Surgery Flashcards
summary of management of NoF fracture
sliding hip screw is same as dynamic hip screw
You review a middle-aged man with shoulder pain. He has limited movement of the right shoulder in all directions. Which of the following clinical findings is most consistent with a diagnosis of frozen shoulder (adhesive capsulitis)?
- external rotation is affected most
- both active and passive movement is affected
A 33-year-old businesswoman presents to the GP with persisting pain and swelling in her fore-foot. She describes that she moved to London 3 months ago for a new job, and as such she is often on her feet and usually wears high heels. She says that the pain is worse when she is weight bearing. Squeezing her foot recreates the pain. You suspect that she has a stress fracture.
What bone is most likely involved?
2nd metatarsal
hip fracture presentation
leg would be shortened and externally rotated
A 48-year-old man presents following a recurred episode of back pain. The patient has had multiple issues following a disc prolapse sustained during his career working in manual labour. The patient reports today he was bending over to pick something up and had an acute onset of lower back pain.
On exam, he had a unilateral, decreased sensation on the posterolateral aspect of the right leg and lateral foot. A straight leg raise test results in pain in the thigh, buttock and calf region and there is weakness on plantar flexion with reduced ankle reflexes.
What root compression has this patient experienced?
S1 lesion features = Sensory loss of posterolateral aspect of leg and lateral aspect of foot, weakness in plantar flexion of foot, reduced ankle reflex, positive sciatic nerve stretch test
A 48-year-old man presents following a recurred episode of back pain. The patient has had multiple issues following a disc prolapse sustained during his career working in manual labour. The patient reports today he was bending over to pick something up and had an acute onset of lower back pain.
On exam, he had a unilateral, decreased sensation on the posterolateral aspect of the right leg and lateral foot. A straight leg raise test results in pain in the thigh, buttock and calf region and there is weakness on plantar flexion with reduced ankle reflexes.
What root compression has this patient experienced?
S1 lesion features = Sensory loss of posterolateral aspect of leg and lateral aspect of foot, weakness in plantar flexion of foot, reduced ankle reflex, positive sciatic nerve stretch test
The straight leg raise test
is a fundamental maneuver during the physical examination of a patient with lower back pain.
It aims to assess for lumbosacral nerve root irritation. This test can be positive in a variety of conditions, though lumbar disc herniation is the most common.
A 56-year-old motorcyclist is involved in a road traffic accident and sustains a displaced femoral shaft fracture. Not other injuries are identified on the primary or secondary surveys. The fracture is treated with closed, antegrade intramedullary nailing. The following day the patient becomes increasingly agitated and confused. On examination he is pyrexial, hypoxic SaO2 90% on 6 litres O2, tachycardic and normotensive. Systemic examination demonstrates a non blanching petechial rash present over the torso. What is the most likely explanation for this?
fat embolism
A 65 year old man is admitted to the surgical assessment unit with urinary frequency. He has noticed particulate matter and air in his urine stream. He has felt unwell for several months with lower abdominal discomfort.
He has been treated by his GP for urinary tract infections several times in recent months.
What is the most likely diagnosis?
Diverticular disease with a colo-vesical fistula
Passing air in the urine (pneumaturia) is always pathological and most commonly suggests the presence of a fistula between the bowel and the urinary tract
A 78 year old man is admitted with acute right lower limb ischaemia. The patient has no sensation in their foot and cannot move their toes.
This is an image of the patient’s lower limbs:
He has been given opiate analgesia.
What is the most appropriate intervention for this man?
Above knee amputation
The patient presents with a well-demarcated ischaemic leg. It is blue and it will be painful. The leg will be cold to touch and pulseless. The skin will not blanch on pressure (fixed mottling).
It is now too late to salvage the leg through intervention, as the leg is ‘dead’. This is inferred by the fact that the patient has lost sensation (dead nerves) and cannot move it (dead muscle). Fixed mottling demonstrates that there is no blood flow within the skin. Therefore, in this situation the open option available (apart from a palliative approach) would be amputation, as there is no scope for revascularisation. If an ischaemic limb is not identified in time (less than 6 hours), this is the inevitable
consequence. That is why it is so important not to miss an acutely ischaemic limb as it will have life changing consequences for the patient.
