Orthopaedics and Trauma Flashcards
What is the special test used in ankle pain to test achilles rupture?
Simmons test
What classification is used in ankle fractures that indicates it’s site?
Weber’s Classification:
Type A- Below the tibiotalar joint height
Type B- At height of tibiotalar joint
Type C- Above line
Signs of osteoarthritis (LOSS)
Loss of joint space
Osteophytes
Subchondral cysts
Subarticular sclerosis
Intra-articular pathology of the hip will present with pain where?
In the anterior leg
Patient feels like they have a ‘pebble in their toe’ and a lump on their foot above their third metatarsal, with change in sensation (numbness/burning), what might it be? Investigation to confirm diagnosis?
Morton’s neuroma
Benign
IHx: USS
What is Charcot’s joint?
Degeneration of joint due to neuropathic loss of sensation meaning the patient doesn’t realise when they are damaging joint- seen in diabetics
Painkiller given for acute gout + side effect?
Colchicine (type of NSAID)
Diarrhoea
Garden’s Classification of hip fractures?
Grade 1: partial fracture of the bone, no displacement
Grade 2: complete transverse fracture of bone, no displacement
Grade 3: complete fracture, partially displaced (one side)
Grade 4: complete fracture, completely displaced
(1,2 screw, 3,4 Austin Moore aka hemiathroplasty etc)
Obese teenage with hip pain, coming on without trauma?
What systemic condition is it associated with?
Slipped upper epiphysis
Hypothyroidism
How are intracapsular and extracapsular hip fractures managed?
Intracapsular-
Grade 1+2 Garden’s- screw
Grade 3+4 Garden’s- hemiarthroplasty, total hip replacement
Extracapsular- screw
What’s the difference between mallet toe, hammer toe, claw toe?
Mallet toe is like swan-necking
Hammer toe is like Boutonierres (first interphalangeal joint is bent, next phalanx is extended)
Claw toe is where all the joints are bent
In the elbow joint of paediatric patients what order do things ossify?
CRITOE 2 years Capitulum 4 years Radial 6 years Internal Condyle 8 years Trochlear 10 years Olecranon 12 years External Condyle
If a part is not visible (looks like its fused, but shouldn’t have yet then there may be a fracture)
Kienbock’s Disease is avascular necrosis of what bone?
Lunate
(Closest to elbow from thumb to little finger:
So long to pinkie (scaphoid, lunate, triquetrum, piseform)
From little finger to thumb, closer to finger
Here comes the thumb (hamate, capitate, trapezoid, trapezium)
Carpal bones of hand
Closest to elbow from thumb to little finger:
So long to pinkie (scaphoid, lunate, triquetrum, piseform)
From little finger to thumb, closer to finger
Here comes the thumb (hamate, capitate, trapezoid, trapezium)
Difference between Monteggia and Galeazzi fractures of forearm?
Monteggia is ulnar shaft fracture, with proximal radial dislocation
Galeazzi is radial shaft fracture and ulnar dislocation
Colles fracture is:
Transverse fracture of radius, with dorsal displacement of distal fragment
Winging scapula is due to nerve damage of which nerve?
Long thoracic nerve to serratus anterior (C5,6,7) to point to heaven
External (lateral) rotation of the shoulder joint is mediated by which two muscles?
Tear open the present and see what’s inside- teres minor + infraspinatus
(Two muscles that originate from the posterior back of the scapula)
What is the ‘lightbulb bulb’ sign on shoulder xrays?
Rather than a nobbly head of humerus interacting with the glenoid part of the scapula, a more symmetrical rounded ‘lightbulb’ looking humerus head is apparent (reflecting that it has rotated from the dislocation)
When do posterior dislocations typically occur?
Following an epileptic fit, ECT or electrocution
Name 5 shoulder exam special tests and what they test for:
Neer’s test- passive flexion with supination of hand (impingement)
Speed’s test- flex arm with extended elbow + supinated, flex against resistance (biceps tendonitis)
Jobe test- empty can, abduct + flex 30 degrees forward, thumb point down, and abduct against resistance (supraspinatus)
Drop arm test- lower arm from abduction, sudden drop (rotator cuff tear)
Apprehension test- Elbow flexed 90, abduct 90, try to push the hand back (external rotation) anterior joint instability
Which special test on shoulder would you do if suspecting biceps tendonitis?
