sarah gill trying to kill us Flashcards
1
Q
Fall with shoulder in external rotation?
A
Anterior dislocation of shoulder
2
Q
What should you check if you have anterior shoulder dislocation?
A
Axillary badge patch!!
3
Q
Fall with shoulder in internal rotation?
A
Posterior dislocation
4
Q
Arm held in abduction
Humeral head inferior to the glenoid
A
Inferior dislocation
-NEEDS PROMPT NEUROVASCULAR ASSESSMENT AND REDUCTION
5
Q
Light bulb sign on x-ray, which type of shoulder dislocation?
A
Posterior shoulder dislocation
6
Q
Elbow dislocation gives small risk of which two fractures?
A
Coronoid process and radial head
7
Q
Say you pull a child’s arm upwards, what could you dislocate?
A
Radial head
8
Q
Management of shoulder dislocation?
A
Closed reduction under sedation
Open reduction
Stabilisation & rehabilitation
9
Q
Management of elbow dislocation?
A
Closed reduction under sedation
Open reduction rarely required
2 weeks in sling & rehabilitation
10
Q
Hippocratic, Kocher’s, in-line traction used to reduce which type of dislocation?
A
Shoudler
11
Q
Traction in extension +/- pressure over olecranon used to reduce which type of dislocation?
A
Elbow dislocation
12
Q
Closed reduction under digital or metacarpal block
Open reduction rarely required
2 weeks in neighbour strapping
Volar slab in Edinburgh position if unstable ++
A
IPJ dislocation
13
Q
Which way will the patella dislocate?
A
It will always be a LATERAL dislocation
14
Q
Always a lateral dislocation?
A
Patella!
15
Q
Who is most likely to sustain a patella knee dislocation?
A
Teenage girls
16
Q
Associations/causes of patella dislocation?
A
Hypermobility
Under-developed (hypoplastic) lateral femoral condyle
Increased Q-angle
Genu valgum
Increased femoral neck anteversion
Lateral quads insertions or weak vastus medialis
17
Q
Q angle
A
Line 1: ASIS to midpoint of patella
Line 2: Tibial tuberosity to midpoint of patella
18
Q
Examination of dislocated knee cap?
A
Pain medially (from torn medial retinaculum)
Effusion (haemarthrosis)
Patella apprehension test +ve
19
Q
Management of knee dislocation
A
Reduce with knee extension Radiographs Aspiration Brace Physiotherapy
20
Q
Surgery for repeat dislocations of the knee
A
Lateral release with medial reefing
Patellar tendon reallignment
21
Q
Lateral collateral ligament injury and peroneal nerve injury, what have you probably done to your knee?
A
Dislocated it
-beware of spontaneous relocation, you do not want to miss diagnosis of dislocation!!
22
Q
Knee dislocation and vascular damage, when do you observe and when do you do arteriorgram?
A
Vascular injuries: Popliteal artery / vein injury
May not be obvious (intimal tear or thrombus
NORMAL EXAM = OBSERVE IN HOSPITAL CLINICAL CONCERN = ARTERIOGRAM / MRI
23
Q
How would you stabilise a knee after reduction?
A
Splint or external fixation
24
Q
Time window for vascular repair following knee dislocation?
A
6 hours
25
Complications of knee dislocation
Arthrofibrosis and stiffness
Ligament laxity
Nerve or arterial injury
26
Fractures associated with hip dislocation?
Posterior acetabular wall
| Femoral fractures
27
Flexed, internally rotated and adducted knee
Hip dislocation
28
Complications of hip dislocation
Sciatic nerve palsy
Avascular necrosis of the femoral head
Secondary osteoarthritis of hip
Myositis ossificans
29
General principles for treatment of open fractures?
Antibiotics, tetanus, early debridement and operative stabilisation
30
Approx blood loss in femoral fracture?
1 litre
31
Risks associated with femoral shaft fracture?
