Orthopedic Xray Presentation

Question 1

Introduction

Answer 1

Name DOB
Date
Part of body
View

Question 2

History key questions

Answer 2

Age, Sex, Handedness, Occupation and hobbies

MOI and date

Smoking - affects bone healing
PMHs, AC/AP use - fitness for GA, LA

Question 3

Examination

Answer 3

Closed
Open - is there a pathway between environment and bone

Neurovascularly intact before and after every intervention
-UL - median, radial, ulnar

Specific tests
-Scaphoid # - press on AS

Question 4

Management

Answer 4

Analgesia - pain relief

Reduce

Hold - cover half of arm with plaster

Question 5

Distal radius fracture in adults

Answer 5

High energy, comminuted

Colles - FOOSH, dinnerfork, EA DA
Smiths - inverse FOOSH, EA, VA
Bartons - V or D
Chauffeurs - IA, radial styloid fracture, scaphoid-lunate ligament diastasis

Radial inclination - 22deg
Radial height - 11mm
Ulnar variance +-2mm
Volar tilt - 11-15deg

ORIF needed if

• unstable
• dorsal comminution
• dorsal angulation 20deg+
• IA
• age
• ulnar fracture
• radial height
• prereduction position

Question 6

Distal radius fractures in children

INCOMPLETE

Answer 6

Often incomplete => buckle, torus
-periosteum is thicker in children so they buckle instead of break

Very rarely need plaster
Splints may be enough

Salter Harris classification - break in relation to growth break
1S - separation
2A - above MOST COMMON
3L - lower

Question 7

Scaphoid fractures

Answer 7

High index of suspicion - often not visible on initial xray

MOI - high energy, sports

Clinical examination

• press on AS
• scaphoid tubercle tenderness
• deep flexion, extension painful, ulnar deviation

Imaging
-scaphoid series or MRI
IMPORTANT TO DOCUMENT SPECIFICALLY

Proximal pole - poorest blood supply

Question 8

Greenstick

Answer 8

Could this be non accidental injury - Hx is key

Question 9

Galeazzi vs Monteggia

Answer 9

GR
Distal 1/3 radius fracture
Ulnar dislocation

UM
Proximal 1/3 ulnar fracture
Radial dislocation

Question 10

Olecranon

Answer 10

extensor mechanism may be disrupted

Consider age

Question 11

Elbow radiographic lines

Answer 11

Elbow fat pads - occult bony injury

Question 12

Supracondylar humerus fracture in paeds

Answer 12

Gartland
1 - UD => plaster
2 - disrupted ant humeral line 
3 - displaced 
4 - displaced, rotational unstable

Puncture wound, pucker sign
Check AIN - ok sign
Ulnar nerve
Brachial artery
Pulse
Check colour

Question 13

Clavicle

Answer 13

SLing

Question 14

Humeral

Answer 14

Holstein Lewis spiral fracture - radial nerve palsy

Collar and cuff

Question 15

Hand examination

Answer 15

CRT - injured and non injured comparison
Sensation of both sides of finger

Passive, active movement of fingers

Joint stability comparisons

Passive lateral MCPJ and PIPJ stress
AP - test volar plate

Question 16

Hand imaging

Answer 16

ASK FOR SPECIFIC IMAGES OF AREA OF CONCERN
Xray
CT
MRI
US - dynamic concerns, tendons
Bone scan

Question 17

Sensory innervation of hand

Answer 17

Ulnar - little finger
Radial - dorsal between 1st and 2nd finger

Median - palmar index

Question 18

Motor function of hand

Answer 18

Ulnar - key pinch’
-Froments sign - thumb flexion = median compensating for ulnar issue

Median -

Radial - wrist drop

Question 19

Sharp injuries

Answer 19

Concerns over FDS FDP

Question 20

Tendon lacerations

Answer 20

Must test specifically unless you can see the damage

-FDS, FDP

Question 21

Wound exploration

Answer 21

zig zag incisions

-prevent contractures forming over joints

Question 22

Mallet finger

Answer 22

Drooping distal phalanx - unable to ext
-ext tendon ruptured or avulsed bone

Tendinous - finger splints
-keeps finger straight
Bony - Kwire

Question 23

Digital nerve laceration

Answer 23

Microsurgical nerve repair

Question 24

Hand infections

-common organisms

Answer 24

Most common - trauma, post op, foreign bodies

S aureus
Mixed - staph, streph
Anaerobes - dog/cat/human bites, IV, DM, dental scrapings

Occupational
-works with water, fish tanks

Question 25

Dangers of cat bites

Dangers of dog bites

Answer 25

Bacteria needle like teeth => very deep but small skin breaks

Dogs have strong teeth => crush injuries, fractures

Question 26

Assessment

Answer 26

Hx - predisposing factors

• DM
• IVDU, alcohol, HIV, chronic CS, AI, malnutrition

Symptoms - 
-local, systemic
Signs - 
-local, systemic
-superficial, deep
-hand posturing

Trends are useful
FBC, cultures, ESR, CRP
MC&S

Imaging
XRay - FB fragments, fractures

Question 27

Management

Answer 27

Incision - extension of small/penetrating wounds

Debridement - leave open => let them drain

Irrigation/drains

Splinting to keep it open

ABx - culture before start

Question 28

Pyogenic flexor tenosynovitis

Answer 28

Kanavel’s cardinal signs
-sausage fingers, pain passive extention

Urgent treatment
-exploration, cont irrigation

Question 29

Bites, contaminated wounds

Answer 29

DON’T CLOSE THEM IMMEDIATELY

Question 30

Fight bite

Answer 30

Tooth fragments may be there

Question 31

Goal of fracture treatment

Answer 31

Restore function
Prevent complications
Get fracture to heal in position that will produce optimal functional recovery

Question 32

Non operative fracture treatment

Answer 32

Manipulation for reduction if displaced
Hematoma block
LA
IV morphine

Question 33

Skiers thumb

Answer 33

Collateral thumb ligament torn