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
saddle anesethisa and back pain think
cauda equina
urinary retnetions/incontienceand back pain think
cauda equina
faceal incontinece and back pain think
cauda equina
history of cancerand back pain think
cauda equina/ spinal mets
fever and back pain think
spianl infection
bladder distention and back pain think
urinary retention- cauda equina
deceased anal tone and back pain think
cauda equinea
sciatic stretch test
sciatica
cacners that commonly metastes to bone
portable
prostate
renal
thyroid
breast
lung
how to asses to developing chronic back pain
STarT
managemnt of acute lower back pain
self treatment
education
analgeisa
acitve and conitue mobilise
reassurance
saftey netting
NSAIDS- forst line
or cdoeine as alternative
benzodiasapines for 5 day max use for m spasm
what meds not to use in low back pain analgesai
dont use opiods, anti d, amitryptoline, gabapenitn, pregablin
in medium- high reisk developing chroni cback pain treamtnet of acute back pain
physio
group exercise
cbt
treatment sciatica acute
same as acute low abck pain
dont use gabapentin, pregablin, diazaepa, oral corticosteroids.
neuropathic meds if symtoms persit/worsen= not pregablin/gabapentin :
use:
duloextine
amitriptiline
meds not use chronic sciatica
dont use opiods in chrinic sciatica
rx meds use in chronin=c sciatica
epidural corticosteroid injections
local anaesthesia injection
radiofrequency denervation
spinal decompression
treatment chronic lower back pain if from facet joints
radiofrequency denervation
targets and damages the medial branch nerves that supply sensation to facet joints assocated with back pain
done under local
investigations back pain
xray /ct= ssuspect spianl fracute
bladder scan suspect cauda equinea
mri susepct cuada equina
cauda equina syndrome
surgical emergency
nerve roots of cauda equine compressed
whats cauda equia and what supply
L3-S5 and co nerve roots ar epart of cauda equina
lower motor neruons as already left the spinal cord
sensations to perineum, bladder, rectum
PNS supply to bladder and rectum
motor-lower limb, anal and urethral sphincters
causes of cauda equina syndrome
herniated disc- most common
tumours- esp metasatises
spondylolithiasis- anteior displacement of vertbrae to one below
abscess- infection
trauma
red flags of cauda equina syndrome
saddle anaesthesia- does it feel norma when you wipe yourself after opneng bowels
loss of sensation of bladder and rectum
faceal incontinece
urinary incntirence/retentoin
bilateral sciatica
bilateral/sevre motor weakness in legs
decreased anal tone on PR
managemnt for cauda equia syndrome
immediate hosp
surgical emergency
bladder scan- if susepct retention
emergecny mri
neuro
surgical decompression - but symptoms may not resolve
metastatic spinal cord compression
metastatic lesion that compresses on spinal cord - before the end of the sc and start of cauda equina
oncological emergecny
presentation of MSCC
similar to cauda equina
back pain- worse on coughin / straining
sensory s
morotr s
progressive lumba pain
pain throacic/cervical spine
localsied spine tenderness
any limb weakness/ diff walking
bladder dysfunction
bowel dysfunction
signs ofspinal cord/ cauda equina compression
treatment MSCC
high dose dexamethasone= 16mg = reduce swelling in tumour and relive compression
analgesia
surgery
radio/chemo
diff between cauda equina and MSCC
cauda equina= lmn= reduced reflexes and reduced tone
MSCC= umn= increase tone, brisk reflexes, up going plantar reflex
spinal stenosis
narrowing of part of the spinal canal resulting in compression of the spinal cord or nerve roots
which stenosis is more common
lumbar more than cervical
types of spinal stenosis
central stenosis - narrowing of central spimal canal
foramina stneosis- narrowing of intervertebral foramina
lateral stenosis - narroinwing of nerve root cancal
casues of spinal stenosis
congenital
degenrative- facet changes, disc disease, bone spurs
herniated discs
thickening of ligametum flava/ posterior longituidanl l
spinal fractures
spondylolithiasis
tumours
presentation of spinal stenosis
intermittendt neurological claudication!!- lower back pain, leg weakness, buttcok/leg pain
over 60 more common cus degernative
gradual onset - as opossed to causda equina and MSCC
severity depneds on narrowing and compression
can present similar symtpoms to cauda equina- urinary incontineces, bowel incontinecen, sex dysfucntion
, saddle anaesthesia
sciatica- esp eith lateral stenosis and foramina stenosis in lumbar spine
whats intermittent neruological claudication
key feature of spinal stenosis
lower back pain
buttock/leg pain
leg weakness
absent wehn seated/rest
worse/ occurs on standing/walking
bending forward improves symtpoms cu opens cana
standing straight worsens cus closes cancal
whats radiculopathy
compression of nerve roots as they exit sc/coloum =? sensory and motor symptoms
differential to intermitent neurological claudication
peripheral arterial disease
pad has no back pain though.
