Orthopaedics Mushkies Flashcards
1
Q
What is the composition of bone?
A
Cells and Matrix
2
Q
What cells are bone composed of?
A
Osteoblasts
Osteoclasts
Osteocytes
OPCs
3
Q
What kind of matrices are bone composed of?
A
- Organic (40%) = Osteoid
2. Inorganic (60%)
4
Q
What is organic bone matrix mainly composed of?
A
Collagen Type I
5
Q
What is the main function of organic bone matrix?
A
Resists tension, twisting and bending
6
Q
What is inorganic bone matrix mainly composed of?
A
Calcium hydroxyapatite
7
Q
What is the main function of inorganic bone matrix?
A
Resists compressive forces
8
Q
How can you classify the types of bone?
A
Woven bone and Lamellar Bone
9
Q
What is woven bone?
A
Disorganised bone that forms the embryonic skeleton and fracture callus
10
Q
What is lamellar bone?
A
Mature bone that can be of two types
11
Q
What are the 2 types of lamellar bone?
A
- Cortical/compact = dense outer layer
2. Cancellous/trabecular = porous central layer
12
Q
What are the two ways in which bone is formed?
A
- Intramembranous ossification
2. Endochondral ossification
13
Q
What is intramembranous ossification?
A
Direst ossification of mesenchymal bone models formed during embryonic development e.g. skull bones, mandible and clavicle
14
Q
What is endochondral ossification?
A
- Mesenchyme –> cartilage –> bone
2. Most bones ossify this way
15
Q
What are the 3 phases of fractuer healing?
A
- Reactive phase
- Reparative phase
- Remodelling phase
16
Q
What is the reactive phase of fracture haling?
A
- Injury - 48hrs
- Bleeding into # site –> haematoma
- Inflammation –> cytokine, GF and vasoactive mediator release –> recruitment of leukocytes and fibroblasts –> granulation tissue
17
Q
What is the reparative phase of fracture healing?
A
- 2 days - 2 weeks
- Proliferation of osteoblasts and fibroblasts –> cartilage and woven bone production –> callus formation
- Consolidation (endochondral ossification) of woven bone into lamellar bone
18
Q
What is the remodelling phase of fracture healing?
A
- 1 week - 7 years
2. Remodelling of lamellar bone to cope with mechanical forces applied to it (Wolff’s law = form follows function)
19
Q
What is Wolff’s law?
A
Form follows function, i.e. bone in a healthy person will adapt to the loads under which it is placed
20
Q
What kind of fractures have a healing time of 3 weeks?
A
- Closed
- Paediatrics
- Metaphyseal
- Upper limb
21
Q
What complicating factors double healing time?
A
ALDO
- Adult
- Lower limb
- Diaphyseal
- Open
22
Q
How can you classify fractures?
A
- Traumatic
- Stress
- Pathological
23
Q
How can you classify traumatic fractures?
A
- Direct = assault with metal bar
- Indirect = FOOSH –> clavicle #
- Avulsion
24
Q
What causes a stress fracture?
A
Bone fatigue due to repetitive strain e.g. foot #in marathon runners
25
What is a pathological fracture?
Normal forces but diseased bone
26
How can you classify pathological fractures?
1. Local = tumours
| 2. General = osteoporosis, Cushing's, Paget's
27
What are some things you must take into account when requesting radiographs for fractures?
1. Radiographs must be orthogonal --> request AP and lateral films
2. Need images of joint above and joint below #
28
How do you describe a fracture?
D PAIDSS
1. Demographics = pt details, date, orientation and content of image
2. Pattern
3. Anatomical location
4. Intra/extra-articular (dislocation/subluxation)
6. Deformity
7. Soft tissues
8. ? Specific classification/type
29
What are the 7 patterns of fracture?
TOMS CAG
1. Transverse
2. Oblique
3. Multifragmentary
4. Spiral
5. Crush
6. Avulsion
7. Greenstick
30
What is meant by deformity and what are the 4 types of deformity?