Fat embolism, ARDS
32
Analgesia for femoral shaft fracture?
Femoral block
33
Splintage for femoral shaft fracture?
Thomas splint
34
Treatment for unstable femoral shaft fracture?
IM nailing
35
Treatment for distal femur fractures?
```
Extra-articular
If not too distal, can nail
Distal = plating
Intra-articular:
Anatomical reduction, rigid fixation
Plate and screws
```
36
Usual fracture of proximal tibia?
High energy young, low energy old
Usually Valgus stress lateral tibial plateau # with disruption articular surface
37
What investigation should you carry out for proximal tibial fracture?
CT scan!! (to determine personailty of fracture)
38
Internal rotation and tibial shaft fracture?
Internal rotation POORLY toerated
| Can tolerate 5 degress angulation any plane, 50% bony contact
39
Pilon fracture?
Intra-articular distal tibial fracture
40
Injuries associated with a distal tibial fracture?
Calcaneous
Pelvis
Spine
(distal tibial fracture is usually high energy)
THIS IS A SIGNIFICANT SOFT INJURY
- external fixation
- +/- limited internal fixation
- CT
41
What happens if you have a distal fibular fracture with deltoid ligament rupture?
Talar shift
42
Often avulsion fracture from triceps contraction
Olecranon fracture
43
Radial head fracture
can occur with dislocation elbow
Minimally displaced marginal fractures treated conservatively (unless fragment blocking ROM)
Can fix displaced fractures with large fragments
Comminuted fractures excise +/- replacement
44
Galeazzi fracture
Fracture of radius, dislocation of DRUJ
45
Monteggia
Fracture of ulna and dislocation of radial HEAD
46
Management of night stick fracture?
Conservative
| (direct blow to ulna *may* cause isolated ulna fracture
47
Management of galeazzi or monteggia?
ORIF fractured bone
| Once reduced, radial head or distal ulna should reduce
48
Treatment for Colles fracture
Colles fracture – FOOSH extra-articular #, dorsal angulation, dorsal displacement
Stable, minimally displaced / angulated POP
Displaced simple # MUA
Displaced, comminution MUA & K-wiring, ORIF
49
Complications of colles fracture
Complications – Median nerve compression, EPL rupture, CRPS, loss grip strength
(CRPS: complex regional pain syndrome)
50
Treatment for smiths fracture?
Smiths fracture is VERY UNSTABLE!!! Colles you might be able to get away with conservative but smiths you need to ORIF!
(Smiths = fall on back of hand, extra-articular, volar displacement and angulation)
51
Which x-ray view do you need for Barton's wrist fracture?
Lateral view
52
What is a bartons fracture?
```
INTRA-articular fracture of the radius
-extend through dorsal aspect
-Usually associated with carpal displacement
(colles and smiths = extra articular)
Need a lateral view
Ex-fix +/- k wires
```
53
Lethal triad associated with polytrauma?
Hypothermia
Acidosis
Coagulopathy
54
Polytrauma --> what do you do?! This is serious
Aim for rapid skeletal stabilisation with reduced biological load reduce bleeding & fat embolism
Ex-fix, rapid plate fixation, ?nailing
Leave minor fractures until later
55
Fractures to prioritise in polytrauma?
```
Treat only :
Unstable pelvic #, femoral #, tibial #
Injuries with vascular compromise
Open fractures
(Impending) Compartment syndrome
```
56
Open debridement / removal of osteophytes suitable for which joints?
Ankle
1st MTP
Elbow
57
Arthrodesis is gold standard for which joints?
```
Hallux rigidus
Ankle
Wrist
PIP and DIPJ hand
Spine (temporarily)
```
58
Gold standard for hallux valgus?
Osteotomy
59
Gold standard for hallux rigidus?
Excision arthroplasty
60
Main indication for joint replacement (lower limb)?