intermittendt neruologicl claudications has back pain and normal ABPI/ peripheral pulses
back pain
worse on walking
leg pain
normal pulses and normal ABPI
spinal stneosis
- have intermittent neurological claudication
investigations spinal stenosis
mri
exlcude PAD with ct angiogram/ABPI if have symtpoms of intermittent claudication
managemnt of spinal stneosis
weight loss
exericse
analgesia
physio
decompression surgery
lamiectomy
trochanteric bursitits
inflammation of the bursa over the greater trocheter on the outer hip
bursae are what
synovial membrane with synovial fluid in to redcue fribction between bone and soft tissue - at bony prominences
bursitts have thickening of synovial mebrane and increased fluid producition-> swelling
casues of trochanteric bursitits
friction from repetitive actions
infection= septic bursitits
inflam conditions- RA
trauma
presentaion of trochanteric bursitits
gradaual onset
lateral hip pain- can radiate down outer thigh
pain feels aching/burning
worse with activity/ standnng after stting for a long time, truying to cross legs
may disrupt sleep
tenderness over greater torchanter
usually no swelling
presentaion of trochanteric bursitits
gradaual onset
lateral hip pain- can radiate down outer thigh
pain feels aching/burning
worse with activity/ standnng after stting for a long time, truying to cross legs
may disrupt sleep
tenderness over greater torchanter
usually no swelling
speical test to test for trochanteric bursitis
resisted abduction at hip
resisted internal rotation at hip
resisted external rotation at hip
treneleburg test- stand on one leg affected side and the other side will drops down= postive test= weakenss of affected hip side
resited movement causing pain supports bursitits
manamgent trochanteric bursitis
rest
ice
nsaids- ibruprofen/naproxen
6-9months recover
physio
steoridinjections
abx if septic bursitits
septic bursitits s and s
inflammation- red
swelling
wrmth
fever
pain over area of greater trochanter
whats mesicsu
cartilage in knee
fucntion- shock absr=orber, redistribute weight throughout joint
stabalise joint
presentation of meniscal tear
often due to twisting motion
hear/feel pop sound/sensation
knee give way/ instability
pain- can be refered to hip/ lower back
swelling- rapid normally
stiffness
restricted range of motion
locking of knee
localised tnederness to joint line
investigations meniscal tear
mc murrays test
apley grind test
ottawa knee rules
MRI- frisrt line fr dx
athroscopy- gold stander for dx
ottawa knee rules
say if need xray after acute knee injury if any presetn:
55 and over
patella tenderness and no where else
fibular tenderness
cant felx knee to 90 degress
cant weight bear- cant do 4 steps- limping counts
managment for mensical tear
urgernt referal if acute onset knee pain
a and e
fracture clinic
varies
conservative- rice
nsaids= frisrt line analgesia
physio
surgery- arthroscopy- repair/ resection affected part often reusts in OA
what casues instability to knee
injury to acl
pcl
meniscus
which acl or pcl injury more common
ACL
acl attaches where and fucntion
acl attach from lateral aspect intercondylar notch to anterior intercondylar area on tibia
stops tibia moving forward inrelation to femur
pcl attaches where and function
pcl medial aspect intercondylar nothc to posterior interocndylar area of tibia
stops tibia sliding backwards in relation to femur
presentation acl injury
typically twisting motion
pain
swelling
pop sound/sensation
insability
tibia moves anteriorly
knee can buckle- lack of confience wlaking- msucles weaknes- more injury likely to occur
tests for acl injury
anterior draw test- psotiove if feel no clear end point to tibia moving forward
lachman test- same anteiro draw but knee at 20-30 degrees
investigations acl injury
mri forst ine dx
arthrocopy- gold stander dx
managment acl injury
urgent referla if sudeden onset knee pain with any symptoms suggesting acl injury- pop, rapidonset swelling, instaiblity/give wat
rice
anaglesia- nsaids
brace/cruchtes- help protect knoee
physio
arthroscopic surgery- reconstruct ligament- graft from hamstring tendon, quad tendon, bone-patella-tendon-bone(use some bone the tendon inserts into_
pop sensation in knee
rapid swelling
insbility/knee give way
urgent referal
