Orthopaedics VI Flashcards
What are the cardinal features of acetabular labral tears? [3]
The cardinal clinical features of acetabular labral tears are hip pain, locking and instability:
- Pain is felt in the groin/hip region: specifically in the anterior hip or groin region.
- Clicking, locking, catching and giving way of the hip
The two main diagnostic investigations for acetabular labral tears are [2]?
MR-arthrogram
* An MRI scan combined with injecting contrast direct into the hip joint.
Diagnostic laparoscopy
* The gold standard definitive investigation.
Describe the treatment for acetabular labral tears [3]
Physiotherapy:
Medical management:
- NSAIDs
- Intra-articular steroid and local anaesthetic injections
Surgery:
- Hip arthroscopy is the surgical management of choice for acetabular labral tears: debridement or repair
What causes an ACL injury? [1]
ACL injuries typically occur due to a sudden change in direction, deceleration, or landing from a jump with an extended, twisted, or hyperextended knee
The majority of ACL injuries occur without contact and result from a sudden change of direction twisting the flexed knee.
NB Understanding the pathophysiology of an ACL injury begins with recognising its biomechanical role in the knee. The ACL is subjected to high tensile forces during activities involving sudden deceleration, changes in direction, or landing from a jump. When these forces exceed the ligament’s load-bearing capacity, an ACL tear can occur.
Desribe the clinical presentation of an ACL injury [3]
Acute onset of pain
- severe and local to knee joint
- hear a pop at time of injury
Swelling
Instability:
- knee ‘gives way’
Describe which clinical tests you can perform to test an ACL injury [2]
Anterior drawer test:
- Increased anterior translation, along with a soft or absent endpoint, suggests an ACL injury
Lachman test:
- patient is positioned supine with the knee flexed to 20-30 degrees
- The examiner stabilizes the femur with one hand and grasps the proximal tibia with the other hand
- The tibia is then pulled anteriorly while stabilizing the femur
- Increased anterior translation and a soft or absent endpoint compared to the contralateral side indicate an ACL injury.
NB: The Lachman test is considered more sensitive and specific than the anterior drawer test for detecting ACL injuries
How would you differentiate ACL to meniscal injury:
- based off the history [1]
- based off the symptoms [1]
- clinical test [1]
meniscal tears are typically associated with a twisting injury or direct impact to the knee while it’s flexed and weight-bearing.
Meniscal injuries classically have a ‘locking’ of the knee joint
A positive McMurray’s test - characterised by pain or a palpable click during flexion and rotation of the knee - is suggestive of a meniscal tear.
https://litfl.com/mcmurray-test/ for video
The biceps muscle has 2 tendons at its origin; the long tendon which attaches to the [] and the short tendon which attaches to the [] process.
It inserts distally via another tendon onto the [] tuberosity.
A biceps tendon rupture is when one of these tendons separates from its attachment site or is torn across it’s full width
The biceps muscle has 2 tendons at its origin; the long tendon which attaches to the glenoid and the short tendon which attaches to the coracoid process.
It inserts distally via another tendon onto the radial tuberosity
An iliopsoas abscess describes a collection of pus in iliopsoas compartment (iliopsoas and iliacus).
What is the most likely causative agent? [1]
Staphylococcus aureus: most common
What is the gold standard for testing for an iliopsoas abscess? [1]
CT is the gold standard.
Describe what is meant by meralgia paraesthetica [1]
syndrome of paraesthesia or anaesthesia in the distribution of the lateral femoral cutaneous nerve (LFCN).
- compression of this nerve anywhere along its course can lead to the development of meralgia paraesthetica.
The [] test is highly sensitive, and often, meralgia paraesthetica can be diagnosed based on this test alone.
Describe this test [1]
The pelvic compression test is highly sensitive, and often, meralgia paraesthetica can be diagnosed based on this test alone
deep palpation just below the ASIS:
- causes pain; numbness; coldness or burning
Tx for meralgia parasethetica? [1]
Injection of the nerve with local anaesthetic will abolish the pain. Using ultrasound is effective both for diagnosis and guiding injection therapy in meralgia paraesthetica
The menisci are nourished primarily by the blood supply from the [] arteries.
Describe how the vascularity of the menisci changes and why this is clinically relevant [3]
The menisci are nourished primarily by the blood supply from the geniculate arteries
The vascular supply decreases from the periphery to the inner third, creating three distinct zones: the red-red, red-white, and white-white zones. The red-red zone has the best healing potential, while the white-white zone has a limited ability to heal due to avascularity.
