Passmedicine MSK

Question 1

An 86-year-old female suffers a fall and is subsequently taken to the emergency department. Plain films of the right hip show a displaced fracture above the level of the greater and lesser trochanter of the proximal femur.

What type of fracture is this?

What is the risk here?

What is the most appropriate operative management?

Answer 1

The capsule of the hip joint attaches to the intertrochanteric line distally. Therefore, this is a displaced intracapsular fracture.

Due to the risk of avascular necrosis (in any displcaed hip fracture) these are generally managed with hemiarthroplasty (or total hip replacement in those fit enough).

Question 2

Features of a hip fracture

Answer 2

• pain
• the classic signs are a shortened and externally rotated leg

Question 3

How is a hip fracture classified by location?

Answer 3

• intracapsular (subcapital): from the edge of the femoral head to the insertion of the capsule of the hip joint
• extracapsular: these can either be trochanteric or substrochanteric (the lesser trochanter is the dividing line)

Question 4

Describe the Garden system

Answer 4

Type I: Stable fracture with impaction in valgus

Type II: Complete fracture but undisplaced

Type III: Displaced fracture, usually rotated and angulated, but still has boney contact

Type IV: Complete boney disruption

Question 5

Treatment of an intracapsular undisplaced hip fracture

Answer 5

Internal fixation, or hemiarthroplasty if unfit

Question 6

Treatment of an intracapsular displaced fracture

Answer 6

• young and fit i.e. <70 years
  
  • Reduction and internal fixation (if possible)
• older and reduced mobility
  
  • Hemiarthroplasty or total hip replacement

Question 7

Treatment of an extracapsular hip fracture

Answer 7

• dynamic hip screw
• if reverse oblique, transverse or subtrochanteric: intramedullary device

Question 8

What is pseudogout?

Answer 8

Pseudogout is a form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate crystals in the synovium.

Question 9

Risk factors for pseudogout

Answer 9

• haemochromatosis
• hyperparathyroidism
• acromegaly
• low magnesium, low phosphate
• Wilson’s disease

Question 10

Features of pseudogout

Answer 10

• knee, wrist and shoulders most commonly affected
• joint aspiration: weakly-positively birefringent rhomboid-shaped crystals
• x-ray: chondrocalcinosis

Question 11

Management of pseudogout

Answer 11

• aspiration of joint fluid, to exclude septic arthritis
• NSAIDs or intra-articular, intra-muscular or oral steroids as for gout

Question 13

Where is venous ulceration typically seen?

Answer 13

above the medial malleolus

Question 14

Venous ulceration investigations

Answer 14

ankle-brachial pressure index (ABPI) is important in non-healing ulcers to assess for poor arterial flow which could impair healing

Question 15

Management of venous ulceration

Answer 15

compression bandaging, usually four layer

Question 16

Features of compartment syndrome

Answer 16

• Pain, especially on movement (even passive)
• Parasthesiae
• Pallor may be present
• Arterial pulsation may still be felt as the necrosis occurs as a result of microvascular compromise
• Paralysis of the muscle group may occur

Question 17

Diagnosis of compartment syndrome

Answer 17

• Is made by measurement of intracompartmental pressure measurements. Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic
• Compartment syndrome will typically not show any pathology on an x-ray

Question 18

Treatment of compartment syndrome

Answer 18

This is essentially prompt and extensive fasciotomies