could be mensicus tear
ACL injury
investifations for mesnicus tear/acl injury
mri forst lin for dx
arthroscopy- gold standerd for dx
whats most common shoulder dislocation and cause
anterior dislocation
as if catching a big rock with arm abducted and extended and then forced backward
humerus head moves anteriorly
casues of posterior shoulder dislocation
seizures
electric shock
associated damage with shoulder dislocation anterior
bankart lesions = tears to the anterior portion of the labrum
occur with repead subluxation/dislocation
hill sachs lesion= compression fracture on posterolateral head of humerus
as the humerus head dislocates forward the head impacts with the anterior rim of the glenoid cavity
=> makes the shoulder les stable and risk further dislocations
axiallry nerve damage- c5 and c6
= loss sensation on regimental patch of deltoid and weakness of deltoid and teres minor
fractures:
clavicle, humerus head, greater tuberosirty of humerus, acromion of scapula
rotator cuff tears
- esp in older peopl
presentation of anterior dislocation of shoulder
acute pai
occur after acute injury
muscles go into spasm and tighten shortly after
deltoid appears flatter and buldge of humerus head anterioly
asses for:
fractures
vascualr damage- absent pulses, prolonged cap refil time, pallor
nerve damage- loss sensation deltoidon regimental patch
what test can do to see if patient has shoulder instability
apprehension test
supine
abduct arm 90
flex at elbow 90
then slwly externally rotate and pt will become worrued it will dislocate- no pain just apprehension
investigations shoulder dislocation
xray= confrim dx and asses for fractures
not always needed do before relocation but do after to cehck in right place and no fractres
magnetic resonance arthrogrpahy= mri with cintrast injected into shoulder to asses for shoulder damage-> bankart lesions/ hill-sachs lesion
acute managment of shouder dislocaition
analgesia, m relxants, sedation - if appropriate
gas and air- entonox
braod arm sling
closed reduction- after excluding fractures
post reduction xray
immobilisation for bit after relocation
ongoing managment for shoulder dislocation
have increased risk of recurrent dislocation esp if younger
physio- inc movement and reduce risk recur
shoulder stabalisation surgery-
correct underlying strucutral issues:
repair bankart lesions
tighten capsule
bone graft - caracoid process to correct injury rto glenoid= laatarjet procedure
correct hills-sachs lesion= remplissace procedure
long recovery- 3 months
frozen shoulder
common cause of shoulder pain and stiffness
also called adhesive capsulitis
loss of range of motion and function in shoulder joint
inflammation and fibrosis in joint capsule leads to adhesions=> bind to the capsule and cause it to tighten aorund the joint
types of frozen shoulder
primary= occur spontaneously
seondary= occurs in response to trauma/ surgery/ immobilisation
presentation frozen shoulder
3 phases
painful phase: shoulder pain first sy,tpkms - can be worse at night
stiff phase: shoulder becomes stiff, affected in passive and active movement
external rotation most affected
pain settles during this phase
thawing phase- gets less stiff
can last 1-3 years but some never resolves
what movement is most affected in frozen shoulder
external rotation
differentials for shoulder pain with no truama before
suraspinatous tendinopathy= inflamm and irritation of tendon- empty can test postive = pain
acrominoclavicular joint arthritits= tenderness when palpate AC joint and pain worse at extreme abduction of shoulder - over 170 degress when above head
glenohumeral joint arthritis
psotive scarf test
frozen shoulder
rare but important:
septic arthritis
inflammatory artheitits
malignacny- osteosarcoma/mets
differentials for shoulder pain preceded buy truama
shoulder dislocation
fracturea- clavicle, proximal humerus
rotator cuff tear
managment for frozen shoulder
keep moveing but dont exasrbeate pain
analgesia- nsaids
physio
intraarticular steorid inkectios
hydrodilation= inkject fluid intp capsule to strecth capsule
surgery if persitant:
arthroscopy- cut adhesions
manipulation under anaesthesia- frocefully stretch capsule
risk factor for frozen shoulder
middle age
DIABETES
muecles of rotator cuf
SITS