A 78 year old man is admitted with acute right lower limb ischaemia. The patient has no sensation in their foot and cannot move their toes.
This is an image of the patient’s lower limbs:
He has been given opiate analgesia.
What is the most appropriate intervention for this man?
A. Above knee amputation
B. Angioplasty to occluded vessel
C. Embolectomy
D. Femoral-popliteal bypass graft
E. Intra-arterial thrombolysis
Above knee amputation
The patient presents with a well-demarcated ischaemic leg. It is blue and it will be painful. The leg will be cold to touch and pulseless. The skin will not blanch on pressure (fixed mottling).
It is now too late to salvage the leg through intervention, as the leg is ‘dead’. This is inferred by the fact that the patient has lost sensation (dead nerves) and cannot move it (dead muscle). Fixed mottling demonstrates that there is no blood flow within the skin. Therefore, in this situation the open option available (apart from a palliative approach) would be amputation, as there is no scope for revascularisation. If an ischaemic limb is not identified in time (less than 6 hours), this is the inevitable
consequence. That is why it is so important not to miss an acutely ischaemic limb as it will have life changing consequences for the patient.
6 Ps of ischaemia
pain, pale, pulseless, perishingly cold, paraesthesia and paralysis
Note that these findings are a continuum and by the time there is paraesthesia and paralysis, it is usually too late to save the limb.
A 46 year old man with Type 2 Diabetes is due to have an anterior resection next month. He takes metformin with good control of his diabetes (HbA1c 6.7% or mmol/L).
He is likely to miss more than two meals following the surgical procedure.
What is the best approach to managing his diabetes?
Stop metformin and start peri-operative variable rate insulin infusion
In a cohort study of elderly women, the relative risk ratio for hip fractures among those who exercise regularly is 1.2 (95% confidence interval of 1.1 to 1.8).
Which is the most appropriate conclusion about the effect of regular exercise on the risk for hip fracture?
A. It is not possible to draw a conclusion with the available data
B. There is a statistically non-significant increase in risk of hip fracture
C. There is a statistically non-significant overall decrease in risk of hip fracture D. There is a statistically significant overall decrease in risk of hip fracture
E. There is a statistically significant overall increase in risk of hip fracture
Explanation:
The relative risk ratio is a statistical analysis. It estimates the strength of the association between treatments or risk factors, and outcome.
Assuming the causal effect between the exposure and the outcome, the RR can be interpreted as follows:
RR = 1 means the exposure does not effect the outcome
RR < 1 means the risk of the outcome is decreased by the exposure
RR > 1 means the risk of the outcome is increased by the exposure
In our example the outcome is a hip fracture and the risk factor is exercise in a cohort of elderly women.
The RR is 1.2 which means the risk of hip fracture is increased by exercise.
This conclusion is statistically significant because the confidence interval range starts above 1. If the CI started below 1 ie was from 0.8 to 1.8 then both outcomes for exercise could be valid – exercise could either increase or decrease the risk of a hip fracture.
A 35 year old female long distance lorry driver has an 8-week history of pins and needles in the right thumb and index finger with weakness of wrist extension.
She suffers from neck and right-sided shoulder pain.
What is the most likely cause of her symptoms?
C6 nerve root impingement
A 56 year old man presents with a 36-hour history of colicky right flank pain that radiates to the groin and dipstick haematuria.
CT KUB shows a 7mm distal ureteric stone, which is visible on plain x-ray.
What is the stone most likely to be formed from?
calcium oxalate
A 55 year old woman develops a hoarse voice following a a thyroidectomy.