Describe the surgical repairs used for meniscal injuries [3]
State when they are indicated [3]
Meniscal repair:
- Indicated for tears in the vascular red-red or red-white zones, with a higher likelihood of healing. Repair techniques include inside-out, outside-in, and all-inside methods
Partial meniscectomy:
- Indicated for tears that are not amenable to repair, such as those in the avascular white-white zone or complex degenerative tears.
- The goal is to remove the unstable, non-viable tissue while preserving as much healthy meniscus as possible.
Meniscal transplantation:
- Indicated in select cases where the patient has undergone a previous total or subtotal meniscectomy and experiences persistent pain or functional impairment.
- The procedure involves transplanting a cadaveric meniscus to replace the missing or non-functional meniscus.
What would indicate someone has an osteoporotic vertebral fracture? [3]
- Loss of height: vertebral osteoporotic fractures of lead to compression of the spinal vertebrae hence a reduction in overall length of the spine and thus the patient becomes shorter
- Kyphosis (curvature of the spine)
- Localised tenderness on palpation of spinous processes at the fracture site
Which is the specific artery that supplies the meniscus? [1]
Middle genicular artery
What is the pathognomonic fracture associated with ACL tears? [1]
Segund fracture - this is an avulsion fracture of the proximal lateral tibia.
What is the most sensitive test for cruciate ligament rupture? [1]
Lachmans test
How do you treat an undisplaced and displaced patella fractures? [1]
Undisplaced fractures, particularly vertical fractures with an intact extensor mechanism can be managed non-operatively in a hinged knee brace for 6 weeks and patients allowed to fully weight bear.
Displaced fractures and those with loss of extensor mechanisms should be considered for operative management with either tension band wire, inter-fragmentary screws or cerclage wires. Again, patients are placed in a hinged knee brace for 4 to 6 weeks and allowed to fully weight bear.
Describe Garden’s classification (intra-capsular fractures) [4]
Type I - Incomplete, impacted in valgus
Type II - Complete, undisplaced
Type III - Complete, partially displaced
Type IV - Complete, completely displaced
What the classical feature of a NOF? [1]
the classic signs are a shortened and externally rotated leg
TOM TIP: It is worth understanding and remembering the concept of the retrograde blood supply to the head of the femur and how this determines the choice of operation
Describe the blood flow in the hip joint x [+]
The head of the femur has a retrograde blood supply:
- The medial and lateral circumflex femoral arteries join the femoral neck just proximal to the intertrochanteric line
- Branches of this artery run along the surface of the femoral neck, within the capsule, towards the femoral head.
- They provide the only blood supply to the femoral head.
- A fracture of the intra-capsular neck of the femur can damage these blood vessels, removing the blood supply to the femoral head, leading to avascular necrosis.
Basic overview:
What is important about the managament of intra and extra-capsular fractures due to the blood supply being affected? [2]
Non-displaced fractures (Grade I-II Gardeners):
internal fixation e.g. with screws to hold femoral head in place
Displaced fractures (Grade III-IV Gardeners):
- Head of femur needs to be removed and replaced either via hemiarthroplasty (replacing the head of the femur but leaving the acetabulum (socket) in place) or total hip replacement (involves replacing both the head of the femur and the socket)
Describe the different types of extra-capsular fractures [2]
Intertrochanteric fractures:
- occur between the greater and lesser trochanter.
Subtrochanteric fractures:
- occur distal to the lesser trochanter (although within 5cm).
- The fracture occurs to the proximal shaft of the femur.
Where is the fracture in this patient? [1]
Figure 3. A hip X-ray showing a right-sided intertrochanteric (extracapsular) hip fracture
Describe the fracture in this x-ray [1]
Figure 2. A hip X-ray showing a left-sided intracapsular hip fracture with partial displacement.
Describe the different managment options for a hip fracture? [4]
Internal fixation:
- using screws, plates, or intramedullary nails to stabilize the fracture, allowing for bone healing.
Hemiarthroplasty:
- This surgical procedure involves replacing the femoral head and neck with a prosthesis, typically used for displaced femoral neck fractures in elderly patients.
Total hip arthroplasty:
- This involves replacing both the femoral head and the acetabulum with prosthetic components, usually indicated for patients with pre-existing hip joint arthritis or those who may not be suitable candidates for hemiarthroplasty.
Conservative management:
- Non-operative treatment, including pain control, traction, and early mobilization, may be considered for stable, non-displaced fractures or in patients with significant medical comorbidities.
Describe how you manage a subtrochanteric fracture [1]
These may be treated with an intramedullary nail (a metal pole inserted through the greater trochanter into the central cavity of the shaft of the femur).
Describe how you would manage an:
- Intracapsular, undisplaced fracture [1]
- Intracapsular, displaced fracture [2]
Intracapsular, undisplaced fracture:
- internal fixation, or hemiarthroplasty if unfit.