Speed’s test- supinate forearm, extend elbow, flex arm against resistance = pain
Which special test on shoulder would you do to check for impingement?
Neer’s test- passive flexion of the arm whilst arm is pronated and scapula stabilised
Painful arc between 60-120 degrees
What special test on the shoulder can you do to check for supraspinatus tear or weakness?
Empty can (Jobe test): Abduct to 90, forward flex to 30, pronated with thumb pointing down, abduct against resistance
What special test can you do to look for rotator cuff tear?
Drop arm test- abduct arm to 160, get patient to lower slower, sudden drop + patient can’t control = positive
What special test can be performed to look for anterior joint instability?
Apprehension test (look for risk of anterior dislocation) Abduct to 90, flex elbow to 90, whilst keeping elbow still push the hand backwards- look for facial apprehension
How does a partial and complete rotator cuff tear present differently?
Supraspinatus controls first 15 degrees of abduction
Partial- painful arc
Complete- supraspinatus does 15 degrees, deltoid does next degrees but can only abduct to 45-60 degrees as scapular does not rotate to allow any further movement.
If passively abducted to 90 the deltoid kicks in and can continue abduction.
Imaging used if rotator cuff muscle tear is suspected?
USS
MRI if labrum involvement (the ligament running around the glenoid aspect of the scapula, making up the joint)
How would partial and complete rotator cuff tears be managed differently?
Complete- open or arthroscopic surgery
Partial- close watchful waiting
Name 3 causes of painful arc/impingement?
Impingement (rotator cuff tendons getting pinched under the acromion) causes painful arc (pain 60-120 degrees of abduction) so things that narrow the space of the tendon in this passage.
- Suprinaspinatus tenditinitis/rupture
- Calcifying tendon (acute inflammation with resorption of calcium)
- Acromioclavicular joint arthritis
Treatment of supraspinatus tendinopathy (tendinitis, degeneration or partial tears)
NB 90% of tendinopathy is without inflammation, not tendonitis but tendonosis
Physio + analgesia
Injections of steroid into the subacrominal bursa
Eventually arthroscopic acromioplasty
Patient was lifting heavy weight and felt pain, on flexion there is a ball of muscle over the upper arm. Diagnosis?
Rupture of long head of biceps = ‘Popeye muscle’
Repair rarely indicated, still functions
What is a frozen shoulder and it’s signs?
Adhesive capsulitis, inflammation of the capsule around the joint, preventing abduction ± external rotation
May be unable to lie on shoulder at night
Rx: NSAIDs, steroid injections
On examination how is painful arc and frozen shoulder differentiated?
Rotator cuff tear- if complete patient can’t abduct past 60 degrees, but passive movement unimpeded and once past 90 degrees deltoids can kick in
Frozen shoulder- capsule is inflamed so abduction limited to 90 degrees, no passive or active movement beyond that
Painful arc- (impingement, partial tear, tendinopathy) pain on abduction 60-120 degrees, then fine above and below that range
How can you tell if a patient has a vertebral wedge fracture on xray?
Difference in anterior and posterior height greater than 3cm, means a wedge of the vertebrae has been crushed
What does it mean if a fracture is avulsed? (Avulsion fracture)
A fragment has separated from the main body of the bone
To rule out an odontoid peg fracture (the dens upward sticking process of the axis vertebrae) in the elderly,what xray view is needed?
Open mouth 'peg' view. The dens (odontoid process) is a sticking up process of the axis that articulates with the atlas joint above
Difference between cervical spondylosis and spondylolisthesis?
Spondy just = spiny
Spondylosis is degeneration of the spine as bony spurs form, discs wear down narrowing the canal and intervertebral foramina
Spondylolisthesis = is slippage of one vertebral disc over another, typically in cervical cases the skull and atlas can slip forward over the axis.
What is the risk of cervical spondylothisthesis and management to reduce this risk?
Slippage of vertebrae over another (skull+ atlas over the axis)
> Spinal cord compression
Rx: Immobilization, spinal fusion
Patient has numbness in ulnar side of hand, muscle wasting of thenar and hypothenar eminances + weak radial pulse. What could be the diagnosis and way of investigating this?