Distal relative to proximal: TARI
1. Translation
2. Angulation (tilt)
3. Rotation
4. Impaction (shortening)
31
How can you describe soft tissues in a fracture?
1. Open or closed
2. Neurovascular status
3. Compartment syndrome
32
What is a Colles fracture?
Distal forearm fracture in which the radius is bent backwards, typically due to falling on an outstretched hand
33
What is a Smith's fracture?
Distal forearm fracture in which the distal fracture fragment is displaced volarly, typically due to falling onto a flexed hand
34
What is a Galeazzi fracture?
Fracture of the mid to distal third of the radius with dislocation or subluxation of the distal Radioulnar Joint (DRUJ)
35
What is a Monteggia fracture?
Fracture of the proximal third of the ulna with dislocation of the proximal head of the radius
36
What is a Salter-Harris fracture?
A fracture that involves the epiphyseal plate or growth plate of a bone, specifically the zone of provisional calcification
37
In general, how stable/unstable are the Garden fractures?
In general, stage I and II are stable fractures and can be treated with internal fixation (head-preservation) and stage III and VI are unstable fractures and hence treated with arthroplasty (either hemi- or total arthroplasty)
38
What are the types of Salter-Harris fracture?
```
SALTeR
1. Slip (straight across)
2. Above/Away
3. Lower
4. Through everything
5. Rammed (crushed)
Types 6 to 9 are rarer and have been added later
```
39
What are the main principles of fracture management?
4 Rs
1. Resuscitation
2. Reduction
3. Restriction
4. Rehabilitation
40
What are the 4 components of Resuscitation in Fracture management?
FOGC
1. First principles
2. Open #s require urgent attention: 6 As
3. Gustillo classification of open #s
4. Clostridium perfringens
41
What are the 6 first principles of resuscitation?
1. Follow ATLS guidelines
2. Trauma series in primary survey = C spine, chest, pelvis
3. Fractures in secondary survey
4. Assess neurovascular status and look for dislocations
5. Consider reduction and splinting before imaging ut reduce pain, bleeding and risk of neurovascular injury
6. X-ray once stable
42
What is the management of an open fracture?
6 As, with ultimate management being debridement and fixation in theatre
1. Analgesia
2. Assess: NV status, soft tissues, photograph
3. Antisepsis: wound swab, copious irrigation, cover with betadine-soaked dressing
4. Alignment: align # and splint
5. Anti-tetanus (check status, booster lasts 10yrs)
6. Abx = Fluclox 500mg IV/IM + benpen 600mg IV/IM
43
What is the Gustillo classification of open fractures?
1. Wound <1cm in length
2. Wound >1cm in length with minimal soft tissue damage
3. Extensive soft tissue damage
44
What is are the complications and management of C. perfringens?
1. Most dangerous complication of open fracture, leading to wound infections and gas gangrene +/- shock and renal failure
2. Management = debridge, benpen + clindamycin
45
What are the principles of fracture reduction?
1. Displaced #s should be reduced unless no effect on outcome e.g. ribs
2. Aim for anatomical reduction (esp if articular surfaces involved)
2. Alignment is more important than opposition
46
What are the methods of reduction?
1. Manipulation/closed reduction
2. Traction
3. Open reduction (and internal fixation)
47
What are the features of a closed reduction?
1. Under local, regional or general anaesthetics
2. Traction to disimpact
3. Manipulation to align
48
What are the features of traction reduction?
1. Not typically used now
2. Employed to overcome contraction of large muscles e.g. femoral #
3. Skeletal traction vs. skin traction
49
What are the features of open reduction (and internal fixation)?
