Orthopedics Flashcards
whats compartment syndrome
pressure within a fascial compartment is abnormally rasied cutting off blood supply to the contents of the compartment
whats in a fascial compartment
msucles
nerves
blood vesles
surrounded by fascia- un able to stretch expand
casues of acute compartment syndrome
usally due to an acute injury
get bleeding/ swelling (oedema) associated with the injury casuing increase in pressure
eg.
crush injury
bone fractures
presentation of acute compartment syndrome
most commonly in one of the compartments in legs but can be feet, thighs, buttcls , forearm
pain- disproportionate to the injury- pain meds dont help. main worse on passively stretching hte muscle
paraestheisa - pins and needles
pale
presure- high
paralysis- later and worrying feature
normally can feel the pulses - if not then probs more liekly acute limb ischemia
differnetial for acute compartment syndrome if cant feel pulse
acute limb ischemia
investigation of acute compartment syndrome
needle manometry - measure resitance of saline injected into compartment
usually dx is clinical
inital managemtn of acute compartment syndrome
escalate to reg/consultant orthopedic
remove external bandages/ dressings
elevate to level with heart if leg
maiantain good bp- avoid hypotension
definitive managemnt of acute compartment syndrome
emergency fasciotomy
- within 6hrs ideally
need to open up the compartment all the way and explore and debride any necrotic tisssue. leave wound open and then re op a few days a;ater can have many to keep debriding necrotic tissue and then eventually can cover the wound opnce swelling reduced. may need skin graf to close eventually
whats chronic compartment syndrome
also called chronic exertional compartment syndrome
not an emergency unlike acute
casues of chronic comparmtent syndrome
usually asscoaited with exertion
during exertion pressure in compartment increases and blood flow becomes restircted so symtooms start
when rest the pressure relives and so symtpoms start to resolve
symtpoms of chronic compartment syndrome
isolated to specific location at the affected compartment
pain
worse on exertion
relives by rest quickly
numbness/ paraestheisa
investigation and management for chronic compartment syndrome
needle manometry
measure p before during and after exertion
treat- fasciotomy - but not emergency
whats osteomyelitits
inflammation of bone and bone marrow usually casued by bacterial infection
can be acute or chronic
can have recurrent/ chronic infections after rx for acute
casues of osteomyelitits
usually bacterial- staphylcoccus aureus most common
modes of infection for osteomyeleitis
haematogenous osteomyleitits- spread through blood and seeds in bone = most common mode of infection
direct contamination of bone- fracture site/ ortho op
risk factors for osteomyeltitis
orthopedic surgery- esp prosthetic and esp revision surgery of prostehtic joints (hence give perioperative prophylactic abx for joint replacemnt)
diabetes - esp with diabetic foot ulcers
peripheral arterial disease
iv drug use
immunosupression
open fractures
presentation of osteomyeliti
fever
tender/bone pain
swelling
erythenma
generalsied infection:
nasuea and vomiting, lethargy, muscle aches
investigations for osteomyelitits
mri best for dx
xray can be donw but may not show changes- if no changesshown doesnt mean dont have it- cant use xray to exclude osteomyelitits
bloods- rasied crp, wbc, esr
blood culture may be psotive
bone cultures to find casue and anx senstivities
what may you see on xray in osteomyeltitis
periosteal rxn= changes to bone surface
locaslied osteopenia- thinning of bone
destruction of bone area
managemnt of osteomyltits
surgical debridment and abx
acute= 6 weeks abx of flucloxacillin and maybe rifampacin or fursolic acid for first 2 weeks
if allergic to penacillin use clindamycin
if mrsa then vancomycin/ teicoplanin
chronic= abx for 3 months or more
if associated wth prosthetis then may need compelete revision surgery to replace entire joint
what abx use for osteomyeltitis
flucloxacillin 6 weeks and maybe rifampacin/fusolic acid for the first 2 weeks
what abx use for osteomyletitis if allergic to penicllin
clindamycin instead of flucloxacillin
and maybe rifampacin/fusolic acid for first 2 weeks
6 week course
what abz use if mrsa cause osteomyleittis
vancomycin/teicoplanin
whats sarcoma
cancer originating from bone/ soft tissue/ other connective tissue
types of bone sarcoma and most common type of bone sarcoma
osteosarcoma= most common
chondrosarcoma - orginate from cartilage
ewing sarcoma= bone and soft tissue affecting children and young adults
rhabdomyosarcoma
cancer orignate from skeletal muslce
leiomyosarcoma
cancer originate from smooth muscle
liposarcoma
cacner originate from adipose tissue
synovial sarcoma
cancer orignate from soft tissue around joint
angiosarcoma
cancer orignate from lymph and bv
kaposis sarcoma
cancer casued by human herpes simplex virus 8 = most often seen in endsatge hiv
see typical purple/red srasied skin lesion and may have other body parts afected