Thoracic outlet compression
(Thoracic outlet is space between clavicle and first rib that structures pass under)
Lower trunk of brachial plexus (C8-T1) aka ulnar nerve- which supplies 1.5 fingers sensation and most intrinsic hand muscles
± subclavian artery- hence weak pulse
Cause: cervical rib or fibrous bands
Lateral epicondylitis is known as tennis or golfers elbow?
Tennis is for LADS (lateral)
Golf is for MUMS (medial)
How can you test for lateral epicondylitis on the elbow exam?
Tennis elbow- the common extensor tendon originates from the lat epicondyle
Get the patient to try to extend the wrist against resistance with elbow extended
Where do the ulnar and median nerve run around the shoulder joint?
Both are found medially, the median nerve on the anterior aspect of the cubital fossa (nerve, brachial artery, biceps tendon over to radial side) and the ulnar nerve under the medial epicondyle.
Radial nerve runs on the radial side, duh
Management of olecranon bursitis? (Student’s elbow- swelling at the back of the elbow joint)
Can be due to trauma (pressing on desk whilst studying), gout or septic joint so aspirate bursa and send for Gram stain and microscopy
When looking at microscopy of gout and pseudogout what would you find with aspirations of each?
Gout- Negative Needles
Pseudogout- Positive rhomboids
Cubitus valgus- where the forearm hangs laterally compared to the elbow is associated with chromosomal defect?
Turner’s syndrome- carrying angle is increased so hand points out from the body more
Causes and treatment of Dupuytren’s contracture?
Genetic- A with Peyronie’s disease
Smoking + drinking
Diabetes
Antiepileptics
In De Quervain’s tenosynovitis which tendons are involved?
Abductor pollicis longus and extensor pollicis brevis (so forcing flexion of the thumb causes them to be stretched the most)
What test is used to illicit pain indicative of De Quervain’s disease (tenosynovitis)?
Finkelstein’s sign- get patient to ulnar flex hand with thumb left free (no pain)
Get patient to ulnar flex hand whilt holding thumb in palm of hand (pain)
= positive
What is trigger finger?
Tendons of the fingers are kept close to the bone by slings of tissue, if the tendon thickens it get’s caught and can’t pass under the sling without some more force causing it to ‘lock, catch or pop thorugh’ or get stuck in a bent position
Patient is found to have supracondylar fracture of the humerus (above the epicondyles), not their hand is fixed such that their forearm is pronated, wrist flexed and swan necking of the fingers. Radial pulse cannot be palpated and passive finger extension is painful. What is the eponymous diagnosis?
Vlkmann’s ischaemic contracture:
Compartment syndrome or brachial artery interruption causes ischaemia and muscle necrosis leading to fixed flexion deformity
Why do a straight leg raise?
To test for a herniated disc (L4 - S1 level)- stretching the sciatic nerve
Flex hip with extended leg, pain at 30-70 degrees = Laségue’s sign positive.
If unsure if the patient is genuine, sit the patient up in bed with legs out front, if they can do this it’s not genuine sciatica
Why and how to do a crossed straight leg raise?
Having illicited pain on the straight leg raise, if the unaffected leg is lifted and it causes pain on the other side it is a more specific indicator of herniated disc.
If a patient has come with acute onset back pain, no red flags, how long should the pain have been lasting before you consider do blood tests?
4 weeks
Patient started getting back pain 5 weeks ago that is severe, what blood tests should the GP order and why?
FBC- chronic disease CRP- inflammation ESR- raised in myeloma + metastases Alk Phos- high in Paget's Calcium
4 main categorical causes of scoliosis?
Idiopathic
Congenital- abnormal development of spine
Neuromuscular- nerve lesions, cerebral palsy/muscular dystrophy
Syndromic- Marfan’s, neurofibromatosis
What retroperitoneal pathology can cause back pain?
How can you differentiate it from spine-related pain?
Duodenal ulcer- calmed by milk
Pancreatic cancer
Aortic aneurysm
Won’t restrict spine movement or cause pain on spinal movement
Red flag signs of cauda equina?
