Surgery: Ortho Flashcards
The general principles of T&O
Trauma: Resus, Reduce, Restrict, Rehabilitate
Ortho: Look, Feel, Move, Special Tests
What are the clinical signs of a fracture?
Pain, swelling, crepitus, deformity, adjacent structural injury
How would you describe a fracture?
Location, pieces, pattern, displacement, plane
Outline translation and angulation
Coronal Plane:
- Medial/Lateral
- Varus/Valgus
Sagittal Plane:
- Anterior/Posterior
- Dorsal/Volar
Axial Plane:
- Proximal/Distal
- Internal/External
When is external fixation most commonly used?
Large amount of soft tissue damage inc risk of infection and also as a quick fix to save life
Where is Shenton’s line?
Imaginary curved line drawn along the inf border of the superior pubic ramus and inferomedial border of NOF
What is the % risk of AVN in a displaced intracapsular #?
25-30%
Hemi vs THR
If young, fit, mobile -> THR
If older and less fit -> hemiarthroplasty
Why don’t you give everyone a THR?
Lower mobility, multiple comorbidities, risk of dislocation, requires specialist hip surgeons
Important points in an OA hx
Pain (exertional, rest, night)
Disability (walking distance, stairs, giving way)
Deformity
Prev hx of trauma or infection
Tx given physio, injections, ops
Other joints affected
What is the angle of flexion if the leg is straight?
0°
The mx of OA
Conservative: analgesics, physio, walking aids, avoidance of exacerbating activity, infections
Operative: replace, realign, excise, fuse, synovectomy, denervate
RA vs OA
RA - inflammatory - worse in the morning
OA - degenerative - worse w activity
Look
Scars
Swellings
Deformities
Redness
Feel
PET: pain, effusion, temp
Move
Active -> Passive
Active ❌ Passive ✅
Think muscle, tendon, neuro
Active ❌ Passive ❌
Think mechanical block
Why do osteophytes form?
They’re outgrowths of bone to try spread the SA and dec friction
What are the special tests?
Knee - C’s - collaterals, cruciates, cartilages
Hip - T’s - Trendelenburg’s and Thomas’s
Shoulder - I SITS - impingement, supraspinatus, infraspinatus, teres minor, subscapularis
What should you always ask for before performing Thomas’s test?
If they have a hip replacement
How does a frozen shoulder present?
Extremely painful, global dec ROM, normal xray
Bone growth in width and length?
Width - intramembranous ossification
Length - endochondral ossification
What are the two types of bone healing?
Primary/Direct - by direct union and cutting cone where haematoma has been disturbed - slow
Secondary/Indirect - by callus formation where haematoma has NOT been disturbed - fast
Which type of bone healing can the union be evaluated by xray?
Secondary
Which type of bone healing is fastest?
Secondary
The prerequisites for bone healing
Blood supply and periosteum, minimal fracture gap and movement, optimum pH/nutrients/growth factors
How many planes must you ensure you xray a fracture in?
Two
What are the biggest RFs for poor bone healing that you should always elicit from the hx?
Diabetes
Smoking
How does movement affect bone healing?
If direct bony contact there shouldn’t be any movement vs if indirect up to 10% can be helpful
What should you avoid when using k wires in children?
The physis i.e. growth plate
The principles of fracture mx
Save Life -Then- Save Limb
Resus, Reduce, Restrict, Rehabilitate
What are the benefits of reducing the fracture?
Helps to prevent malunion
Places the soft tissues under less direct stress, inc blood flow to skin, red secondary damage
Red pain and risk of carpal tunnel syndrome etc
PWB vs TWB
Partial - a % of BW is placed on the injured limb
Touch - the injured limb is used only for balance
Methods of restriction
Non-Op: casts (backslab or full POP/fibreglass), splints, traction
Operative: external/percutaneous/internal fixation + replacement
When would you immobilise just that joint or both above/below?
If near epiphysis then below vs midshaft above
The ALTS principles
Primary Survey A - C spine control w manual inline stabilisation B - ?pneumothorax C - ?haemorrhage D - GCS, spine, log roll Secondary Survey E - top to toe
What is a pathological fracture?
