Radiology & Trauma Flashcards
What are the seven steps of reporting X-rays?
- View e.g. AP, lateral
- Anatomy visible (right or left)
- Name and age
- Date and time (most recent radiograph?)
- Most obvious abnormality
- Describe deformities
How should the obvious deformity on an X-ray be described?
Location: diaphyseal, metaphyseal, epiphyseal, articular surfaces, junctional/combination
Displaced or undisplaced
- obvious indicates displaced
- difficult to tell indicates “relatively undisplaced”
Differentiate how well tolerated different types of fracture are.
Deformity in plane of movement is well tolerated
Rotational/angular deformity is not well tolerated
Children: the younger the child the greater the tolerance for deformity due to the propensity for ongoing growth
How should X-ray deformities be described?
Angle of displacement = angle of midpoint of cortices of proximal and distal fragments OR describe where apex of fracture is pointing in space e.g. posterolateral, medial (greater than 7 degees more likely to require fixation)
Change in length = shortening (proximal fragment translated past distal fragment) or lengthening (weight of limb, muscle palsy; periosteum, muscle, blood vessels, and nerves may become trapped between fragments)
Translation = movement of bone fragments across from each other in terms of %
Apposition = do fragments appear to fit together
Rotation = mismatch in width of bone cortices, pattern of fracture, different views above and below joint
Intra-articular?
Loss of congruity = subluxation or dislocation
Name some different types of fracture.
Comminuted - reserve for multiple small fragments that could not be fixed by screws
Transverse - direct high energy
Oblique - indirect low energy
Butterfly - direct high energy
Spiral - indirect low energy
Greenstick/buckle
Segmental
Linear
What are the different types of bone lesion?
Sclerotic = more bone (tumours activate osteoblasts and inhibit osteoclasts)
Lytic = less bone (tumours activate osteoclasts and inhibit osteoblasts)
Mixed
What is the zone of transition referring to in bone lesions?
Margin around bone elsion
Discrete margin indicates less aggressive, slower growing tmour
Ill defined margin indicates more aggressive, faster growing lesion
note: may have marginal sclerosis around a lytic lesion
What are the features of Paget’s disease on an X-ray?
Visible trabeculae
Asymmetrical rotation
What are the MSK indications for USS?
Shoulder:
- rotator cuff tears
- rotator cuff tendinopathy
- impingement
Carpal tunnel syndrome
Tenosynovitis
What are the MSK indications for CT?
Occult bone pathology
MRI contraindicated
What is scintigraphy?
Technetium radioisotope injected IV causes body to emit gamma rays.
Osteoblastic activity highlighted as bright spots (+ bladder)
Random distribution of bright spots indicates metastases, ordered indicates OA
note: myeloma/TB gives “cold scan”
note: superscan when too much Tch given (bladder empty)
What is the Gustillo classification of open fractures?
Type I = clean wound <1cm long
Type II = wound >1cm without extreme soft tissue damage
Type III = wound usually >5cm with associated extensive soft tissue damage OR contaminated wound irrespective of size e.g. farm, river, marine
- a = adequate periosteal cover (wound can be covered by existing tissue)
- b = significant periosteal stripping (req. soft tissue cover)
- c = vascular repair req. to revascularise leg
Outline the assessment of the limb in an open fracture.
ATLS: Airway & cervical spine control, Breathing, Circulation, Cannulation, Crossmatch, Catheterisatio, Dysfunction (nerves), Examine Everything
- pulses: dorsalis pedis, pos. tibial
- temperature
- sensation: distal to wound, in same compartment as injury, peripheral nerve territories
- movements
- visible bones +/- periosteum
- wound debris
- soft tissue envelope
- colour
- size of wound
- obvious deformities (length, rotation)
- photograph fracture before moving on
What are the investigations and management of an open fracture?
- Take blood (group and save, Hb, glucose, U&Es, LFTs) and cannulate
- Anti-emetic (before analgesia) e.g. cyclizine
- Analgesia e.g. IV morphine 10mg
- Fluids e.g. bolus of Hartmann’s, then as maintenance
- Abx e.g. 1.2g IV co-amoxiclav
- ?tetanus jab req.
- Limited washout and removal of obvious debris OR dress without touching (see BAPRAS)
- Reduce fracture (realign limb) and backslab (splint and plaster)
- Reassess neurovascular status
- Organise X-ray
- Contact: anaesthetist, orthopaedic reg., plastics, ward/bed coordinator, theatres
- Prepare for theatre/ward
- theatre within 24hrs UNLESS there is vascular injury or contamination
- NICE: consultant has to debride within 12hrs (?plastics req. to do this)
What is compartment syndrome?
Raised pressure within an enclosed fascial space leasing to localised tissue ischaemia
Increased pressure within body compartment which contains muscles or nerves
- due to change in pressure-volume relationship within a tight fascial compartment
- normal pressure ~10mmHg
- increase in pressure > 40mHg —> veins compressed —> blood moves in but not out —> arteries compressed —> acute limb ischaemia
What are the signs and symptoms of compartment syndrome?