Which nerve is most likely to have been injured?
recurrent laryngeal
tamoxifen
Indication
- Pre-menopausal women with breast cancer
MOA
- SERM- selective oestrogen receptor modulator
- converse effects in breast and endometrial tissue
- in endometrium = ER agonist
- in breast = ER antagonist
- cell cycle arrest
- converse effects in breast and endometrial tissue
- Blockage of oestrogen receptor in breast tissue
ADR
- Risk of thromboembolism during and after surgery or during periods of immobility
- Uterine carcinoma (due to pro-oestrogenic effect on the uterus)
which hormonal therapy for post-menopausal women with breast cancer
Aromatase Inhibitors (post-menopausal)
e.g such as Anastrozole, Letrozole, or Exemestane
Indication
- Post-menopausal patients as adjuvant therapy, shown to be superior in this patient subgroup to Tamoxifen, however are more expensive.
MOA
- Act through binding to oestrogen receptors to inhibit further malignant growth and preventing further oestrogen production, as well as blocking the conversion of androgens to oestrogen in peripheral tissues.
in situ breast cancer surgical treatment
wide localise excision- if localised
mastectomy
- High tumour: breast tissue ration
- Disease recurrence
- Patient choice (or in risk-reducing cases)
common side effect of herceptin
cardiotoxicity, hence cardiac function must be monitored before and during treatment
where is pain usually with intermittent claudication and important questions to ask in history
the calves
- not many branches come off the tibial-perineal artery off into the lower leg
- lots of branches in the foot, so pain isn’t experiences so much into the foot
history
- worse on exercise
- important to ask how far patient can walk
- pain at night → critical limb threatening ischaemia (red flag)
- less gravity
- blood pressure decreases at night → reduced blood flow
- may sleep in a chair
signs of critical limb ischaemia
Pallor
Perishingly cold
Pain
Paraesthesia
Paralysis
Pulselessness
needs to be removed with 6 hours
→ symptoms may be less if chronic PAD→ development of collateral arteries
all patients with PAD should be on
statins (regardless of cholesterol)
clopidogrel (anti-platelet)
+-
- diabetes medication
- antihypertensives
types of colorectal resection for bowel cancer
+ Hartmans (a type of colectomy that removes part of the colon and sometimes rectum (proctosigmoidectomy). The remaining rectum is sealed, creating what is known as Hartmann’s pouch. The remaining colon is redirected to a colostomy.)
Anterior resection- removal of rectum and sigmoid colon- healthy tissue stiched back together
- low anterior- most of the rectum
- high anterior- less of the rectum
Hartmanns pouch
analgesia for NOF
WHO pain ladder
regional block: fascia iliac block important
management of intracapsular NOF
total hip replacement vs hemiarthroplasty
A 54-year-old woman visits her general practitioner with a painful right hip which has been bothering her for the last 10 months. Her pain control consists of codeine and paracetamol four times a day. There is no history of trauma or injury to her hip. She has a background of mild asthma, and she is in remission from breast cancer that was treated with a bilateral mastectomy and chemotherapy 3 years ago. She drinks 2 glasses of wine over the weekend and does not smoke.
On examination, there is no visible deformity of her right hip, but it is tender on palpation. She walks with a visible limp and appears to be in discomfort.
Pelvis X-ray: crescent sign.
Which of the following is the strongest risk factor for this patient’s presentation?
chemotherapy- RF for AVN
A 50-year-old man presents to his GP complaining of numbness and tingling in his left hand. He works as a building site manager, is right-handed, and denies any trauma. He has not had any symptoms like this before.
On questioning, he says the numbness and tingling wake him up at night and is mainly in his 4th and 5th fingers. On examination, there is no objective neurological deficit. Tinel’s sign is positive.
The GP recommends a splint and refers the patient to physiotherapy.
What is the most likely diagnosis?
cubital tunnel syndrome.
This affects the 4th and 5th fingers and is caused by compression of the ulnar nerve. Tinel’s sign, where tapping on the problematic nerve reproduces symptoms, is positive.
A 24-year-old man falls sustaining an inversion injury to his ankle. On examination he is tender over the lateral malleolus only. On x-ray there is a fibular fracture that is distal to the syndesmosis.
management
Application of below knee plaster cast to include the midfoot
These distal injuries are generally managed conservatively. Conservative management will involve a below knee cast, this will need to extend to the midfoot. It can be substituted for an aircast boot once radiological union is achieved.