1. Accurate reduction vs. risks of surgery
| 2. Used for #: intra-articular, open, 2 in 1 limb, bilateral identical, failed conservative Rx
50
What are the principles of restriction>
1. Interfragmentary strain hypothesis dictates that tissues formed at the site of the # depends on the strain it experiences
2. Fixation --> reduced strain --> bone formation
3. Fixation --> reduced pain, increased stability + ability to function
51
What are the 6 methods of restriction?
1. Non rigid
2. Plaster
3. Functional bracing
4. Continuous traction
5. Ex-fix
6. Internal fixation
52
What are examples of non-rigid restrictions?
Slings and elastic supports
53
What are plaster restrictions?
POP, in first 24-48hrs use back-slab or split cast due to risk of compartment syndrome
54
What is functional bracing?
Joints free to move but bone shafts supported in cast segments
55
What is an example of continuous traction?
Collar and cuff
56
What is ex-fix?
1. Fragments are held in position by pins/wires which are then connected to an external frame
2. Intervention is away from field of injury
3. Useful in open #s, burns, tissue loss to allow wound access and reduce infection risk
4. Risk of pin-site infections
57
What is internal fixation?
1. Use of pins, plates, screws, IM nails
2. Usually perfect anatomical alignment
3. Increased stability
4. Aid early mobilisation
58
What are the principles of rehabilitation?
1. Immobility --> reduced muscle and bone mass, joint stiffness
2. Therefore need to maximise mobility of uninjured limbs
3. Quick return to function reduces later morbidity
59
What are methods of rehabilitation?
1. Physiotherapy = exercises to improve mobility
2. OT = splints, mobility aids, home modification
3. Social services = meals on wheels, home help
60
How can you classify the complications of fractures?
General and Specific
61
How can you classify the general complications of fractures?
1. Tissue damage
2. Anaesthesia
3. Prolonged bed rest
62
What tissue damage can occur?
1. Haemorrhage and shock
2. Infection
3. Muscle damage --> rhabdomyolysis
63
What are 3 complications of anaesthesia?
1. Anaphylaxis
2. Aspiration
3. Damage to teeth
64
What are complications of prolonged bed rest?
1. Infection = chest, UTI
2. Pressure sores and muscle wasting
3. DVT, PE
4. Reduced bone mineral density
65
How can you classify the specific complications of fractures?
1. Immediate
2. Early
3. Late
66
What are the immediate specific complications of fractures?
1. Neurovascular damage
| 2. Visceral damage
67
What are the early specific complications of fractures?
1. Compartment syndrome
2. Infection
3. Fat embolism --> ARDS
68
What are the late specific complications of fractures?
1. Problems with union
2. Avascular necrosis
3. Growth disturbance
4. Post-traumatic osteoarthritis
5. Complex regional pain syndromes
6. Myositis ossificans
69
What is myositis ossificans?
1. A condition where bone tissue forms inside muscle or other soft tissue after an injury, usually in the large muscles of the arm or legs (elbow and quadriceps)
2. Due to heterotopic ossification of muscle at sites of haematoma formation, resulting in restricted, painful movement
3. Can be excised surgically
70
What classification is used for describing the degree of nerve injury?
Seddon Classification
71
What are the grades of nerve injury according to the Seddon classification system?
NAN
1. Neuropraxia
2. Axonotmesis
3. Neurotmesis
72
What is Neuropraxia?
Temporary interruption of conduction without loss of axonal continuity
73
What is Axonotmesis?
1. Disruption of nerve axon --> distal Wallerian degeneration
2. Connective tissue framework of nerve preserved
3. Regeneration occurs and recovery is possible
74
What is Neurotmesis?
Disruption of entire nerve fibre --> surgery required and recovery usually not complete
75
What is Wallerian degeneration?
Active process of degeneration that results when a nerve fiber is cut or crushed and the part of the axon distal to the injury (i.e. farther from the neuron's cell body) degenerates
76
An anterior shoulder dislocation/humeral surgical neck leads to what kind of palsy and test/result?