- disproportionate pain to injury/increase in pain following immobilisation on passive movement/stretch of muscles within compartment (therefore can be above injury) due to hypoxia and buildup of toxic metabolites
- swelling/tightness of compartment
- paraesthesia
- dysaesthesia (normal stimulus gives abnormal sensation)
- pallor
- paralysis
- pulseless
- perishingly cold
What is the treatment of compartment syndrome?
Dermatofasciotomy of all limb compartments Debridement of necrotic tissue Skeletal stabilisation Treatment of underlying cause Can do compartment pressure monitoring
What are Klein’s line and Trethowan’s sign?
Klein’s line = line drawn parallel to superior femoral neck should intersect the most lateral portion of the capital femoral epiphysis
Trethowan’s sign = line of Klein passes above femoral head (sign of SUFE)
What is Paget’s disease of bone (osteitis deformans)
Idiopathic disorder of bone remodelling causing healthy mature bone to be replaced by thick, vascular, osteoid bone
Hx:
- 50yrs<
- deep-seated aching/gnawing pain
- often asymptomatic (incidental finding)
- headache (incresed vascularity of skull)
O/E:
- skull enlargement
- kyphosis
- deafness
- sabre tibia
- blindness
etc.
Mx: bisphosphonates + analgesia + calcium
What is Perkin’s classification of fracture healing?
Upper limb:
- spiral: union = 3wks, consolidation = 6wks
- transverse: union = 6wks, consolidation = 12wks
Double for lower limb
What components are required for normal fracture healing?
Viability of fractures i.e. intact blood supply
Mechanical rest: not moving, external immbolisation
Absence of infection
What are the complications of disturbed fracture healing?
Delayed union
Non-union (pseudoarthritis)
Refracturing
Malunion
What are the sesamoid bones of the body?
Bone embedded in tendon or muscle
- patella (quadriceps tendon)
- 2 in distal portions of 1st MCP
- distal portion of 2nd MCP
- pisiform (flexor carpi ulnaris)
- 2 in 1st MTP
- lenticular process of incus
What is the Garden classification?
Intracapsular fractures degree of displacement
I = impacted; fracture line through one cortex II = minimally displaced; fracture through both cortices III = partially displaced IV = totally displaced
What is the Schatzer classification?
Tibial plateau fractures
I = pure cleavage fracture of lateral tibial plateau ("just split up")
II = type I + depressed component ("split and feeling depressed")
III = pure depression of lateral tibial plateau ("pure depression")
IV = medial tibial plateau fracture ("other side of break up"
V = bicondylar fracture ("see both sides of split")
VI = dissociation of tibial metaphysis and diaphysis ("complete emotional mess")
What is a Pilon fracture?
Fracture of distal tibia involving its articular surface at the ankle joint +/- fibular fracture
What is the Weber classification?
Ankle fracture
A = below syndesmosis; fibula and tibia still joined ---> cast B = through syndesomosis; stable or unstable C = above syndesmosis; unstable
What is a Maisonneuve fracture?
Spiral fracture of proximal fibula and ankle injury
What is a Lisfranc fracture?
Disruption between the articulation of the medial cuneiform and base of second metatarsal
What is an Ilizarov apparatus?
Method of external fixation using anteromedial and perpendicular pins inserted directly into fragments
Used to fix tibial fractures where fracture has extended into the ankle joint (so no support for intramedullary pins)
Also used to lengthen limbs
What are the different types of suture?
Monofilament v.s. polyfilament
- monofilament = better passage through tissues, reduced tissue reaction
- polyfilament = better knot securing
Absorbable v.s. Non-asorbable
- absorbable = internal
- non-asorbable = external or in heart, bladder
e. g. monofilament, absorbable = catgut, monocryl
e. g. monofilament, non-absorbable = nylon/ethilon
e. g. polyfilament, absorbable = vicryl
e. g. polyfilament, non-absorbable = silk
What are the types of suturing techniques?
Interrupted
- horizontal mattress (6 throws: 2, 1, 1, 1, 1)
- simple (2, 1, 1)
- vertical mattress
Continuous
- simple
- running subcuticular
Buried = distribute wound tension to dermis
What materials are used in arthroplasties?
Hybrid = use two different materials e.g. steel acetabulum + cemented femoral head
Polyethylene = strong (cross-linked); release molecules which are engulfed by macrophages —> inflammatory reaction —> ?bone destruction
Metal = can cause pseudotumour formation with associated osteolysis and periprosthetic bone loss; ?hypersensitivity to metal
Ceramic
What mnemonic can be used in the trauma history?
AMPLE
- Allergies
- Medical Hx
- Past Medical Hx
- Last meal
- Events (mechanism of injury)