An 86-year-old lady stumbles and falls whilst opening her front door. On examination her ankle is swollen with both medial and lateral tenderness. X rays demonstrate a fibular fracture at the level of the syndesmosis.
Application of below knee plaster cast to include the midfoot
Application of below knee plaster cast to include the midfoot42%
Although, this is a potentially unstable injury operative fixation in this age group generally gives poor results owing to poor quality bone. A below knee cast should be applied in the first instance. If this fails to provide adequate control it can be extended above the knee.
25-year-old man suffers an injury whilst playing rugby involving a violent twist to his left lower leg. On examination both malleoli are tender and the ankle joint is very swollen. On x-ray there is a spiral fracture of the fibula and widening of the ankle mortise.
Surgical fixation74
This is a variant of the Weber C fracture in which disruption of the tibio-fibular syndesmosis occurs leading to joint disruption. Surgical repair is warranted.
A 27-year-old man was admitted to hospital 6 hours previously following a fractured right tibia while playing a football match. His pain has been well controlled until 30 minutes ago, but he is now complaining of intense pain in his right lower leg. On examination he is in severe pain, worsened by passive movement of the foot. You are able to palpate the dorsalis pedis and posterior tibial pulse on the right foot. His heart rate and respiratory rate are both raised (110/min and 22/min respectively), and you notice he is sweating. Which is the definitive management for this condition?
fasciotomy
- compartment syndrome
remember presence of …… does not exclude compartment syndrome
pulses
Pain of passive movement is characteristic of compartment syndrome, and it is important to remember presence of a pulse does not rule out compartment syndrome! He will need analgesia, but it is not the definitive treatment. Intracompartmental pressure measurements can aide in the diagnosis of suspected compartment syndromes that aren’t clear, but the question asks for the definitive management, not investigations.
dynamic hip screw
A 24-year-old male patient presents to their GP with abdominal pain and bloody diarrhoea which started around six weeks ago. He has never had any previous episodes like this. He feels he may have lost some weight over the last three months. When asked about family history, he says that his father was diagnosed with bowel cancer aged 30, and though his Grandfather passed away when the patient was a child, he can remember him having a stoma.
The GP suspects bowel cancer and is suspicious of an underlying genetic abnormality
At colonoscopy, a large tumour is found in the ascending colon, close to the hepatic flexure. Other than this, the colonic mucosa looks normal.
What is the most likely underlying genetic problem?
Lynch syndrome (HNPCC) is characterised by development of bowel cancer (among other cancers) with little formation of adenomatous polyps
differential
FAP is ruled out here by the normal colonic mucosa aside from the tumour.
A previously healthy 56-year-old man comes to the GP after noticing a lump in his groin. It is not painful but he says it gets bigger when he coughs. On examination, there is a soft, non-tender, ill-defined mass in the left inguinal region. Straining increases its size but the mass disappears with the patient supine. There are no overlying skin changes. Vital signs are within normal limits. A subsequent ultrasound reveals visible abdominal contents lateral to the inferior epigastric vessels, with no ischaemic changes noted.
What is the most appropriate next step in management for this patient?
A non-tender protrusion of abdominal contents that is reducible and lateral to the inferior epigastric vessels is highly indicative of an uncomplicated indirect inguinal hernia. This should be referred for routine repair as the patient has no comorbidities and these cases often require surgery in the future.
A 33-year-old male presents to your GP evening clinic complaining of pain in his abdomen. They have described pain which is located in the lower left abdomen which has become more severe across the day. He feels feverish, nauseous, and has vomited twice in the last hour. He cannot remember the last time he passed urine or stool, and he mentions that he has had a small painless lump on his lower left abdomen for the past month which he has not sought medical attention for.
