Others Flashcards
How to predict risk of growth disturbance?
Bone age by radiograph (Greuloch and Pyle Atlas)
Knee radiographs
Menarchal status in females
Tanner staging
–> Tanner 3 and above have less chance of sig issues due to their reduced growth potential
Skeletal growth is usually complete by 14 in gis and 16 in boys
Corona mortis and in which approach to be ligated?
Vascular connection between the obturator and external iliac vessels
Located behind the superior pubic ramus at variable distance from the symphysis pubis
To gain visualisation laterally and into the true pelvis during the Stoppa (anterior intra pelvic) approach
Indications for Stoppa approach
anterior intra pelvic approach
- Acetabular fractures
2. Pelvic ring fractures
Protrusio acetabuli when seen
Medial migration of the femoral head past the radiographic teardrop
Seen in:
- RA
- Marfan’s syndrome
- Paget’s disease
- Otto’s pelvis
- Other metabolic diseases
Rituximab
Rituxan
Monoclonal AB to CD20 antigen (inhibits B cells)
Rituximab
Rituxan
Monoclonal AB to CD20 antigen (inhibits B cells)
Anakinra
Kineret
Recombinant IL1-receptor antagonist
Most frequently injured tarsal bone?
Calcaneus
Accounts for 60% of all tarsal fractures and 1-2% of all fractures
Approximately 75% of these have a displaced Intra-articular component
Radiographs for calcaneal fractures
–> 2 important radiographic measurements for measuring the degree of posterior facet collapse
- AP ankle view
- Lateral ankle view
- Calcaneal Harris view
–>
- Bohler’s angle (normal 20-40°)
- Giassane’s angle (normal 120-145°)
Classic appearance of stress fractures in MRI
Low signal on T1
Increased signal on T2
Inferior gluteal artery
Leaves pelvis beneath piriformis
If it is cut and retracts into the pelvis, then treat by flipping patient, open abdomen, and tie off internal iliac artery
Kocher-Langenbeck approach
Posterior approach to the acetabulum
Uses same interval as Southern /Moore approach (no internervous plane (gluteus max innervated by inf gluteal nerve) (vascular plane (upper 1/3 of muscle supplied by superior gluteal artery, lower 2/3 of muscles supplied by inferior gluteal artery))
Provides access to
- Posterior wall of acetabulum
- Lateral aspect of the posterior column of acetabulum
- Indirect access to true pelvis and anterior aspect of posterior column through palpitation
- Proximal femur
Functional knee instability
Symptom that refers to the sensation of buckling, slippage or giving way of the knee during functional activities
Passive knee laxity
Clinical sign that indicates either lack of tension in the capsuloligamentous structures of the knee, or the degree of ‘joint looseness’ on passive motion testing
Which type of nerve is most commonly injured with extension type pediatric supracondylar fractures?
Anterior interosseous nerve, a branch of the median nerve, is a principally motor nerve and innervates the flexor digitorum profundus index, the flexor digitorum profundus middle, flexor pollicis longus and pronator quadratus
Henry approach
Volar approach to radius shaft
Internervous plane
Proximally between brachioradialis (Radial nerve)
Pronator tere (median nerve)
Distally between
Brachioradialis (radial nerve)
FCR (median nerve)
Supinate arm to minimise injury to posterior interosseous nerve (branch of the radial nerve)
Wartenberg syndrome
Superficial radial nerve compression syndrome
Test nerves hand
Thumbs up - posterior interosseous nerve (radial nerve)
OK sign - anterior interosseous branch (median nerve)
Cross fingers - (ulnar nerve)
Hip anterior approach
Smith-Petersen
Superficial internervous plane
Satorius (femoral nerve)
Tensor fascia lata (superior gluteal nerve)
Deep internervous plane Rectus femoris (femoral nerve) Gluteus medius (superior gluteal nerve)
Dangers
1. Lateral femoral cutaneous nerve, most commonly between sartorius and tensor fascia lata
- Femoral nerve
- Ascending branch of lateral circumflex artery, Proximally in superficial internervous plane, be sure to ligate to prevent excessive bleeding
What needs to be reduced in Intra-articular radius fractures?