what ccasues kaposis sarcoma
human herpes virus 8
presnetation of sarcoma
depnds location and cancer form
can be soft tissue lump eso if growing and painful/large
bone swelling
persistant bone pain
inital investigations for sarcoma
bone
soft tissue
xray best for bony lumps / peristant pain
us best for soft tissue lumps
definitive investigations for sarcoma -bone and soft tissue
ct/mri = can visualise in more detail and look for metasitc spread
ct thorax as sarcomas often spread to lungs
where do sarcomas commonly metastases to
lungs
managment of sarcomas
surgery- prefered option
radiotherpay
chemo
palliative
indications for elective joint replacement
osteoarthitis- main indication- if severe and not manageble by conservative rx
rheumatoid arthritits
fractures
septic arthritis
bone tumours
osteonecrosis
options for elective joint replacement
total joint replacement - replace both articualr surfaces
hemiarthroplasty= replace half joint
partial joint resurficing- replace part of the joint surgace eg. just medial surface
how does total hip replacment be donw
lateral incsion on outer aspect of hip
disolacte hip=expose both surfaces
remove head of femur and replace with ceramic or metal head on a metal stem
cement or push stem into shaft of femur
acetabulm hollowed out and metal socket put in place and spacer inbetween
total knee replacment done
vertical anterior icision
patella move out way
articular surfaces of femur and tibia removed (cartilage and some bone)
new metal surfaces that are cemented or screed in
spacer inbetween
total shoulder repalcment done
anterior incision down front shoulder - along deltoid
shoulder disolacted
head of humerus removed and replaced with ceramic/metal ball and attacthed to humerus either on a stem or screws
glenoid hollowed out and metal socket put in
reverse total shoulder replacment done
glenoid put a sphere on and humerus put a cup on head and then spacer inbetween
same function
whats need done before surgery for elective joint replacement
x ray
ct/mri
group and save and cross match
pre op assesment
consent
marker correct limb and side
med changes- temp stop anticoag
vte assesment
nbm before
whats done during surgeryfor elective joint replacment
ga/spinal
prophylactic abx to reduce risk infection
tranexamic acid = decreased blood loss
done after surgery for elective joint replacment
vte prophylaxis- LMWH or can use alternatively doac,aspirin, antiembolism stockings
physio
analgesia
post op xray
post op bloods- anemia
montior for complciatios- vte/ osteomyeltitis
how long LMWH for after hip replacment
28 days
how log LMWH for after knee repalcmeent
14 days
risks of elective joint replacemnt
bleeding
infection
pain
anestheitc risks
damage to nearby structures
not better
joint dislocation
sitff/restricted movement
looseing
fracutre during procedure
vte- pe and dvt
whats a big complication of joint replacement
prosthetic joint infection - osteomyelitis
whats done to prevent psteomyltiyis/prsthetic joint infection
perioperative prophylaxiss abx
increased chance happening in revision surgeries
most common its staphylcoccus aureus
risk facotrs of post op prostetic joint infection
diabetes
prolinged op tme
obestiy
investifations for osteomyltits/ prosthetic joing infection
clinical
can do xrya
bloods- increased crp
culutures- blood/ synovial fluid
treatment of osteomyltits in prostheitc joint surgery
repeat srugery - joint irrigation/ debridement/ complete repalcement
and
prlonged abx
whats meralgia parasthetica
localsied sensory symtoms of the outer thigh casued by compression of the lateral femoral cutaneous nerve
= mononeuropathy- only involes one nerve
what nerve roots supply the lateral femoral cutaneous nerve
L1,2,3
whats the route the lateral cutaneous femoral nerve takes
behind psoas muscle, aroud the surface of the iliacus muscle, under the iguinal ligament, ont the thigh medial and infeiort ASIS
what innervation does the lateral femoral cutaenous nerve supply
sensory only
to outer upper thigh
what casues meralgia parasthetica
pressure, deformity, trauma to nerve of lateral femoral cutaenous enrve
can ccur lots places
esp at where nerve goes under iguinal ligament
presentatin of meralgia parasthetica
abnormal sensation and loss of sessation of the lateral femoral cutaenous nerve districution- upper outer thigh
= dysaesthesia and anasthesia
skin of upper outer thigh affected
burning
numbness
pins and needles
cold sensation
localised hair loss
worse on walking/standing long time
better sat down
worsened by extention of hip on affected side= can do this in examination to test
diangosis of meraligia parasthetica
clincial
can do other investigations to exlcude other patholgy such as nerve root compression of spine
pelvic tumour compressin the nerve
managment of meralgia parasthetica
depends on severity
conservative:
rest
weight loss
loose clothing- no belts as this can casue compression of nerve
physio
medical:- analgesisa
nsaids
paracetamol
steoid injections/ local anesthitics