On examination, he appears clammy and looks unwell. He is tachycardic and normotensive. His abdomen appears mildly distended and is very tender to touch. There is evidence of localised tenderness in the left iliac fossa. You also notice a lump in the left inguinal area that is 2cm x 2cm in diameter which is erythematous and is now extremely painful to touch.
What is the most appropriate next step?
strangulated inguinal hernia
call 999 and arrange ASAP assessment in hospital
difference in presentation of osteomalacia and osteoporosis
Osteomalacia is a condition characterized by soft bone due to vitamin and mineral deficiencies i.e. will have low calcium
Osteoporosis is the deterioration of bone mass over time i.e. calcium will be normal
Osteomalacia
Osteomalacia is a condition that softens bones. In children, it’s called rickets. It involves problems with bone formation and the bone-building process, resulting in weakening of the bones.
It is most often caused by a vitamin D deficiency, which helps you absorb calcium.
osteoporosis
Osteoporosis is when your bone mineral density and bone mass decreases, or when the quality or structure of the bone changes. Over time, this can cause a reduction in bone strength, increasing the risk of fractures.
The inside of a bone typically has spaces akin to a honeycomb structure.
Osteoporosis is the more serious progression of osteopenia.
A 32-year-old lady has previously undergone a wide local excision and axillary node clearance (5 nodes positive) for an invasive ductal carcinoma. It is oestrogen receptor negative, HER 2 positive, vascular invasion is present. She has a lesion suspicious for metastatic disease in the left lobe of her liver.
Trastuzumab76%
This ladies young age, coupled with ER negativity and extensive nodal disease with suspicion of metastatic disease makes her a candidate for treatment with trastuzumab (herceptin).
A 22-year-old lady has severe peri anal crohns disease with multiple anal fistulae, the acute sepsis has been drained and setons are in place. She is already receiving standard non biological therapy. %
Infliximab is a popular choice in managing complex peri anal crohns. It is absolutely vital that all sepsis is drained prior to starting therapy.
A 63-year-old man presents with a locally unresectable gastrointestinal stromal tumour. Biopsies confirm that it is KIT positive.
Imatinib is licensed for treatment of GIST in the United Kingdom for this situation. The guidance from the National Institute of Clinical evidence is that patients be reviewed at 12 weeks after initiating therapy.
A 67-year-old male presents to the emergency department complaining of new-onset pain in his left groin. On examination, a large, warm, non-reducible mass located inferolateral to the pubic tubercle can be observed. It is accompanied by erythema of the overlying skin. When asked, he admits to vomiting twice and passing stools with blood mixed in them once. He looks in pain and sweaty. He has a past medical history of peptic ulcer disease, managed with omeprazole.
Which one of the following is the most likely diagnosis?
strangulated femoral hernia
Strangulation is an important complication of femoral hernias
A 46-year-old man with alcohol dependence presents to the emergency department with epigastric pain of sudden onset. He describes the pain as severe and radiating to the back. He admits to consuming two bottles of vodka the night before. His heart rate is 70/min, his respiratory rate is 15/min, his blood pressure is 130/70 mmHg and his temperature is 38.1 ºC. Blood results show the following:
low calcium
glasgow score (PANCREAS)
A 46-year-old man with alcohol dependence presents to the emergency department with epigastric pain of sudden onset. He describes the pain as severe and radiating to the back. He admits to consuming two bottles of vodka the night before. His heart rate is 70/min, his respiratory rate is 15/min, his blood pressure is 130/70 mmHg and his temperature is 38.1 ºC. Blood results show the following:
low calcium
glasgow score (PANCREAS)
best test for acute pancreatitis
- serum amylase
- raised in 75% of patients - typically > 3 times the upper limit of normal
- levels do not correlate with disease severity
- specificity for pancreatitis is around 90%. Other causes of raised amylase include: pancreatic pseudocyst, mesenteric infarct, perforated viscus, acute cholecystitis, diabetic ketoacidosis
- serum lipase
- more sensitive and specific than serum amylase
- it also has a longer half-life than amylase and may be useful for late presentations > 24 hours
best test for acute pancreatitis
- serum amylase
- raised in 75% of patients - typically > 3 times the upper limit of normal
- levels do not correlate with disease severity
- specificity for pancreatitis is around 90%. Other causes of raised amylase include: pancreatic pseudocyst, mesenteric infarct, perforated viscus, acute cholecystitis, diabetic ketoacidosis
-
serum lipase (BETTER)
- more sensitive and specific than serum amylase
- it also has a longer half-life than amylase and may be useful for late presentations > 24 hours
A 38-year-old woman attends the Emergency Department with central, tearing chest pain that does not radiate. Upon questioning, she reveals she had food poisoning and had been vomiting roughly every hour for the past day. She described the vomit as liquid with no blood.