Intracapsular, displaced fracture:
- replacement arthroplasty (total hip replacement or hemiarthroplasty) to all patients
NICE recommend replacement arthroplasty (total hip replacement or hemiarthroplasty) to all patients with a displaced intracapsular hip fracture
How do you decided if a THR or hemiarthroplasty is most appropriate? [3]
total hip replacement is favoured to hemiarthroplasty if patients:
* were able to walk independently out of doors with no more than the use of a stick and
* are not cognitively impaired and
* are medically fit for anaesthesia and the procedure.
Describe how you treat an intertrochanteric fracture [1]
Intertrochanteric fractures:
- These are treated with a dynamic hip screw (AKA sliding hip screw).
- A screw goes through the neck and into the head of the femur
- A plate with a barrel that holds the screw is screwed to the outside of the femoral shaft.
- The screw that goes through the femur to the head allows some controlled compression at the fracture site, whilst still holding it in the correct alignment. Adding some controlled compression across the fracture improves healing.
Describe the mechanisms that causes a tibial plateau fracture [2]
Fractures arise from a:
- valgus force, which describes an outside force pushing the knee inwards along a coronal plane.
- varus force: an inside force pushing the knee outwards along a coronal plane.
Which part of the tibial plateau bears 60% of the load through the knee? [1]
Why is this clioically significant? [1]
The medial tibial plateau bears 60% of the load through the knee.
Therefore the medial condyle is generally larger, stronger and transmits more weight compared to the lateral condyle. The lateral tibial condyle is convex in shape, compared to the concave medial side.
As a result the the lateral condyle is more frequently affected
Describe how you manage closed tibial plateau fractures [2]
Nonoperative management:
- generally involves a hinged knee brace.
- Can partial weight bear for 8-12 weeks
Operative management:
- open reduction and internal fixation (ORIF).
Describe how you manage open tibial plateau fractures [1]
External fixators are often used as a temporising measure in severe open fractures with contamination. Staged procedures to wash, debride and later fix the fracture can be arranged.
Describe the clinical features of a rib fracture [+]
- severe, sharp chest wall pain is the most common symptom; the pain is often more severe with deep breaths or coughing
- there is usually significant chest wall tenderness over the site of the fractures and there may be visible bruising of the skin
- auscultation of the chest may reveal crackles or reduced breath sounds if there is an underlying lung injury
- pain and underlying lung injury can also result in a reduction in ventilation causing a drop in oxygen saturation
- pneumothorax: this can be a serious complication of a rib fracture and presents with reduced chest expansion, reduced breath sounds and hyper-resonant percussion on the affected side
Describe what is meant by a flail chest [1]
Describe how a flail chest moves [1]
A consequence of multiple rib fractures that can occur following trauma:
- two or more rib fractures along three or more consecutive ribs, usually anteriorly
- moves paradoxically during respiration and impairs ventilation of the lung on the side of injury
What is a potential complication of not treating a flail chest? [1]
the segment can cause serious contusional injury to the underlying lung if left untreated
What is the best imaging modality to view a flail chest? [1]
the best diagnostic test is a CT scan of the chest as this will show the fractures in 3D as well as the associated soft tissue injuries.
Describe management of a flail chest [2]
Most are managed conservatively with good analgesia to ensure breathing is not affected by pain
Surgical fixation can be considered to manage pain if this is still an issue and the fractures have failed to heal following 12 weeks of conservative management
Management of avascular necrosis of the hip is a stepwise approach.
What are the different steps? (overview) [3]
Conservative Management:
- Pharmacological therapy
- Physiotherapy
Surgical Management:
* Core decompression surgery:
* Osteotomy
* Bone grafting
* Arthroplasty
Describe the managment plans for the following options for AVN of the hip
Conservative Management:
- Pharmacological therapy [3]
- Physiotherapy
Surgical Management:
* Core decompression surgery:
* Osteotomy
* Bone grafting
* Arthroplasty
Conservative Management:
- Pharmacological therapy: NSAIDS; Bisphosphonates (may slow the progression of bone necrosis and disease-related osteoporosis); Vasodilators such as iloprost can be used to improve blood flow to the affected area.
- Physiotherapy
Surgical Management:
Core decompression surgery:
- reduces intraosseous pressure, relieves pain, promotes vascular infiltration
Osteotomy:
- repositioning the necrotic segment away from the weight-bearing zone
- typically reserved for younger patients with good remaining articular cartilage
Bone grafting
- Autograft or allograft options can be used to support the subchondral bone and reduce collapse risk.
Arthroplasty
- Total hip replacement or hemiarthroplasty is usually reserved for patients with advanced disease.