supraspinatus= abduction arm
infraspinatus= external rotation arm
teres minor= external rotation arm
subscapularis= internal rotation arm
caues of rotator cuff tear
acute injury= foosh
degernerative chagnes with age
overhead activities- tennis, overhead construction work
presentatin of rotator cuff tear
acute onset if after acute injury
gradual onset can be if degenerative
shoulder pain - disrupt sleep
weakenss and pain on specific movement eg. if supraspinatus tendon torn then pain and weakness on abduction of arm
investigations rotator cuff tear
xray can be done to exclude bony patholpogy eg. OA
MRI/US for dx
management of rotator cuff tear
if degernatiove cause:
conservative
esp if complcaition indicated for surgery
rest and adpat movement
analgesia-nsaids
physio
if acitive/young/ acute injury/ complete tear = surgery
arthroscopic rotator cuff repiar- tendon reattatched
presentation of plantar fascitits
pain on plantar aspect of heel
gradualt onset
worse on standing/walking
tnederness on palpation
= inflamamtion of plantar facia
managemnt of plantar fascitits
rest
ice
analgesia-nsaids
physio
steorid inkections- although v painful and can casue achilles rupture / fat pad atrophy
rarely can do suegery/ESWT
risk of steroid injections in plantar fascia
fat pad atrophy
achilles rupture
casues of fat pad atrophy
age
inflammation from reptitive impact- jumping, walking, obestiyy, running
steroid injections local
presentation of fat pad atrophy
pain on heel
similar to platnar fascitits
worse standin/ wlaking and worse barefoot on hard surgace
investigations fat pad atrophy
us can measure fat
treamtent fat pad atrophy
comdortbale shoes
insoles
adapt activiteis- no high heels
wight loss
pain on heel difffernetial
plantar fasciaitis
fat pad atrophy
mortons neuroma
dysfunction of nerve in the intermetatasral spalce at top foot- usually between 3 and 4th metatarsal
causes of mortons neuroma
irrirtated nerve duet o biomechanics of foot
snesation of lump in shoe
burning, numbness, pins and needles in distal toes
tests for mortons neuroma
deep pressure - on afected area = pain
metatarsal squeeze test- concave foot and with other hand press on plantar side and pain
mulders sign= painful clikc when metatarsal heads rub
us/mri confrim
management of mortons neuroma
adapt activities- no heels
anaglesai- nsaids
insoles
wight loss
steroid injkection
radiofrequency ablation
excision of neurome
hallux valgus
bunions
bony lump created by deformity at the metatarsalphalangeal joint at base big toes
mtp become sinlfammed and enlarge
over time stress can cause oa in it
presentation hallux valgus
develop slwoly
painful
esp walking and tight shoes hurts
bony lumo
investigations bunion/hallux valgus
weight bearing xray
treatment for hallux valgus
conservative:
wide shoes
anaglesia
bunion pads
definitve is surgery
gout in foot wehre
common casue of pain and swellng in MTP joint at base big toe
= acutely hot, swollen and painful
investigations gout in mtp big toe
clincial dx
exclude septic arthritis- joint fluid aspiration
:
no bacterial growth
needles shaped crystals
negative birefringent of polarised light
monosodium urate crystals
managent acute flare of gout
nsaids - first line
colchine= second line
steorids- 3rd line
dont start allopurinol until acute settled as can casue/make it worse
managment for prophylaxis of gout
allopurinol
dont start until acute flare gone down
once started it and then have acute flare can keep using it
decrease alchol and ourine diet- low seafood and red meat, keep hydrated
risk factors achilles tendon rupture
sports that stress achilles- basetball, tennis, track
increasing age
existing achilles tendiopathy
flouroquinolones- ciprofloxacin, levofloxacin
fam hist
system steroids
flouroquinolones can casues what within 48hrs starting
can cause spontaenous achilles rupture - need warn pts starting flouroquinolones about it
presentation of achilles tendon rupture
sudden onset injury
sudden onset pain in calf/achilles
snapping sound/sensation
feel something hit them in back of leg
swelling
no prior warnings
o/e
with ankle relaxed more in dorsiflexion
palpable gap- but may be hidden by swelling
weakness on plantar flexion on affected side
cant walk/stand on tip toes on affected side