She is alert, appears thin and has dry mucous membranes. Upon questioning, she has no relevant past medical history or family history, is a non-smoker, drinks 8 units a week and works as a cleaner.
When placing the ECG leads, the doctor notices crepitus over her chest wall. The ECG reveals sinus tachycardia.
What is the most likely cause of her presentation?
Subcutaneous emphysema may be found in Boerhaave’s syndrome (oesophageal rupture)
A 65-year-old man with a history of dyspepsia is found to have a gastric MALT lymphoma on biopsy. What treatment should be offered?
H.pylori eradication therapy
A 55-years-old man presents to the emergency department with severe epigastric pain and fever. He looks unkempt and affirms to be drinking 40 units of alcohol per week. He presented to the emergency department after suffering from the symptoms for two days, due to a phobia of hospitals.
Given the most likely diagnosis, which of the following is the single best investigation to order?
Serum lipase has a longer half-life than amylase when investigating suspected acute pancreatitis and may be useful for late presentations > 24 hours
You are asked to review a 65-year-old woman who has become breathless on the surgical ward. Earlier in the day she had a laparoscopic cholecystectomy for gallstone disease. A chest x-ray has already been obtained:
What complication has developed?
This radiograph demonstrates subcutaneous (surgical) emphysema which is a known complication of laparoscopic surgery. If the anterior chest wall is affected air can outline the pectoralis major muscle, giving rise to the ‘ginkgo leaf’ sign.
Discuss (11)Improve
A 65-year-old male presents to the GP with recurrent mild upper abdominal pain following a meal. He also complained of foul-smelling greasy stools. He has not experienced any weight loss or change in appetite, no nausea or vomiting, and is not clinically jaundiced. He has a past medical history of chronic alcohol abuse - he drinks 80 units per week and has been doing so for the past 10 years.
What is the most appropriate diagnostic test?
CT pancreas is the preferred diagnostic test for chronic pancreatitis - looking for pancreatic calcification
A 72-year-old man presents to his GP complaining of reduced sensation in his lower limbs that has been progressively worsening over the last 3 months. He feels increasingly unsteady on his feet but is otherwise well.
On examination, vibration and pinprick sensation are reduced symmetrically and he has a wide-based ataxic gait. His ankle reflexes are absent however his knee reflexes are brisk.
His past medical history includes hypertension, managed with ramipril, and gastric cancer, which was treated with a sub-total gastrectomy 4 years ago. He has a body mass index of 29.2kg/m² and drinks 10 units of alcohol per week.
What is the most likely cause of this patient’s symptoms?
Subacute combined degeneration of the spinal cord is a neurological complication of vitamin B12 (cobalamin) deficiency. A deficiency of vitamin B12 can occur as a result of nutritional deficiency, reduced absorption due to altered gastrointestinal anatomy or function, or due to the intake of certain drugs.
A 68-year-old man is brought into the emergency department with sudden onset epigastric pain which he describes as burning in nature, radiating into his back. He has had an episode of vomiting and reports feeling nauseated still. His only past medical history is recurrent gallstones and is awaiting a semi-elective cholecystectomy. He takes no regular medications. On examination, he has jaundiced sclera. His abdomen is diffusely tender with guarding and there is some periumbilical superficial oedema and bruising. Bowel sounds are decreased on auscultation.
Given the likely diagnosis, what is an important feature of this patient’s immediate management?