Saddle area numbness
Urine or faeces retention or incontinence
Poor anal tone (do PR)
Paralysis
= MRI in 4 hours
In suspected disc prolapse, what signs suggest the disc between L4/5 has prolapsed compared to L5/S1?
L4/5 affects L5 root compression- weak big toe extension
L5/S1 affects S1 root compression- no ankle reflex (S1,S2), stand on S1 so numbness on sole of foot, weak foot plantarflexion
What’s the difference between disc prolapse and spondylolisthesis?
Disc slips between vertebrae to compress spinal cord in disc prolapse
Vertebrae slip over each other to compress spinal cord in spondylolisthesis
How does lumbar spinal stenosis (spinal claudication) differ from disc prolapse on examination?
Lumbar spinal stenosis has negative straight leg raise test
Patient had previous cancer of the spine and was cured, has begun getting back pain again, what is first line imaging?
Bone scan- followed by xray of affected areas
TB of the spine requires TB treatment to be continued for how long?
Bone TB >6 months
Spinal TB = 9 months
TB meningitis = 1 year
When looking at a hip xray, disruption of the contour of which line indicates a hip fracture?
Shenton’s line
Name 3 causes of a positive trendelenburg sign?
On opposite side to the leg being lifted glut maximus contracts to tilt the pelvis on that side closer to the femur allowing the pelvis on the other side to rise. If there is a problem generating this force due to the muscle being weak or being unable to anchor to the femur (dislocation/fracture) there will be a positive trendelenberg sign
- Abductor muscle paralysis of opposite side- glut maximus and minimus
- Upward displacement of greater trochanter due to dislocated hip
- Un-united fracture of the neck of femur
Child has a painful hip, before diagnosing transient synovitis of the hip (irritable hip) what needs to be ruled out and how?
Septic arthritis- FBC, CRP, EHx, joint aspiration if needed
Multiple joint involvement- juvenile idiopathic arthritis of young
If bloods abnormal- TB arthritis, Perthes (osteochondritis of femoral head), slipped upper femoral epithesis
What causes osteochondritis of the hip (Perthes disease) commonly?
Avascular necrosis of the developing femoral head as it outgrows it’s blood supply.
Occurs in 3-11 year olds, often bilateral
9 year old has started limping, has hip pain and on examination reduced movement of hip. If it is due to Perthes disease what might be seen on xray?
- Widening joint space
- Patchy density of femoral head with reduced femoral head size
- Collapse of femoral head
What should be suspected in a patient aged under 10 or over 16 with a slipper upper femoral epiphysis?
Endocrinopathy:
Hypothyroidism
Hypogonadism
Growth hormone imbalance
Definitive investigation to confirm TB arthritis?
Synovial membrane biopsy
In terms of pathology what’s the difference between osteochondritis dissecans, chondromalacia patellae, patellar tendonopathy + Osgood Schlatter’s?
Osteochondritis dissecans = typically the femoral plateau becomes avascular + fragments
Chondromalacia patellae= inflammation and softening of the cartilage under the patella
Patellar tendinopathy= inflammation and tears
Osgood Schlatter= tibial apophysis
Difference between semimembranous bursitis and Baker’s cyst?
Baker’s cyst isn’t a true cyst or bursa, is it fluid from the joint space herniating out
Semimembranous bursitis is inflammation of a true bursa round the back of the knee
How are movements of the knee limited when there are loose bodies in the joint compared to a torn meniscus?
Loose bodies- all movements may be jammed
Torn menisci- extension is limited
Name 3 commonly affected bursa of the knee that may become inflamed?
Prepatellar bursa (anterior swelling over patella) Infrapatellar bursa (under the patellar) Semimembranous bursa (popliteal fossa, different to baker's cyst)
Also a large effusion of the knee will cause a horse-shoe shaped swelling over the top of the knee)
Patient has bursitis, what investigation is needed to differentiate cause?
Aspiration- is it due to friction (mechanical) or infection (requires antibiotics and drainage)
Differential causes of heel pain?
Diseases of the calcaneum Arthritis of subtalar joint (between talus + calcaneum) Achilles tendon rupture Achilles paratendinopathy (connection tissue between tendon + sheath) Plantar fasciitis Postcalcaenal bursitis Tender heel pad Lymphoma in children
Common organisms of osteomyelitis?