1. Axillary nerve palsy
| 2. Numb chevron and weak abduction
77
A humeral shaft fracture leads to what kind of palsy and test/result?
1. Radial nerve palsy
| 2. Waiter's tip
78
An elbow dislocation leads to what kind of palsy and test/result?
1. Ulnar nerve palsy
| 2. Claw hand
79
A hip dislocation leads to what kind of palsy and test/result?
1. Sciatic nerve palsy
| 2. Foot drop
80
A neck of fibular fracture/knee dislocation leads to what kind of palsy and test/result?
1. Fibular nerve palsy
| 2. Foot drop
81
What is compartment syndrome?
A condition where there is extremely high pressure within a muscle compartment
82
What is the pathophysiology of compartment syndrome?
1. Osteofascial membranes divide limbs into muscle compartments
2. Oedema following fracture --> raised compartment pressure --> reduced venous drainage --> raised compartment pressure
3. Compartment pressure > capillary pressure --> ischaemia
4. Ischaemia --> muscle infarction
5. Muscle infarction --> rhabdo and ATN, fibrosis and Volkmann's ischaemic contracture
83
What is Volkmann's ischaemic contracture?
A permanent flexion contracture of the hand at the wrist, resulting in a claw-like deformity of the hand and finger, especially associated with a supracondylar fracture of the humerus. It results from acute ischaemia and necrosis of the muscle fibres of the flexor group of muscles of the forearm, especially the flexor digitorum profundus and flexor pollicis longus. The muscles become fibrotic and shortened.
84
How may compartment syndrome present?
1. Pain > clinical findings
2. Pain on passive muscle stretchgin
3. Warm, erythematous swollen limb
4. Long CRT and weak/absent peripheral pulses
85
What is the management of compartment syndrome?
1. Elevate limb
2. Remove all bandages and splint/remove cast
3. Fasciotomy
86
How can you classify problems with union?
1. Delayed union
2. Non-union
3. Malunion
87
What are the causative factors of union problems?
5 Is
1. Ischaemia
2. Infection
3. Interfragmentary strain
4. Interposition of tissue b/w fragents
5. Intercurrent disease e.g. malignancy/malnutrition
88
How can you classify non-union?
1. Hypertrophic = bone end is rounded, dense and sclerotic
| 2. Atrophic = bone looks osteopenic
89
What is the management of problems of union?
1. Optimise biology = infection, blood supply, bone graft, BMPs
2. Optimise mechanics = ORIF
90
What is malunion?
Fracture is healed in an imperfect position, leading to poor appearance and/or function e.g. gunstock deformity
91
What is avascular necrosis?
Death of bone due to deficiency supply
92
What are common sites of avascular necrosis?
Femoral head, scaphoid, talus
93
What is the consequence of avascular necrosis?
Bone becomes soft and deformed --> pain, stiffness and OA
94
What can you see on X-ray with avascular necrosis?
Sclerosis and deformity
95
What is Pellegrini-Stieda disease?
A form of myositis ossificans - calcification of the superior attachment of the MCL at the knee following traumatic injury
96
What are 2 other names for Sudek's atrophy?
1. Complex Regional Pain Syndrome Type 1
| 2. Reflex Sympathetic Dystrophy
97
What is Sudek's atrophy?
A complex disorder of pain, sensory abnormalities, abnormal blood flow, sweating and trophic changes in superficial and deep tissues with no evidence of nerve injury
98
What are some causes of Sudek's atrophy?
1. Fractures
2. Carpal tunnel release
3. Dupuytren's operations
4. Zoster
5. MI
6. Idiopathic
99
How does Sudek's atrophy present?
1. Weeks to months after injury
2. NOT traumatised area that is affected, it affects NEIGHBOURING area
3. Lancing pain, hyperalgesia or allodynia
100
What are some signs you can see with Sudek's atrophy?