Aggressive fluid resus
One of the key management protocols in acute pancreatitis is early and aggressive fluid resuscitation which is to correct the third space losses and increase tissue perfusion with the aim of preventing severe inflammatory response syndrome which can lead to pancreatic necrosis.
signs of radial head fracture on x-ray
The sail sign on an elbow radiograph, also known as the anterior fat pad sign, describes the elevation of the anterior fat pad to create a silhouette similar to a billowing spinnaker sail from a boat. It indicates the presence of an elbow joint effusion.
in children may be sign of supracondylar fracture
types of wrist fracture
- Colles’ fracture (distal radius with dorsal (more behind) displacement of fragments).
- Smith’s fracture (distal radius with volar (more forward) displacement of fragments).
- Scaphoid fracture.
- Barton’s fracture (fracture dislocation of the radiocarpal joint).
colles fracture referred to as
dinner fork deformity
- distal radius is dorsal
- within 2cm or articular surface (joint)
bisphosponates e.g. alendronic acid work by
Q
bisphosponates e.g. alendronic acid
A
reducing osteoclasts activity, preventing the reabsorption of bone. There are a few key side effects to remember:
- Reflux and oesophageal erosions (oral bisphosphonates are taken on an empty stomach sitting upright for 30 minutes before moving or eating to prevent this)
- Atypical fractures (e.g. atypical femoral fractures)
- Osteonecrosis of the jaw
- Osteonecrosis of the external auditory canal
Fracture healing
(1) Haematoma- tissue damage and bleeding at the fracture site; the bone ends die back for a few mm
(2) Inflammatory reaction- inflammatory cells appears in the haematoma
(3) Callus- the cell population changes to osteoblasts and osteoclasts; dead bone is mopped ip and woven bone appears in the fracture callus
(4) Consolidation- woven bone is replaced by lamellar bone- fracture is united
5) Remodelling- newly formed bone is remodelled to resemble the normal structure
he is cool cat rapping
investigation for compartment syndrome
A
- 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
A 60-year-old male is admitted to A&E with a fall. He lives with his wife and still works as a restaurant manager. He has a past history of benign prostatic hypertrophy and is currently taking tamsulosin. He is otherwise fit and healthy. On examination there is right hip tenderness on movement in all directions. A hip x-ray confirms an intertrochanteric fracture.
Dynamic hip screw
An 86-year-old retired pharmacist is admitted to A&E following a fall. She complains of right hip pain. She is known to have hypertension and is currently on bendrofluazide. She lives alone and mobilises with a Zimmer frame. Her right leg is shortened and externally rotated. A hip x-ray confirms a displaced intracapsular fracture.
Hemiarthroplasty
A 74-year-old male is admitted to A&E with a fall. He is known to have rheumatoid arthritis and is on methotrexate and paracetamol. He lives alone in a bungalow and enjoys playing golf. He is independent with his ADLs. He complains of left groin pain, therefore has a hip x-ray which confirms a displaced intracapsular fracture.
total hip replacement
A 23-year-old rugby player falls directly onto his shoulder. There is pain and swelling of the shoulder joint. The clavicle is prominent and there appears to be a step deformity.
Acromioclavicular dislocation78%
Acromioclavicular joint (ACJ) dislocation normally occurs secondary to direct injury to the superior aspect of the acromion. Loss of shoulder contour and prominent clavicle are key features. Note; rotator cuff tears rarely occur in the second decade.
A 22-year-old man falls over and presents to casualty. A shoulder x-ray is performed, the radiologist comments that a Hill-Sachs lesion is present.
Glenohumeral dislocation61%
A Hill-Sachs lesion is when the cartilage surface of the humerus is in contact with the rim of the glenoid. About 50% of anterior glenohumeral dislocations are associated with this lesion.
An 82-year-old female presents to A&E after tripping on a step. She complains of shoulder pain. On examination there is pain to 90o on abduction.
Supraspinatus tear78%
A supraspinatus tear is the most common of rotator cuff tears. It occurs as a result of degeneration and is rare in younger adults.