neuropathic pain meds= gabapenti, pregabalin, amitryptilin, duloxetine
what fractures are mainly for children
greenstick
buckle
salter harris fracture
only occur in children
growth plate fracture
whats a comminuted fracture
fracture in lots of pieces
colles fracture
transverse fracture of distal radius causing distal portion to displace posteriorly
fractures common from fall on outstretched hand
colles fracture
scaphoid fracture
tenderness in anatomical snuffbox
scaphoid fracture
whats worry about about scaphoid fracture
it has retrograde blood supply - fracture can cut off blood supply and casue avascular necrosis and non union
what bones have a vulnerable blood supply if they are fractured
scaphoid
head of femur
humeral head
talus
navicular
5th metatarsal in foot
whats important in ankle fracturs
the tibiofibular syndesmosis
- v important for joint stability and function
type of lateral malleous ankle fracturs
type a= below ankle joint - syndesmosis intact
typpe b= a level of joint- sysndesmosis intact or partially torn
type c= fractur above ankle joint= syndesmosis disrupted
casues of pahtological fractures
osteoporosis
tumour
pagets disease of bone
disease of bone
common in femur and vertebral bodies
common metastases to bone
portable
prostate
renal
thyroid
breast
lungs
pelvic ring fracturs are dangerous why
break in two places like a polo mint
can often lead to intrababdominal bleed-
due to vascualr injury or from cancellous bone
imaging inital for fractur
xray
imaging for more detail fracture
ct
early complications of fracture
dvt/pe
damage to nearby structures
haemorrhage
compartment syndrome
fat embolism
long term complications of fractures
stiffness
arthritits
chronic pain
malunion
non union
delayed union
avascualr necrosis
osteomyleitits
joint instability
complex regional pain syndrome
managemnt of fracitr
abcde
mechanical alighnment- open or closed
stability - cast, k wires, intrameduallry wires, intramedullary nails, screw/plate
pain management
whats fat embolsim syndrome
fat embolsim can occur after fracture of long bone
fat globules relased into circulation and can become lodged and pbstruct bv eg. pulmoary a
can also casue systemic inflammatory repsonse which casues fat embolsim syndrome
incresaed vessel permeability leads to problems
presentaiton of fat embolsim syndrome
presents typically 24-72 hrs after fracture
jaundice
fever
confusion
worsening sob
tachycardia
tachypnoeic
hyoxic
drowsiness
organ dysfunction on late stages
diangoosis of fat embolsim syndrome
GURDS criteria
2 major or 1 major and 4 minors
majors:
petechial rash
resp distres- t1 resp failure
cerebral involvement- confusion / drowsy
minors:
jaundice
fever
anemia
tachycardia
tachypnoea
retinal changes
rasied ESR
thrombocytopenia
fat macroglobulinamiea
investigfations for fat embolsim syndrome
abg - t1 resp distress
fbc, crp, u and e, lft, clotting
blood film = fat globules
cxr= diffuse bilateral pulmonary infiltration
ctpa= ground glass
differntials for fat embolsim
pe
menigiococcal septicaemia- petechial rash and fever ad confusion
treament fat embolsim
supportive esp ventialtion
prevention of fat embolsim
early surgery for fixing fracture
rf for fat embolsim syndrome
young
long bone fracutre
close fracturs/multiple fractures
conservative managment of fracture
acute back pain resolve in
1-2 weeks
sciatica resove in
4-6 weeks - unless chronic obvc
aims of back pain
see if serious underlying patholgy
speedy recovery
decrease risk of chroni cback pain
manage symtoms of chronic back pain
casues of mechanical back pain
muscle/ligament spasm
facet joint dysfunction
sacroiliac joint dysfunction
herniated disc
spondylolisthesis= anterior displacement of vertebrae to one below it
scoliosis
degeneration changes- arthritits- f discs and facet joints
casues of neck pain
muscle/ligament spasm- poor posture/ repeitivtive activities
torticollis - wake up and unilateral stiff and painful neck= muscle spasm
whiplash - cervical spondylsis
red flag casues of back pain
cauda equina -> saddle anesthesia, urinary retention, incontinece of bladder and feacal
spinal fracture- major trauma
spinal stenosis- intermittent neurogenic claudication
ankylosing spondylitits - under 40, gradual morning stiff/night pain
spinal infection- fever/ iv drug use
other casues of back pain (not back)
pneumonia
ruptured aortic aneurysm
pancreatitis
kidney stones
pyeloneprhtitis
prostitis
PID
endometriosis
what nerve roots of sciatic nerve
L4-S3
what does sciatic nerve split into
common peroneal nerve
tibial nerve
what innervation does the sciatic nerve do
sensation to lateral lower leg and foot
motor to posterior thigh, lower leg and foot
s and s sciatica
UNILATERAL pain from buttock radiating down bakc of thicgh to below knee/foot (if bilateral then consider cauda equina)
parasthesia
bumbness
motor weakness
rfexles depedning on nerve root affected
osgood schaltter disease
caused by inflammation at tibial tuberosity and avulsion fractures occur
inflamamtion at the tibial tuberosity where the patella ligament/tendo, insert.