1. Vasomotor = hot and sweaty/cold and cyanosed
2. Skin = swollen/atrophic and shiny
3. NM = weakness, hyper-reflexia, dystonia, contractures
101
What is the management of Sudek's atrophy?
1. Usually self-limiting - refer to pain team
2. Amitryptiline, gabapentin
3. Sympathetic nerve blocks can be tried
102
What is another name for CRPS Type II?
Causalgia
103
What is Causalgia?
Persistent pain following injury caused by nerve lesions
104
What is the epidemiology of hip fractures?
1. 80/100,000
2. 50% in >80 y/o
3. 3F: 1M
105
What is the pathophysiology of hip fractures?
1. Old = osteoporosis with minor trauma
| 2. Young = major trauma
106
What are the risk factors for osteoporosis?
Age + SHATTERED
1. Steroids
2. Hyperpara/thyroidism
3. Alcohol and Cigarettes
4. Thin (BMI < 22)
5. Testosterone low
6. Early menopause
7. Renal/liver failure
8. Erosive/inflammatory bone disease (e.g. RA, myeloma)
9. Dietary Ca low/malabsorption, DM
107
How does a hip fracture present o/e?
Shortened and externally rotated
108
How do you prepare a pt with a hip fracture for theatre?
1. A = anaesthetist and book theatre
2. B = bloods --> FBC, U&E, clotting, X-match
3. CXR
4. DVT prophylaxis: TEDS, LMWH
5. ECG
6. Films: orthogonal X rays
7. Get consent
109
What must you look out for on X ray of a hip fracture?
1. Look at Shenton's lines
2. Intra or extra-capsular?
3. Displaced or non-displaced?
4. Osteopaenic
110
Where does the capsule attach at the hip joint?
Capsule attaches proximally to acetabular margin and distally to the intertrochanteric line
111
What is the blood supply to the femoral head?
1. Artery of ligamentum teres
2. Intramedullary vessels
3. Retinacular vessels, in capsule, distal --> proximal
112
Damage to which vessels can lead to AVN of femoral head?
Retinacular vessels
113
How can you classify hip fractures?
Intracapsular vs. Extracapsular
114
What are the types of intracapsular fracture?
1. Subcapital
2. Transcervical
3. Basicervical
115
What are the types of extracapsular fracture?
1. Intertrochanteric, subtrochanteric
116
what is the Garden classification of Intracapsular Fractures?
1. Incomplete fracture, undisplaced
2. Complete fracture, undisplaced
3. Complete fracture, partially displaces
4. Complete fracture, completely displaced
117
What is the surgical management of intracapsular hip fractures?
1. Garden 1 & 2 = ORIF with cancellous screws
| 2. Garden 3 & 4 depends on age
118
What is the surgical management of intracapsular hip fractures Garden 3 & 4?
1. <55 y/o = ORIF with screws
2. 55-75 y/o = total hip replacement
3. >75 y/o = hemiarthroplasty
119
What is the surgical management of an extracapsular hip fracture>
ORIF with DHS
120
What are specific complications of a hip fracture?
1. AVN of femoral head in displaced fractures (30%)
2. Non/mal-union
3. Infection
4. Osteoarthritis
121
What is the prognosis of a hip fracture?
1. 30% mortality at 1 year
| 2. 50% never regain pre-morbid functioning
122
What are radiographic features of a Colles' fracture?
1. Extra-articular fracture of distal radius
2. Dorsal displacement of distal fragment
3. Dorsal angulation of distal fragment (normally 11 degrees volar tilt)
4. Reduced radial height
5. Reduced radial inclination (usually 22 degrees)
6. +/- avulsion of ulna styloid
7. +/- impaction
123
What is the specific management for a Colles' fracture?
1. Examine for neurovascular injury as median nerve and radial artery lie close
2. If displacement --> reduction, apply dorsal backslab
3. Re X-ray --> satisfactory? (No --> ortho review and consider MUA +/- K wires, Yes --> home with fracture clinic follow up within 48hrs of completion of POP
4. 6 weeks in POP + physio
124
What are specific complications of a Colles' fracture?