Staph aureus
Streptococcus
Pseudomonas (G-ve rod)
E Coli
Gold standard for diagnosing suspected osteomyelitis?
Bone biopsy + culture
Empirical antibiotic treatment for osteomyelitis when organism and sensitivities are unknown?
Vancomycin + Cefotaxime IV for 6 weeks
Surgical drainage + removal of any abscesses or sequestra (necrotic fragments of bone)
If suspecting a patient has pseudomonas osteomyelitis, what antibiotic is suitable?
Ciprofloxacin
How long does an infection need to last before it’s classified as chronic osteomyelitis rather than acute, and how does management differ?
Acute- lasts <6 weeks, Abx for 6 weeks
Chronic- lasts >6 weeks, Abx for 12 weeks
Which types of cancer typically metastasise to bone?
The B's: Breast Bronchus Down Below (prostate) Blood filterers (kidneys)
Most common malignant primary bone cancer and common site of presentation?
Osteosarcoma
In adolescents, arises in metaphyses around the knee.
Metaphyses are between the growth plate and the shaft of the bone (diaphysis)
Which primary bone tumour is characterised by multinucleated giant cells?
Giant cell tumour- benign but can unpredictably be aggressive
‘Onion skin’ sign on periosteal reactions of bone seen on xray is characteristic of what malignancy?
Ewing’s sarcoma- associated with t11:22 translocation
Ewing’s sarcoma is associated with which chromosomal translocation?
11:22
Primary bone malignancy- may see the ‘onion skin’ sign on xray
Methotrexate side effects:
Myelosuppression
Liver cirrhosis
Pneumonitis
Sulfasalazine side effects:
Given for rheumatic conditions
Rashes
Oligospermia
Heinz body anaemia (red bodies of denatured haemaglobin)
Interstitial lung disease
Side effects of Prednisolone:
Cushingoid features Osteoporosis Impaired glucose tolerance Hypertension Cataracts
Commonest benign primary tumour of bone?
Osteochondroma- forms following trauma
On xray appears as a bony spur arising from cortex
Treatment of soft tissue sarcomas?
Wide margin excision
Radiotherapy
Blue sclera is indicative of…?
Osteogenesis imperfecta- type 1 collagen disorder
Different forms of disease affects inheritance and severity.
Commonest form is associated with hearing loss and multiple fractures
Xray- osteoporosis, bowing bones
Commonest mutation responsible for achondroplasia?
FGFR3 in 95%
Achondroplasia = dwarfism, short proximal arms and legs
Which type of antibiotics can cause achilles tendon rupture?
Fluoroquinolones- like ciprofloxacin (given for pseudomonas)
3 Indications for knee replacement:
- Pain at rest
- Pain disturbing sleep
- Pain causing patient to be housebound
Indications for a hip replacement:
Pain and disability due to degenerative or inflammatory arthritis in the hip joint, where non-operative management has failed and quality of life is being significantly interfered with
How does management of a ruptured achilles tendon differ according to patient age and health?
Young athletic patients- surgical repair
Over 50, smokers or diabetics- conservative, casting + no weight bearing for 6 weeks
What are the flexor tendons behind the medial malleolus?
Tom Dick ANd Harry
Closest behind the malleolus- Tibialis posterior
Then posterior to that- flexor Digitorum longus
Post tibial Artery
Post tibial Nerve
Finally- flexor Hallus longus
Signs of carpal tunnel syndrome
Caused by median nerve compression by the flexor retinaculum
> tingling or pain in radial 3.5 fingers (palmar cutaneous branch splits before the wrist to give palmar sensation)
pain at night relieved by shaking
wasted thenar eminence
Phalen’s test + Tinnel’s test
How does median nerve damage around the elbow present differently to carpal tunnel syndrome?
In carpal tunnel, palmar sensation is not affected as the palmar cutaenous branch splits off before the wrist
In elbow damage it is also involved
Patient who does a lot of sport has been complaining of numbness and shooting pain in her anterolateral thigh. What may be the cause?