Pain relief
-May not improve ROM
(upper limb, may improve function)
61
Success and survival rates for joint replacement?
Success rate = 80%
| Lasts for 15-20 years
62
Gold standard surgery for shoulder arthritis?
Total shoulder replacement
- not if glenoid bone loss
- needs intact rotator cuff
63
Requirements for shoulder replacement?
Not if glenoid bone loss
| Needs intact rotator cuff
64
Reverse polarity shoulder replacement?
Allows fulcrum for deltoid to work
Can give decent function in difficult cases
High complication rate – glenoid loosening 25- 50%
65
Scarf test
Acromioclavicular joint
66
Maximum lifting in elbow replacement?
```
5 kg
Total elbow replacement
Best results for RA
For low demand
Max 5kg lifting
14-25% complication rate – infection, loosening, fracture, triceps dysfunction, ulnar nerve injury
```
67
Gold standard for wrist arthritis?
Fusion!! (arthrodesis)
- maintains movement (90 degrees)
- high complication rate
- reduced grip strength
68
DRUJ and ulno-carpal arthritis
Excision arthroplasty
Hemiresection arthroplasty
Fusion & osteotomy
Replacement (long term results not known)
69
Treatment for extensor tendon rupture?
Tendon transfer
70
Boutonniere and swan neck surgery treatment?
```
Boutonniere & swan neck
Complex! Splintage first line
Tendon releases & reconstructions
PIP fusion vs replacement for severe Boutonniere
DIPJ fusion for swan neck
```
71
Treatment for 1st CMC joint arthritis?
Trapeziectomy
Good pain relief
Can have weakness pinch
Arthrodesis
72
Most common cause of acquired flatfoot deformity in adults?
Posterior tibial dysfunction
73
Primary dynamic stabiliser of medial longitudinal arch – elevates arch
Invertor & plantar-flexor
Tibialis posterior
74
Where does the tibialis posterior attach?
The navicular tuberosity and the plantar aspect of the medial and middle cuneiforms
75
Risk factors for posterior tibialis dysfunction?
```
Obese middle aged female
Increases with age
Flat foot
Hypertension
Diabetes
Steroid injection
Seronegative arthropathies
Due to a tendinosis of unknown aetiology
```
76
Pain and/or swelling posterior to the medial malleolus (very specific)
Posterior tibialis dysfunction
77
```
Pain and/or swelling posterior to medial malleolus – very specific
Change in foot shape
Diminished walking ability/balance
Dislike of uneven surfaces
More noticeable hallux valgus
Lateral wall “impingement” pain
```
Tibialis posterior dysfunction
78
Type 1-3 of posterior tibial dysfunction?
Type 1: no deformity
Type 2: flat foot deformity, cannot single heel raise, can see "too many toes" at side
-passively correctable!!
Type 3: rigid, deltoid ligament compromise, ANKLE PAIN
79
Treatment for posterior tibialis dysfunction
```
Physiotherapy
Insole to support medial longitudinal arch
NO steroid injections
Orthoses to accommodate foot shape
Bespoke footwear
Surgery
```
80
Pes Cavus
Idiopathic commonest
Variety of other causes (mostly neurological: HSMN, CP, Polio, Spina bifida, club foot)
Often clawing of toes
Surgery if required may be complex (soft tissue releases, tendon transfers, calcaneal osteotomy, arthrodesis)
81
Typical ankle sprain?
Lateral (anterior talofibular ligament and calcaneofibular ligament)
82
5th metatarsal injury?
1. Avulsion by peroneus brevis tendon (heal predictably in moonboot, do well)
2. Jones fracture, poor blood supply, 25% risk non-union
3. Proximal shaft (common site for stress fracture)
83
Which muscle might cause an avulsion fracture of the fifth metatarsal?
Peroneus brevis
| -this fracture will do well in a moon boot :)
84
Common site for stress fracture of 5th metatarsal?