1. Median nerve injury
2. Frozen shoulder/adhesive capsulitis
3. Tendon rupture, esp. EPL
4. Carpal tunnel syndrome
5. Mal-/non-union
6. Sudek's atrophy
125
What is the management for a Smith's fracture?
Reduce to restore anatomy and POP for 6 weeks
126
What is a Barton's fracture?
Oblique intra-articular fracture involving the dorsal aspect of distal radius and dislocation of the radio-carpal joint
127
What normally causes of scaphoid fracture/
FOOSH
128
How does a scaphoid fracture present?
1. Pain in anatomical snuffbox
| 2. Pain in telescoping the thumb
129
What is the specific management for a scaphoid fracture?
1. If clinical Hx and exam suggest a scaphoid fracture, it should be initially trated even if the X ray is normal (may become apparent after 10 days due to localised decalcification)
2. Place wrist in scaphoid plaster (beer glass position)
3. If initial X-ray is negative, return in 10d for another one
130
What are the possible outcomes for a ?scaphoid fractures that returns 10d later for an X-ray?
1. Fracture visible --> POP 6 wks
2. Not visible but clinically tender --> POP 2 wks
3. Not visible and not tender --> no POP
131
What are specific complications of a scaphoid fracture?
AVN of scaphoid as blood supply runs distal to proximal
132
What is a complication of a Monteggia fracture?
May lead to palsy of the deep branch of the radial nerve, leading to weak finger extension but no sensory loss
133
What are the 2 types of radia and ulna shaft fractures?
Monteggia and Galleazi
134
What is the specific management for radial and ulna shaft fractures?
1. Unstable --> Adults = ORIF, Children = MUA + above elbow plaster
135
How should fractures of the forearm be plastered?
In the most stable position
1. Proximal fracture = supination
2. Distal fracture = pronation
3. Mid-shaft fracture = neutral
136
How can you classify shoulder dislocation?
Anterior and Posterior
137
What are some features of anterior shoulder dislocation?
1. Accounts for 95% of shoulder dislocations
2. Direct trauma or falling on hand
3. Humeral head dislocated antero-inferiorly
138
What are some features of posterior shoulder dislocation?
Causes by direct trauma or muscle contraction (seen in epileptics)
139
What unusual ortho dislocation typically occurs in epileptics?
Posterior shoulder dislocation
140
What are 2 lesions associated with shoulder dislocation?
1. Bankart lesion
| 2. Hill-Sachs lesion
141
What is a Bankart lesion?
Damage to anteroinferior glenoid labrum
142
What is a Hill-Sachs lesion?
Cortical depression in the posterolateral part of the humeral head following impaction against the glenoid rim during anterior dislocation
143
How may a shoulder dislocation present?
1. Severe pain
2, Arm supported in opposite hand
3. Bulge in infraclavicular fossa: humeral head
4. Shoulder contour lost: appears lost
144
What is the specific management for a shoulder dislocation?
1. Assess for neurovascular deficit, especially axillary nerve (sensation over 'chevron' are before and after reduction)
2. X-ray = AP and trans-scapular view
3. Reduction under sedation (e.g. propofol)
4. Rest arm in sling for 3-4 weeks
5. Physio
145
What are the two ways you can reduce a shoulder dislocation under sedation?
1. Hippocratic
| 2. Kocher's
146
What is a Hippocratic shoulder reduction?
Longitudinal traction with arm in 30 degree abduction and counter traction at the axilla
147
What is a Kocher's shoulder reduction?
External rotation of adducted arm, anterior movement, anterior movement, internal rotation
148
What are complications of a shoulder dislocation?
1. Axillary nerve injury
| 2. Recurrent dislocation (90% pts <20y/o with traumatic dislocation)
149
What are the 2 management strategies for recurrent shoulder instability?