postive simmonds test on side= kneeling and squeeze calf and the foot doesnt plantar flex
managment of achilles tendon rupture
orthorpedics same day
immediate:
rest
ice
analgesia
evelation
VTE prophylaxis- immobile
fix:
surgical/ non srugical
- similar recvoery times
surgical- reatch tendon but surgery risks
non surgical- more risk of re rupture but nmo srugical risks
both need be in a boot thats full plantar flexion of ankle and then slowly over time go more to neutral postion
- 6-12 weeks
investigations for achilles tendon rupture
US
fluouroquinolones are associated with what
achiles tendon rupture
achellies tendiopathy
achilles tendinopathy
damage, swellint, inflammation and redcued function in tendon
action of achilles tendon
connects gastrocnemius and soleus to calcaneus
flecion os calf uscles pulls on achiles and casues plantar flexion
achilles tendiopathy 1cm from caclcaeus is what
insertion tendiopathy= within 2cm of insertion point on calcaenus
achilles tendiopathy 3 cm from calcaenus is what
mid-portion tendipathy
2-6cm above insertion point
risk factors achilles tendiopahy
sports that stress the achilles- basketball, tennis, track
inflam condition- ra, ankloysing spondylitits
diabetes
raised cholesterol
fluoroquinolones- ciprofloxacin, levofloxacin
presentation achilles tendonopathy
gradual onset
pain/achingin achilles tendon/ heel with acitivty
stiffness
tenderness
nodualrity on palpation
gradual onset of pain/ aching in heel
tneder to touch achilles
nodules on achilles tenon
stiff ankle
ahcilles tendonopathy
differentials for achilles tendonopathy
achilles tendon rupture- investigate with US and simmons calf test to exclude
managemnt of achilles tendonopathy
clicnial dx
exclude achilles rupture
rest and altered activity
ice
analgesi
physio
orthotics
extracorporeal shockwave therpay- ESWT
surgery- remove nodules and adhesion/ alter tnedon if other rx fails
whats a ganglion cyst
sac of synrovialfluid that orginate from tendon sheath / joint
synovial membrane of tendon sheth/joint herniates forming a ouch and then fluid goes into the ouch
most common places of ganglion cysts
wrist and finger
presentation of ganglion cyst
palpable and visible lump
usally not painful although can compress nerve rarely causing sensory and motor symptoms then
transilluminate
gradual/rapid onset
ranges in size 0.5cm-5cm or more
firm non tender
well circumbised
diangosis for ganglion cycst investigation
usally clinical
x ray normal
us can be sue to exlcude other casues and help confrim dx
managemnt of ganglion cyst
conservative- some go but can take yeasr
aspiration with neede- but 50% recur
surgical excision- v low recur
carpal tunnel syndrome
asued by compression of the median nerve as it goes through the carpal tunnel
casues pain and numbness of the median n distribution
flexor retinaculum = fibrous band over wrist
palmar digital cutanoues branch of median nerve goes through carpal tunnel = supplys innervation of sensory to palmar aspects of full finger tips of thumb, index, middle and lateral half of ring finger
palmar cutanoues bracnh of median nerve supplies palm sensory bu this goes over the flexor retinaculum so palm not affected
median nerve supplies: thenar muscle of hand:
abductor pollicis brevis, oppnens pollicis, flexor pollicis brevis
adductor pollicis is innervated by ulnar nerve
compression of the contents of the carpal tunnel which results in the syndrome is either due to swelliung of contetnseg. tendon due to repptivie strain or narrowing of the sheat
risk factors for carpal tunnel syndrome
diabetes
acromegaly
hypothyroidism
rheumatoid arthritis
fam hist
repetivie strain
obesity
perimenopause
most cases are idiopathic but if they have ct syndrome esp bilateral then look for other features of these risk factors
acromegaly is a risk facotr for what
carpa tunnel syndrome
presentation of carpal tunnel syndrome
gradual onset - initally intermittent symptoms
worse at night - may shake hand to try make symtpoms go
sensory:
thumb, index and mid finger and also lateral half of ring finger and palmar aspects affected:
numbness
pain
paraestheisa
burning
motor:
thenar muscles
weakness of grip strenth
weakenss of thumb movements (adduction spared as this ulnar nerve)
muscle wasting of thenar
