under sedation (e.g. propafol)
§ Hippocratic: Longitudinal traction ¯c arm in
30O abduction and counter traction @ the
axilla
§ Kocher’s: external rotation of adducted arm,
anterior movement, internal rotation
• Rest arm in a sling for 3-4wks
• Physio
complications shoulder disloc
Recurrent dislocation
§ 90% of pts. <20yrs with traumatic dislocation
• Axillary N. injury
impingement syndrome/painful arc
Pathology
• Entrapment of supraspinatus tendon and subacromial
bursa between acromion and grater tuberosity of
humerus.
• → subacromial bursitis and/or supraspinatous tendonitis
Presentation
• Painful arc: 60-120O
• Weakness and ↓ ROM
• +ve Hawkin’s test
inv management impngement syndromfe
Ix • Plain radiographs: may see bony spurs • US • MRI arthrogram Rx • Conservative § Rest § Physiotherapy • Medical § NSAIDs § Subacromial bursa steroid ± LA injection • Surgical § Arthroscopic acromioplasty
ddx painful shouldre arc
Impingement
• Supraspinatous tear or partial tear
• AC joint OA
frozen shoulder presentation
Frozen Shoulder: Adhesive Capsulitis Presentation • Progressive ↓ active and passive ROM § ↓ ext. rotation <30O § ↓ abduction <90O • Shoulder pain, esp. @ night (can’t lie on affected side) Cause • Unknown, may follow trauma in elderly • Commonly assoc. ¯c DM
frozen shoulder manage
Rx • Conservative: rest, physio • Medical § NSAIDs § Subacromial bursa steroid ± LA injection