Lateral femoral cutaneous nerve entrapment under the lateral inguinal ligament
= Meralgia paraesthetica
Rx: NSAIDs ± carbamazepine ± cortisol
A patient had a fibular head fracture and now can’t dorsiflex their foot, which nerve may be involved?
Common perineal nerve
What are the nerves of the leg?
Running deep posteriorally, the sciatic nerve traverses through the greater sciatic formamen, splitting into the tibial and common peroneal nerve at the popliteal fossa.
Anteriorally the femoral nerve eventually forms the saphenous nerve
What is the MRC scale for grading muscle strength?
Grade 0- no muscle contraction Grade 1- flicker of contraction Grade 2- some active movement with gravity eliminated Grade 3- movement against gravity Grade 4- movement against resistance Grade 5- normal
Name 3 cases in which NSAIDs should be avoided for acute pain relief?
Asthmatics
Peptic ulcer disease
Renal impairment
What pain relief is best for renal colic?
NSAIDs- like:
Diclofenac 75mg IM stat
Ibuprofen 400-800mg TDS PO
Motor scoring for GCS:
6- obeys simple movement commands 5- localises to pain 4- withdraws to pain 3- flexes to pain (decorticate) 2- extends to pain (decerebrate) 1- no movement
Verbal scoring for GCS
5- alert, orientated 4- confused 3- inappropriate speech 2- incomprehensible sounds 1- no sounds
Eye opening scoring for GCS
4- alert, spontaneous eye opening
3- eye opening to speech
2- eye opening to pain
1- no eye opening
Management of a haemopneumothorax from gun wound?
Chest drain- ideally with autotransfusion device to recycle blood.
Blood replacements- transfusion, fluids etc
Deterioration or cardiac arrest prompt thoracotomy.
What was Beck’s trial of cardiac tamponade?
Rising JVP
Falling BP
Small quiet heart
Portable USS can confirm
Why does squatting increase preload to the heart and how does this affect different murmurs?
It compresses veins increasing venous return
Squatting, HCM quieter and AS louder
Valsalva, HCM louder and AS quieter
(Want to shut up a body builder who has HCM from anabolic steroids, get them to squat)
In squatting + HCM, more blood in LV reduces turbulence of flow as blood as no space in the chamber to be turbulent and more pressure to overcome obstruction, so murmur is quieter
Whereas Valsalva reduces venous return by increasing intrathoracic pressure
In Valsalva +AS less blood in LV reduces turbulence out of the narrowed valve, so quieter murmur
Commonest primary malignant bone tumour?
Osteosarcoma- adolescents in long bones
Xray- periosteal elevation + sunray spiculation
Match the following primary malignant bone tumours with the xray descriptions:
A. Sunray spiculation
B. Osteolytic at epiphysis
C. ‘Onion ring’ sign with concentric layers around mass
D. Popcorn calcification
A. Osteosarcoma (commonest, occurs in adolescents)
B. Giant cell tumour
C. Ewing’s sarcoma- 11:22 translocation
D. Chondrosarcoma- excision, non chemo responsive
Which of the following are benign bone tumours and which are malignant: Osteosarcoma Osteochondroma Osteoid osteoma Chondrosarcoma Giant cell tumour
Giant cell tumour + all the sarcoma’s are malignant (including Ewing’s sarcoma)
The rest are benign- commonest benign tumour is osteochondroma which presents as a bony spur pointing away from the joint
What is the diaphysis, physis, metaphysis and epiphysis?
Diaphysis is the shaft of the long bone
Physis is the growth plate
Metaphysis is between shaft + growth plate
Epiphysis is the knobbly end of the bone
Which type of cancer mets tend to be sclerotic in bone rather than lytic?
Hormonal cancers: prostate + breast
Which cancers cause mets to bone:
Glandular: Breast Prostate Thyroid Kidney Lung
(PB KTL)
Describe the aspects of a fracture that need to be described:
Which bone
Where in the bone- proximal, shaft or distal
How- transverse, oblique, spiral, multi-fragmented
Displacement- angulation, translated, rotated, impacted, shortening
Soft tissues- open/closed, neurovascular status, compartment syndrome
What is the rule of 3s for predicting fracture healing time?