difficult to do fine movements with thrumb
tests for carpal tunnel syndrome
tinnels test- tap on middle of wrist - get symptoms sensory postigve
phalens test- flex wrists together and get snesory symtpoms postive
carpal tunnel questionarie- if high risk of having ct then may not need do nerve conudciton
primary investigation is nerve conduction studies- see how well signals pass through median nerve
managment of carpal tunnel syndrome
rest and adapt activities
split to hold in neutral position at night for min 4 weeks
steroid injectuins
surgery- la and can be open or laparoscopuc - cut flexor retinaculum to relive pressure on median nerve
dupuytrens contracture
fascia of the palm becomes thickend and tight leading to finger contrcture
contracture= shortening of soft tissue
finger gets tighthend into a flexed postion and cant fully exend it
the palmar fascia is strong ct
this becomes thick and tigher and develops noduels and the cords of dnese ct can extend into the finger which pulls the finger into flexed
presentation of dupuytrens contracture
frisst present with hard nodules on palm
skin thickening and pitting
fascia becomes thickened and gradually the finger is pulled int flexion
eventually impossible to fully extend the finger
can feel a thick nodular cord on the palm to the finger affected
usually no pain
affects fucntion of hand
figner most affected in dupuytrens contracture
ring finger mosy
index finger least afected
test for dupuytrens contracture
table top test
if they cant flatten their hands fully onto the table then suggest got it
managment of dupuytrens contracture
conservative- do nothging
surgical:
needle fasciotomy - needle in and seperate the cords and loosen them
limited fasciectomy- remove the fascia affected and cord
dermofasciaectomy- remove skin assciated and the abnormal fasci anf then need a skin graft
risk facotrs for dupuytrens contracture
smoking and alcohol
epilepsy
diabetes esp T1
age
fam hist- autosomal dominant pattern
male
manual labour- esp vibrating tools
man who has epilepsy and uses vibrating tools cant extend his left ring finger.
could be trigger finger but more liekly dupuytrens contracture as rf for it and cant at all extend it
trigger finger
stenosing tenosynovitis
pain and difficulty moving the affected finger
casue and pathophysiology of trigger finger
flexor tendons pass through ltos of tendon sheaths along the finger
have thickening of the tendon/narrowing of the sheath (tighetning)
then this prevents the flexor tendons from running smoothly through the fliger when flexed and extended
msot common sheath affectedis ths the first annular pulley A1 at the MCP joint
can have a nodule in the tendon stopping it going through sheath
flexed the nodule is outside the A1 pulley but then as you extend the figner the nodule cant go thrugh and gets stuck at the entracne to the A1pulley and so the finger locks and gets stuck in the bent postion
presnetation trigger finger
pain and tender on mcp joint on palmar side usually there
stiffness
locking / finger stuck in flexed psotion
suddenly realses with painful clicl/pop
deosnt move smoothly on flexion and extention
worse in morning and improve thoughout day
risk factors trigger finger
40s and 50s
female more
diabetes esp T1
diangosis investigations of trigger finger
clinical
maagment of trigger finger
rest and analgesua - some resolve spontaenously
splintinh
steroid injection
surgery to release A1 pulley
most common place to have pain and stiffness and tender on trigger finger
A1 pulley @ MCP joint on palmar side hurt
de quervains tenosynovitits
type of repetitive strain injury
swelling and inflammation of the tendon sheaths in the wirst
primarily affects the extensor pollicis brevis tendon and the abudctor pollicis longus tendon
pathology o dequaervains tenosynovitits
APL (abductor pollicis longus) - abduct the thumb and wrist
EPB (extenosr pollciis brevis) - abduct the tumb and wrist
tendon sheath srruounds the tendons - synovial membrane to lubricate and protect tendons
epb and apl got under extensor retinaculum
repetivie movement of the apl and epb casues inflammation and swlling of the tendon sheaths
presentation of de quervains tenosynovitis
pain and tenderness on radia aspect of wrist near base of thumb