1. TUBS
| 2. AMBRI
150
What is TUBS?
Traumatic Unilateral dislocations with a Bankart lesion often require Surgery
151
What is AMBRI?
Atraumatic Multidirectional Bilateral shoulder dislocation is treated with Rehabilitation, but may require Inferior capsular shift
152
What is Impingement syndrome/Painful arc?
Entrapment of supraspinatus tendon and subacromial bursa between acromion and greater tuberosity of humerus --> subacromial bursitis and/or supraspinatus tendonitis
153
How does impingement syndrome present?
1. Painful arc 60-120 degrees
2. Weakness and reduced ROM
3. +ive Hawkin's test
154
What is the Hawkin's test?
The patient is examined while sitting with their shoulder flexed to 90° and their elbow flexed to 90°. The examiner grasps and supports proximal to the wrist and elbow to ensure maximal relaxation, the examiner and the patient then quickly rotate the arm internally. Pain located below the acromioclavicular joint with internal rotation is considered a positive test result.
155
What are the investigations for impingement syndrome?
1. Plain radiograph (may see bony spurs)
2. US
3. MRI arthrogram
156
What is the management for impingement syndrome?
1. Conservative = rest and physio
2. Medical = NSAIDs, subacromial bursa steroid +/- LA injection
3. Surgical = arthroscopic acromioplasty
157
What are the differentials for a painful arc?
1. Impingement syndrome
2. Supraspinatus tear/partial tear
3. AC joint OA
158
What is the medical term for frozen shoulder?
Adhesive capsulitis
159
How does frozen shoulder present?
1. Progressive reduction in active and passive ROM (external rotation <30, abduction <90)
2. Shoulder pain, especially at night (cant lie on affected side)
160
What causes frozen shoulder?
1. Unknown, may follow trauma in elderly
| 2. Commonly associated with DM
161
What is the management for frozen shoulder?
1. Conservative = rest, physio
| 2. Medical = NSAIDs, subacromial bursa steroid +/- LA injection
162
What are the rotator cuff muscles?
```
SITS
Supraspinatus
Infraspinatus
Teres Minor
Subscapularis
```
163
What causes rotator cuff teats>
1. Degenration
| 2. Sudden jolt/fall
164
How can you classify rotator cuff tears?
Partial tears or complete tears
165
How do partial rotator cuff tears present?
Painful arc
166
how do complete rotator cuff tears present?
1. Shoulder tip pain
2. Full range of passive movement
3. Inability to abduct the arm
4. Active abduction possible following passive abduction to 90 degrees
5. Lowering the arm beneath this --> sudden drop ('drop arm' sign)
167
How do supracondylar fractures of the humerus present?
1. Common children after FOOSH
| 2. Elbow very swollen and held semi-flexed
168
What may the sharp edge of the proximal humerus injure, which lies anterior to it?
Brachial artery
169
How can you classify supracondylar fractures of the humerus?
1. Extension
| 2. Flexion
170
What are some features of extension supracondylar fractures of the humerus?
1. Commonest type
2. Distal fragment displaces posteriorly
3. Further classified with the Gartland classification
171
What are some features of a flexion supracondylar fracture of the humerus?
1. Less common
| 2. Distal fragment displaces anteriorly
172
What is the specific management for supracondylar fractures of the humerus?
1. Ensure there is no neurovascular damage
2. Restore the anatomy
a. No displacement --> flex the arm fully as possible and apply a collar and cuff for 3wks (triceps acts as a sling to stabilise fragments)
b. Displacement --> MUA + fixation with K wires + collar and cuff with arm flexed for 3wks
173
What are specific complications of supracondylar fractures of the humerus?
1. Neurovascular injury
2. Compartment syndrome
3. Gunstock deformity
174
What neurovascular injuries can occur in supracondylar fractures of the humerus?