- Radius height
- Articular surfaces
- Volar tilt
Metastatic lesions distal to knee/elbow most likely due to
Primary lung or renal tumor
Outcome measures of Intra-articular fractures
- Correction of meta- and diaphyseal deformity
- Restoration of joint stability
- Restoration of ROM
Glasgow coma scale
Eye opening response 4 spontaneously 3 to speech 2 to pain 1 no response
Verbal response 5 oriented to time, person and place 4 confused 3 inappropriate words 2 incomprehensible sounds 1 no response
Motor response 6 obeys commands 5 moves to localized pain 4 flex to withdraw from pain 3 abnormal flexion 2 abnormal response 1 no response
Severe, GCS <8-9
Moderate, GCS 8 or 9-12
Minor, GCS above 13
Usually 3-8 means in coma
Document as GCS 9 = E2 V2 M3 at 07:35
Severe trauma
ISS > 16
Injury severity score assigns a score of 1-5 (minor to severe) to six organ systems. The three worst organ system scores are squared, and the ISS is the sum of those three squares.
Revised trauma score
Respiratory rate
Systolic blood pressure
GCS
Principles of damage control
Limit the surgical burden (or 2nd hit phenomenon) on the immune response that occurs in poly-trauma patients with an already high risk of adverse outcome
This is based on the finding that prolonged operation on poly-trauma patients can lead to coagulation disturbances and an abnormal immuno-inflammatory state causing remote organ injury
CPP
Cerebral perfusion pressure
CCP = MAP - ICP
(mean arterial pressure)
(intracerebral pressure)
Autoregulatory mechanisms of cerebral blood flow may be disrupted in severe head injury
Hip anterolateral approach
Watson-Jones
Intermuscular plane
Tensor fascia lata (superior gluteal nerve)
Gluteus medius (superior gluteal nerve)
Danger
Compression neuropraxia of the femoral nerve caused by medial retraction
Anterior lumps of the knee
Housemaid’s knee (pre-patellar bursa)
Clergyman’s knee (infra-patellar bursa)
3 Tests for knee effusion
- Ballotment test –> for large effusion
- Patella tap test –> moderate effusion
Obliterate the supra-patellar pouch and press patella posteriorly - Wipe (or bulge) test –> small effusion
Obliterate the supra-patella pouch and wipe fluid from one side of the patella tendon followed by the other side
Pivot shift test
A valgus force is applied to an internally rotated tibia, which, in the presence of a ruptured ACL, subluxes the joint
and when the knee is then passively flexed the iliotibial band, in the presence of an intact MCL, reduces the knee joint with a palpable and sometimes audible clunk.
Best performed under anaesthesia
Differentiate between isolated MCL/LCL tear and rupture of the collaterals + the secondary restraints (cruciates)
Isolated : opening of the joint at 30°flexion (which relaxes the cruciates and isolates the collaterals)
Combined : opening of the joint at full extension
Clark’s test
May indicate chondromalacia or arthritis of the patellofemoral joint
Patient supine
Patient is asked to contract the quadriceps whilst a hand is placed over the superior pole of the patella with a slight downward pressure
–> discomfort
Normal T5-T15 kyphosis
20-50°
Any degree of kyphosis at thoracolumbar area is considered abnormal
Hip direct lateral approach
Hardinge, transgluteal approach
No true internervous plane
Intermuscular plane
Splits gluteus medius distal to innervation (sup gluteal nerve)
Vastus lateralis is also split lateral to innervation (femoral nerve)
For THA and prox femur fractures
Osteoconduction
Promotion of bone opposition to its surface, functioning in part as a receptive scaffold to facilitate enhanced bone formation
Osteoinduction
Provision of a biologic stimulus that induces local or transplanted cells to enter a pathway of differentiation leading to mature osteoblasts
Major complications following autologous chondrocyte implantation or cartilage grafting
Hypertrophy of the transplant
Disturbed fusion of the regenerative cartilage and the healthy surrounding cartilage
Insufficient regenerative cartilage
Arthrofibrosis
Osteonecrosis
Osteochondrosis dissecans
Acquired phenomenon localized to the subchondral bone, which can result in destabilisation of the overlying articular cartilage
Classic : involves lateral aspect of the medial femoral condyle
Males > females
Cause multifactorial or microtrauma
Classic test for Osteochondrosis dissecans of the knee
Wilson’s test