can radiate to forearm
burning
numbness
weaknnes
tenderness
aching
special test for de quervains tenosynovitits
finkelsteins test
eichhoffs test
get pain in radial aspect of wirst then postive
mangagment of de quervains tenosynovitits
repetivie strain injury:
rest and adapt activities
splint to restirct movement
nsaids
physio
steroid injections
surgery to cut extensor retinaculum= reelasing pressure and more space for tendons= done rarely
casue of de quaervains tenosynovitis
repetitive movemnt using abductpr pollics longus and extensor pollicis brevis
- new parent picking up new brn in certain way that stresses the tendons
new parent is lifing baby and they have pain in their forarm and numbness and some aching pain and tenderness in their wrist
dequervains tenosynoviits
pain on radial aspect of wrist where the apl and epb are used repetively
lifing baby up lots in that way abducting the wrist
epicondylitits
inflammation at the point where the tendons of the forearm insert into the epicondyles of the humerus
specific type of repetitive strain injury
what action msucles do insert on medial epicondyle and lateral epicondyle of humerus
medial epicondye= flex wrist
lateral epicondyle= extend wrist
presentation of epicondylitits (lateral and medail)
pain often radiaoting to forearm - pain over affected epicondyle
tender
weakness of grip strength
could have numbness
gradually worsens
oftenmiddle age
presentation and cause of lateral epicondylitis
pain and tendeness on lateral epicondyle
from extending wrist a lot- tennis elbow
tests fir lateral epicondyltitis
mills test- pain postive
cozens test- pain psotive
presentation and casue of medial epicondyltits
pain and tenderness over medial epicondyle can radiate to forearm
flexing wrist a lot- golfers elbow
tests for medial epicondylitis
golfers elbow test- pain is postivie
diangosis for epicondylitits
clinical
management for epicondyltits
repetivie strain injury :
rest and adaptive activites
anaglesai- nsaids
orthotics- wlbow brace / straps
physio
steroid injections
platelet rich plasma injection
extracoreporeal shockwave therpay
srugery rare- debride and release and repair tendons
person has pain in elbow and forearm from playing tennis
tennis elbow- extending elbow- lateral epicondyle
repetitive strain injury
soft tissue irritation, microtrauma, strain
from repetitive action
affect muslce, tendon, nerves
casues of repetitive strain injury
anything dine repetitive for long time
often occupational !!!
factory
computer and keyoard-wrist and arm
poor posture for long time- reading, patining, computer
texting and scrolling0- thumb base
characteristics that increase risk of it:
awkward position
small movements- scrolling
vibration- power tool
presentation of repetitive strain injury
pain - exaserbated by using asscoaited joints, tendons, muscle
tenderness
hx of repetive activites
located in area related to activity
aching
burning
weakenss
numbness
cramping
tender on palpation
mild swelling can occur
recreate pain nby resting the affected tissue
diagnsois of repetitive strain injury
clinical
may need exclude other casues
us- synovitis, ra, rotator cuff tear
bloods- inflamm markers, rf
can do xray to exclude eg. OA
management of repetivie strain injury
rest and adaptive activities
may need speak occupational healthy
ice
compresion
elevation
analgesia- nsaids
physio
steroid inections in certain cases
can use orhtotics etg. braces, splints, strps to help
what specifc repetitive strain injuries are there
de quervains tenosynovitits- abducting wrist lots - pain on radial side of wrist
lateral epicondyltits- tennis elbow- extending wrist lots
medial epicondyltitis- golfers elbow- flexing wrist lots
olecranon bursitits
inflammationvand swelling of the bursa over the olecranon (part of ulnar bone)
casues of olecranon bursitis
inflammation leads to thickening of synovial membrane and increase fluid production casuing swelling
friction from reeptitive movements / leaning on elbow- eg. student elbow, plumbers, drivers
trauma
inflammatory conditions- RA, gout
infection- septic bursitits
presentation of olecranon bursitits
pain / tender- goes as becomes more chronic
tender more when presssure on it- lean on table
swollen- loike a goose egg can be
warm