have multiple minor avulsion fractures occur where the patella ligament pulls away tiny pieces of bone.
so you get growth at tibial tuberisity and so get lump and tender duet o inflammation
anterior knee pain adolescent
male
tneder bony lump anteior on tibial tuberosity
osgood schlatter disease
presentation osgood schaltter disease
10-15yrs common
more common in males
anterior knee pain
usually unilateral- can be bilateral
gradual onset
visible/palpable hard and tender lump on tibial tuberosity
pain worsened by physical activity, kneeling, extension of knee
managment of osgood schlatter disease
reduce ohysical activity
ice
nsaids
= inital
once symptoms setlled can have ohysio and stretching to strenghen the joint
prognosis of osgood schaltter disease
resolve over time
have hard bony lump on tibial tuberosity
can have rare complcation where have complete avuslion fracture and the tibial tuberosity is pulled away from the rest of the tibia= surgical intervention needed
bakers cyst
fluid filled sac in popliteal fossa
casuing lump/swelling in back of knee
popliteal fossa boundaries
back of knee
biceps femoris tendon- lateral and superior
semimembranous and semitendanous tendons- superior and medial
lateral head of gastrocnemius- inferior and lateral
medial head of gastrocnemius- inferior and medial
causes of bakers cyst
in adutls usually secondary to degernative changes in knee:
meniscal tear- imp to see if this cause
OA
inflammatory arthtrits- RA
injury to knee
synovial fliuid is squeezed out joint and into surrounding soft tissue - popliteal fossa
connection to cyst and synovial fluid can remain and so ccyst can increase in size
presentation of bakers cysts
localised to popliteal fossa
pain/discomfort- can be asymtomatic
reduced rang of mition if large
fullnesss
pressure
palpaple swelling/lump
most apparent stood with knee fully extended
smaller/disaperas when knee flexed at 45 degrees = focuhers sign
fouchers sign
bakers cyst
disapperas/smaller when knee flexed at 45 degrees
investigation bakers cyst
us - first line for dx
can check if dvt too
mri if need evaluate further - can show underlying casue eg. meniscal tear
differentials for lump in popliteal fossa
bakers cyst
varicose veins
tumour
dvt!
popliteal artery anuerysm
ganglion cyst
lipoma
abscess
managment of bakers cysts
nothing in asymptomatic
analgesia- nsaids
modify activity to not exaserbate it
physio
us guided aspiration
steroid injections
surgical- arthroscopy to rx underlying cause- resection hard and likely to recur esp other underlying pathology
pain in calf and swelling
dvt
bakers cyst rupture
bakers cyst rupture
cyst can rupture if pressure large enough
inflammation to surrounding tissue and claf:
pain
swelling
erythema
crucial differnetial to bakers cyst rupture
dvt
bakers cyst rupture can rarely casue what
compartment syndrome
causes of sciatica
lumbosacral nerve root compression by:
herniated disc
spondylolisthesis- anterior displaement f vertbrae
spinal stenosis
major ttrauma and back pain think
spinal fracture
stiffness in morning / rest back pain think
anklyoising spondlyitits
under 40 and back pain think
anklyosing spondylitits
gradual onset progressive back pain htink
ankylosingscpondylitits/ cancer
night pain back pain think
cancer/ ankylysing spondylyitits
over 50 and back pain think
cancer
weight loss and back pain think
cancer
bilateral motor.sensory and back pain think
cauda equina