Proximal shaft
85
Problem with jones fracture of 5th metatarsal?
Poor blood supply, 25% risk of non-union
86
Fall from height = might fracture what?
Calcaneus
- look for other injuries e.g. spinal
- often intra-articular
- lots of swelling
- no proven beenfit of surgery
87
Fracture following forced dorsiflexion/rapid deceleration of foot?
Talus fracture
| -Talus has reverse blood supply, risk of AVN and OA
88
Tinel's test positive for Baxter's nerve?
Plantar fasciitis
89
"heel spurs" and "heel pad pain syndrome"
Plantar fasciitis
90
Causes of plantar fasciitis?
overload – excessive exercise, excessive weight
Seronegative arthropathy
Diabetes – why?
Abnormal foot shape – planovalgus or cavovarus
Improper footwear
91
Abnormal foot shape associated with plantar fasciitis?
Planovalgus, cavovarus
92
Treatment for plantar fasciitis?
```
NSAIDS
Night splints
Taping
Heel cups or medial arch supports
Physiotherapy – eccentric exercise programme
Steroid injection
Usually self-limiting over 18-24 months
Self management
```
93
Plantar fasciitis is usually self limiting over how many months?
Self limiting over 18-24 months
94
Splayed forefoot assoc with loss of muscle tone and age
Hallux valgus
95
Problems with Hallux valgus?
```
Problems
Transfer metatarsalgia
Lesser toe impingement
Pain, deformity, cosmesis
Shoe difficulties
```
Management
Non-operative (shoe modifications,padding)
Operative
96
Operative indications for Hallux valgus?
Operative management
Indications – failure of non-op, pain, lesser toe deformities, lifestyle limitation, overlapping, ulceration, functional limitation
Many osteotomies (not core)
Aim to realign the hallux and decrease the HV angle
97
Operation for Hallux valgus?
Break the bone and move the head laterally?
98
Osteoarthritis of 1st MTPJ is called what?
Hallux rigidus?
99
Drugs associated with tendo-achilles tendinosis?
Ciprofloxacin, steroids
100
Tendo-achilles tendinosis?
Implicated – over-training, some drugs (cipro,steroids), CTDs
Pain, morning stiffness, eases with HEAT/walking
101
Clinical features of tendo-achilles rupture?
```
Usually over 40s
Often pre-existing tendinosis
Sudden deceleration with resisted calf contraction
Patients often think somebody has hit them
Clinically
Unable to bear weight
Weak plantar flexion
Palpable painful gap
Positive calf squeeze (Simmonds) test
```
102
Surgery for claw, hammer and mallet toes?
Acquired imbalance between flexors and extensors
Can cause painful callus/corns with skin breakdown
Surgery can include tenotomies (division of tendons), tendon transfer, fusions (PIP) or amputation
103
When do you refer for bow legs?
```
If painful, asymmetry, height more than 2 SDs below normal
Not resolving
(bow legs normal under 2 years, internal tibial torsion if more than 2 years)
```
104
Curly toes
```
Many resolve
3rd/4th toes
6 years
No splints
Tenotomy
```
105
Getting up from squatting
Meniscal tear
106
Twisting injury to knee
ACL or meniscal tear
107
Dashboard/hyperextension
PCL
108
McMurrays
Meniscal provocation test
109
Grade 1 sprain
Macroscopic structure intact
110
Grade 2 strain
Partial tear - some fascicles disrupted
111
Grade 3 strain
Complete tear
112
LCL injury associated with which nerve injury?
Common peroneal nerve
-complete rupture needs urgent repair (later will need reconstruction)
(MCL usually heals with time, PCL usually damaged with other ligaments = reconstruction, if isolated, can consider leaving alone)
113
Fall onto flexed knee with quads contraction
Extensor mechanism rupture
114
Risk factors for extensor mechanism rupture?
Previous tendonitis, steroids, chronic renal failure, ciprofloxacin