fluctuant - fluid filled
if infected:
hot to touch
erythmea spreading to surrounidng skin
more tender
fever
features of sepsis- hypotension, tachycardia, confusion
when to consider septic arthritis in olecranon bursitits
swelling in the joint not the bursa
painful and got decreased rang of motion of joint
differnetials of olecranon bursitits
fracuture of olecranon
RA
septic arthritits
gout
psuedogout
cellulitits is got skin issues
investigaitons for olecranon bursitits
aspiration if susepct infection
apsirate olecranon bursists and its pus. suggest
infection
aspirate olecranon bursittis and its milky-
gout/pseudogout
aspirate olecranon bursitits and its bloody
trauma, infection, inflam casue
aspirate olecranon bursitits and straw colored
infection less likely
management of olecranon bursitits
rest
ice compresion
anaglesia- nsaids
protect elbow from pressure/ trauma
aspiration can relive presssure
steroid injection once excluded infection
managemnt of olecranon bursitits is suspect infection cause or cant exclude it
abx- flucloxacillin, if cant then clarithromycin
aspiration for microscopy and culture
if systemiccaly unwell and got olecranon bursitis
hosp
iv abx
iv fluids
bloods- lactate
blood culture
what blood supplly has the ehad of femur
retrograde blood supply from medial and lateral circumflex arteries from femoral arterites. they join at the femoral neck proximal to the intertrochanteric lone
what important about where the fracture occurs of the femur
if intracapsualr fracture then blood supply may be affected by damage of bv if the bone is displaced especially. this can then lead to avascualr necrosis
extracapsular fractures of the femur arnt an issue this way as blood supply remains intact
whats an intracapsualar fractur of femur
fracture inside the capsule- proximal to the intertrochanteric line
garden classification:
grade 1= incomplete fracture and non displaced
grade 2= complete fracture and non displaced
grade 3= partially displaced- trabeculae at angle
grade 4= fully displaced - trabeculae parralele
intracapsular fracture which grades may only need internal fixation of head
and which may need remobal and replacement of femoral head
grade 1 and 2 the blood supply may not be affected as not displaced so may have intact blood supply. if this the case then internal fixation may only be needed
grade 3 and 4 where displacemnt has occured will need remvoal and replacement of femoral head as the blood supply will be damaged and so avascualr necrosis of the femoral head will have occured
treatment for intracaspualr fractures of femur
if non displaced grade 1 and 2 then may only need internal fixation eg. with screws if the bv arnt damaged
grade 3 and 4 where they are displaced will need removal of femoral head and replacemnt :
hemiarthroplasty= only remove and replace head
or
total hip replacement = head and acetabulum (do if fit and mobile before surgery before fracutre obvs)
qhats an extracapsular fracture of hip and types
fracture occur distal to intertrochanteric line = bood supply of head not affected = head doesnt need replacing
intertrochanteric fractures:
between greater and lesser trochanter
treat with dynamic hi[p screw- adds some cntrolled compression across fracture so improve healing (bones need weight bearing stuff to make them grow eetc)
subtrochanteric fracture:
distal to lesser trochanter- no more than 5cm below
[roximal to shaft of femur fracture
treat:
intrameduallry nail
presentation of hip fracutre
pain- groin, buttocks can radiate to knee
esp older pt fallen
SHORTENED ABDUCTED AND EXTERNALLY ROTATED LEG
look for any underlying illness that cuased it:
anemia
mi
arrythmia
stroke
electroylte imbalance
heart failure
urinary / chest infections
investigations for hip fracture
xray inital - ap and lateral :
shentons line if distrupted then sign of neck of femur fracture
mri/ct if xray neg but suspect fracture still
risk facotrs hip fracutre
female
osteoporosis
increasing age
management of hip fractures
anaglesia
vte asssesment _> enoxaparin
pre op asess- bloods and ecg
orthogeriatrics
surgery same day or day after-> have surgery within 48 hrs of admitted as high mortality
want to weight bear straight away after op and have physio and anaglesia so can mobilise