1. Brachial artery
2. Radial nerve
3. Median nerve esp. the anterior interosseous branch
175
What is a sign of compartment syndrome with supracondylar fractures of the humerus?
Pain on passive extension of the fingers
176
What is another term for gunstock deformity?
Cubitus varus
177
What is the specific management for femoral and tibial fractures?
1. Resus and manage life threatening injuries first
2. X-match = Tibial (2 units), Femoral (4 units)
3. Assess neurovascular status esp. distal pulses
4. If open = Abx and ATT, take to theatre urgently for debridement, washout and stabilisation
5. Fixation methods = IM Nail, Ex-fix, plates and screws, MUA w/ fixed traction for 3-4m
178
What are specific complications of femoral and tibial fractures?
1. Hypovolaemic shock
2. Neurovascular (Superficial femoral artery and sciatic nerve)
3. Compartment syndrome
4. Respiratory complications
179
What are 3 respiratory complications of femoral and tibial fractures?
1. Fat embolism
2. ARDS
3. Pneumonia
180
What are the 2 main ankle injuries?
1. Ligament strains
| 2. Ankle fractures
181
What typically causes an ankle ligament strain?
A twisting inversion injury that strains the anterior talofibular part of the lateral collateral ligament
182
What is the ligament typically affected by an ankle strain?
Lateral collateral ligament
183
What is a rarer ligament affected by an ankle strain?
Medial deltoid ligament
184
What fracture may an ankle ligament strain be associated with/
Malleolar avulsion fractures
185
What are the Ottowa ankle rules?
X ray ankle if pain in malleolar zone + in any of:
1. Tenderness along distal 6cm of posterior tibia/fibula including posterior tip of the malleoli
2. Inability to bear weight both immediately and in A&E
186
What is the Weber classification?
Classification system for ankle fractures, taking into account the relation of fibula fracture to the joint line
1. A = below joint line
2. B = at joint line
3. C = above joint line
187
What do Weber's B and C fractures represent?
Possible injury to the syndesmotic ligaments between the tibia and fibula, leading to instability
188
What is the management of ankle fractures?
1. Weber A = boot or below-knee POP
2. Non-displaced Weber B/C = below-knee POP
3. Displaced Weber B/C = closed reduction and POP if anatomical reduction achieved, ORIF if closed reduction fails
189
What are key components in a knee injury history?
My sore patella looks gory
1. Mechanism
2. Swelling
3. Pain
4. Locking
5. Giving way
190
What does immediate swelling of the knee post injury represent?
Haemarthrosis = fracture or torn cruciates
191
What does overnight swelling of the knee post injury represent?
Effusion = meniscus or other ligament
192
What does pain/tenderness over the knee joint line suggest?
Meniscal involvement
193
What does pain/tenderness over the medial/lateral margins of the knee suggesr>
Collateral ligament inolvement
194
What causes locking of the knee?
Meniscal tear causes mechanical obstruction
195
How can you classify knee haemarthrosis?
1. Primary = spontaneous bleeding
| 2. Secondary = trauma
196
What are some causes of a primary knee haemarthrosis?
Coagulopathy = warfarin and haemophilia
197
What are some causes of a secondary knee haemarthrosis?
1. ACL injury = 80%
2. Patella dislocation = 10%
3. Meniscal injury = 10%
4. Osteophyte fracture
198
What is the unhappy triad of O'Donoghue?
Injury to the:
ACL
MCL
Medial meniscus
199
What is the management of a ruptured ACL?
1. Conservative
| 2. Surgical
200
What are the conservative managements for a ruptured ACL?
1. Rest
2. Physio to strengthen quads and hamstrings
3. Not enough stability for many sports
201
What are the surgical managements for a ruptured ACL?
1. Autograft repair = gold standard
2. Usually semitendinosus and gracilis (though one can also use the patella tendon)
3. Tendon is threaded through heads of tibia and femur and held using screws