Supraspinatus – abducts the arm
extra articular fracture
fracture doesnt extend into joint
- colles
- smiths
articular fracture which extends into joint is more serious
e.g. bartons
which types of distal radius fracture are intra-articular
bartons fracture
- associated dislocation of radio-carpal joint
MOA of smiths
FOOSH backwards
Three measurements on a plain radiograph help with the diagnosis of a distal radius fracture:
Three measurements on a plain radiograph help with the diagnosis of a distal radius fracture:
- Radial height <11mm
- Radial inclination <22 degrees
- Radial (volar) tilt >11 degrees
A 5-year-old boy is seen in the Minor Injury Unit after falling in the playground. His mother observed the fall and describes him falling on an outstretched hand.
The x-ray is shown below
Buckle fracture
Buckling of the cortex of the distal radius is seen without a distinct fracture line. Owing to the elasticity of bone in children, axial trauma leads to deformity, rather than a true fracture, resulting in a buckle fracture.
A 34-year-old kitchen worker presents with a two week history of pain in her right wrist. She has recently emigrated from Ghana and has no past medical history of note. On examination she is tender over the base of her right thumb and also over the radial styloid process. Ulnar deviation of the wrist recreates the pain. What is the most likely diagnosis?
Pain on the radial side of the wrist/tenderness over the radial styloid process ?
De Quervain’s tenosynovitis
A 90-year-old lady is brought to the emergency department by ambulance after falling over the rug in her bedroom. On examination, her left leg is shortened and internally rotated. Her carer states that the patient underwent left total hip arthroplasty four years ago and is taking amitriptyline for pain.
What is the most likely cause of the patient’s clinical findings?
Posterior hip dislocations present with a shortened and internally rotated leg
A 56-year-old woman presents to her GP with left-sided hand pain. She points to the site of the pain, which is at the base of her left thumb and describes the pain as a constant ache that is worse on movement. She says the pain has been getting worse over the last 12 months. The patient has a past medical history of gout in her big toe, for which she takes regular allopurinol.
Her mother was diagnosed with rheumatoid arthritis five years ago, and she is worried that she may also have this.
On examination, there is unilateral squaring of the left thumb and tenderness on palpation of the left thumb base.
Based on this history and clinical examination, what is the most likely diagnosis?
squaring of the thumb base characteristic of osteoarthritis
causes of degenerative hip disease
systemic
- obesity
- inflammatory
- RA
- ankylosing spondylitis
local
- traumatic
- primary OA
- congenital DDH
- septic arthritis
Developmental dysplasia of the hip (DDH)
where the “ball and socket” joint of the hip does not properly form in babies and young children.
anticoagulation for hip and knee
low molecular weight heparin (dalteparin)
- hip= 28 days
- knee= 14 days
perthes disease
- loss of blood supply (avascular necrosis) of the nucleus of the proximal femoral epiphysis.
- Abnormal growth of the epiphysis results.
- Eventual remodelling of regenerated bone.
presentation
- On examination all movements at the hip are limited. In the early phase there is limited abduction of the hip and limited internal rotation in both flexion and extension.
- There is an antalgic gait (due to pain) and a Trendelenburg gait is seen in the late phase
main x-ray finding for perthes
flattening of the femoral head.
gait for OA of hip
antalgic
trendelenburg
SUFE
slipper upper femoral epyphysis
- displacement of the proximal femoral epiphysis from the metaphysis
- MOA: atraumatic or associated with a minor injury
- management: no weight bearing and ORIF
An X-ray is arranged and confirms and un-displaced scaphoid fracture in the right wrist.
Based on the information provided, what is the most appropriate management option?
undisplayed scaphoid fracture- cast for 6-8 weeks
displaced scaphoid fracture - screw fixation
why is displaced scaphoid at risk of AVN
The scaphoid received a retrograde blood supply from the dorsal carpal branch of the radial artery, making avascular necrosis a risk of these fractures go undetected.
→ esp proximal fracture