Aims to impinge the tibial spine on the OD lesiin
Performed by
Internal rotation of the involved knee while extending the knee from 90° of flexion
The pain is relieved when the same motion is performed with the knee externally rotated
Presentation of osteochondrosis dissecans of the knee
Initially : vague knee pain that is worse with activity
If the OD is loose or unstable, mechanical symptoms with episodes of giving way and recurrent effusions are common
The patient may ambulate with an externally rotated gait
On examination :
May have effusion, point tenderness over the condyle, and positive Wilson’s test
Role of MRI in osteochondrosis dissecans
Imaging modality of choice
Differentiating between OD and variations of normal ossification centres
Can assess lesion size, location, and stability
Instability criteria :
High intensity signal rim on T2 imaging
Articular breach
Fluid filled cysts
Prognostic features in osteochondrosis dissecans
Skeletal maturity, juvenile better healing
Lesion stability
Hip medial approach
Open reduction of congenital hip dislocation Psoas release (danger medial femoral circumflex artery)
Plane
Superficial
No superficial internervous plane as both adductor longus and gracilis are innervated by the anterior division of the obturator nerve
Deep
Internervous plane between adductor brevis and adductor magnus
Adductor brevis supplied by the anterior division of the obturator nerve
Adductor magnus has dual innervation
Adductor portion is supplied by the posterior division of the obturator nerve
Ischial portion by the tibial portion of the sciatic nerve
Which view best depicts acetabular fractures?
Judet view
Easily reproducible in the OT for surgical planning
Retroperetoneal (anterolateral) approach to the lumbar spine
Can access L1-sacrum
Bifurcation of great vessels anterior to L4 vertebral body
Only branch of the common iliac vessels
Iliolumbar vein
Must be ligated to safely mobilise the common iliac vessels towards midline from laterally
Systemic, local and other risk factors for patella tendon rupture
Systemic SLE RA DM chronic renal disease
Local
Patellar degeneration (most common)
Previous injury
Patellar tendinopathy
Other
Coricosteroid injection
Insall-Salvati ratio
Patella tendon length /patella bone length
Patella tendon length
Length of posterior surface of the patella tendon from the lower pole of the patella to its insertion on the tibia
Patella bone length
Patellar length :greatest pole-to-pole length
On plain radiographs (30° flexed lateral knee)
Patella baja: <0.8
Normal : 0.8-1.2
Patella alta : >1.2
Slightly different values for sagittal MRI
Clinical findings of patellar tendon rupture
Inability to extend the knee against gravity
Large hematoma
Palpable gap below the inferior pole
When and why primary repair of ruptured patella tendon
Within 2 weeks to prevent extensor mechanism contracture
Most common location of patella tendon rupture
At the junction of the tendon and the distal patella pole
Closed kinetic chain exercises
When terminal or distal segment of an appendage is fixed
Squat, leg press, pull up
Open kinetic chain exercises
When terminal or distal segment is free to move
Leg extension, hamstring curl
Tend to produce greater shear stresses than closed chain
Screw home mechanism
Tibia externally rotates 5° in the final 15° of extension
Acute knee swelling may indicate
ACL tear
Peripheral meniscal tear
Osteochondral fracture
Capsule tear
Most sensitive view for revealing early knee OA
Rosenberg view
Weight-bearing 45-degree knee flexion posteroanterior
Radiographs used in pediatric patients
to evaluate injury to the femoral physis and
to differentiate it from an MCL injury
Stress radiographs
Used to characterise PCL, MCL, LCL, PLC injuries
Arcuate sign on knee radiographs
Avulsion of tip of fibular head
Block of knee ROM
Meniscus (bucket handle) injury
Loose body
Impingement of ACL tear
Kissing lesion
Chondral lesions adjacent to each other on the femur and tibia
Pellegrini-Stieda sign
Calcification at the medial femoral condyle insertion
May be present in chronic MCL injuries
Usually responds to a brief period of immobilisation followed by progressive motion
MCL injuries occur most commonly at
Treatment
The femoral condyle
Non-operative treatment (hinged knee brace) highly successful
What to check in LCL injury?
Rarely isolated, check for PCL and PLC injury
10% associated with peroneal nerve palsy