3 weeks for closed, paediatric, metaphyseal fracture of upper limb
Any factor’s differing from the above doubles recovery time
Closed adult (6 weeks) metaphyseal fracture of fibia (12 weeks) would take 12 weeks
What are the indications for open reduction internal fixation?
- Open fracture
- 2 fractures in 1 limb
- Intra-articular fractures
- Bilateral identical fractures
- Failed conservative Rx
Difference between Monteggia +Galeazzi fractures?
Monteggia- proximal 1/3rd of ulnar, radial head subluxion
Galeazzi- radial shaft fracture with dislocation of distal radioulnar joint at wrist
G befor M, R before U, shafting he who was first (proximal)
What is Malgaigne’s fracture?
Disruption of pelvis anteriorally and posteriorally with displacement of the fragment containing the hip joint (acetabulum with femur)
Signs of intracapsular fractures vs hip dislocation:
Intracapsular fractures = external rotation
Hip dislocation = internally rotated
Both = adducted and shortened
Positioning is related to iliopsoas muscle action
What are the three types of intracapsular fractures:
From proximal to distal
- Subcapital
- Transcervical
- Basicervical
What is a Maisonneuve fracture?
Spiral fracture of the proximal fibula with unstable ankle injury
-may show through widening of the ankle joint because of tibiofibular syndesmosis, deltoid ligament disruption of medial malleolar fracture
What is a Lisfranc fracture dislocation?
Fracture + dislocation of the 1st metatarsal
Seen by widening between medial cuneiform and base of 2nd metatarsal
Weber’s classification of ankle fractures?
A- below talofibular joint
B- at level of talofibular joint
C- above (proximal) to talofibular joint
Which other view in required in xrays if a scaphoid fracture is suspected?
Ulnar deviation
What test signs correlate with otosclerosis
EHx: 10% pink drum tinge
Audiometry: dips at 2kHz (Cahart’s notch)
Causes of sudden sensorineural hearing loss:
V: anterior inferior cerebellar artery infarct I: TB, mumps T: noise exposure A: MS M: gentamicin toxicity I: surgery N: acoustic neuroma
Management of Bell’s palsy:
Glasses to protect the eye, tape during sleep
Artificial tears
Prednisolone PO
Aciclovir- especially if prodrome of stiff neck, ear pain, red ear
Cheek plumpers + cosmetic
Management of sleep apnoea?
Conservative: weight reduction, reduce alcohol and tabacco
Medical: CPAP
Surgical: tonsillectomy, tracheostomy etc
How does otitis media differ from otitis externa in it’s presentation?
Otitis externa- watery discharge, more itch and tragal redness
Otitis interna- mucous discharge, more pain and vomiting, fever, follows URTI
Common organisms of otitis media + Rx:
Strep pneumo
Haemophilus
Moraxella
Staphs
Rx: amoxicillin + analgesia
Patient has ear discharge and a red tender mastoid process, with a temperature. Management?
Admit- risk of intracranial extension
CT scan
IV antibiotics
Myringotomy- incision of tympanic membrane to relieve pressure
Rx for otitis externa?
Ciprofloxacin + dexamethosone ear drops
What is glue ear?
Chronic otitis media with effusion (serous)
Dysfunction of Eustacian tube and cilia leads to increased fluid in the middle ear obstructing hearing.
Signs: retracted or bulging drum
May be bubbles or a fluid level, reduced drum mobility
Management of glue ear (otitis media with effusion):
No medications needed
In extreme cases can try myringotomy + suction of fluid with grommet insertion
(If bilateral and hearing level has dropped 25-30dB in the good ear)
How do the causes of parotid swelling/inflammation differ according to whether it’s unilateral, bilateral, chronic or acute?
Acute unilateral: mumps, ascending oral infection, abscess
Acute bilateral: mumps, staphs/TB/HIV, ALL, sarcoid
Recurrent unilateral: stones
Recurrent bilateral: Sjögren’s, Mikulicz’s disease
Causes of xerostomia- dry mouth:
V: dehydration I: HIV T: stones (sialoliths) A: SLE, Sjögren's, scleroderma, sarcoid M: b blockers, diuretics, antipsychotics, tricyclics I: ENT radiotherapy N:
Rx: sugar free gum, saliva substitute, good oral hygiene, avoid acidic drinks