When there was no trauma, assess fragility, ask FLAWS/hx of cancer
What is the most sensitive marker of blood loss?
RR, UO, HR, BP
Clinically RR>HR>BP + objectively fall in urine output but not immediate
What is the least sensitive marker of blood loss?
RR, UO, HR, BP
Fall in BP
What is the most important marker of resus?
Lactate
Classification for open fractures
Gustillo Anderson:
I - puncture wound <1cm
II - 1-10cm w mod soft tissue injury
IIIa - >10cm but able to close skin
IIIb - either extensive tissue injury or needs flap/graft to close overlying skin
IIIc - vascular injury
How are supracondylar fractures classified?
Gartland:
I - undisplaced
II - displaced w intact posterior cortex
IIIa - completely displaced posteromedially
IIIb - completely displaced posterolaterally
What is the typical cause of a supracondylar fracture?
Child falling on an outstretched elbow fracturing the narrowest part of the humerus
Def of compartment syndrome
Sustained inc pressure within a myofascial compartment leading to reduced perfusion which if left untreated may lead to permanent tissue necrosis
What is the main give away for compartment syndrome?
Pain out of proportion w clinical picture and worse on passive stretching eg wriggling toes
Which blood supply is occluded first in compartment syndrome?
Venous
Mx of suspected compartment syndrome
Take everything off the limb dressings/casts and give analgesia, go back and see them in ~15mins, emerg fasciotomy if lower leg two incision four compartment decomp, excise necrotic tissue, re-exploration <48hrs, early involvement of plastics
What should you do w any erythema you see?
Mark the outline
How long does nec fas take to spread?
Hrs NOT days
What should you always do before sticking a needle into a joint w septic arthritis?
Xray before aspirating before abx
What are vital parts of an ortho examination?
Neurovascular status on both sides + examine the joint above/below
Which blood supply to the bone inc if the nutrient artery is impaired?
The periosteum therefore important not to take too much away during surgery
What is Wolff’s law?
The bone density changes in response to functional force
The two broad categories of a fracture
Simple and comminuted
Why do you straighten and apply pressure to a break before op?
Pain relief, better for the surrounding soft tissue, makes the op easier
When would you measure the compartment pressure?
If the pt is unconscious
NB: compartment syndrome is otherwise a clinical dx
What are the four compartments of the lower leg?
Anterior, lateral and deep/superficial posteriors
What inserts onto the greater trochanter?
Gluteus medius and minimus - hip aBductors
What inserts onto the lesser trochanter?
Psoas - hip flexor
How do you categorise NOF fractures?
Intracapsular - undisplaced (Garden I+II) and displaced (Garden III+IV)
Extracapsular - intertrochanteric and subtrochanteric
The blood supply to the NOF
Major supply - medial and lateral circumflex femoral arteries from profunda femoris and subsequent trochanteric anastomosis w branches of gluteal arteries
Minor supply - ligamentum teres from obturator artery/internal iliac + intramedullary
Mx of NOF#
Upon admission MMSE, seen by orthogeris, operate within 36hrs
Intracapsular: 1,2,Screw + 3,4,Austin-Moore
Extracapsular: inter DHS + sub nail
Mobilise early w physio and minimise risk of future falls and osteoporosis
What is the NOF# give away on inspection?
Shortened + externally rotated leg
What do you do if clinically it suggests NOF# but not present on xray?
MRI>CT
What is non union?
Failure of bone healing within an expected timeframe
What is malunion?
The bone heals but outside normal parameters of alignment: limp, gait, arthritis
The two types of non union
Atrophic - infection, gap, too stiff
Hypertrophic - too much movement
How do you describe a fracture? (3)
Type
Location
Displacement
How do you describe displacement? (3)
In relation of the distal to the proximal: translation, angulation, rotation
Which cells make up the cutting cone?
The osteoClasts lead + osteoBlasts follow that lay osteoids
When would you favour external > internal fixation?
Poor soft tissues and quicker
How do you describe angulation?
Coronal - varus (apex lateral) or valgus (apex medial)
Sagittal - recurvartum (apex posterior) or procurvatum (apex anterior)
Why are some fractures not fixed?
Infection Bleeding VTE NV Injury Nonunion Malunion Stiffness CRPS
Outline the mx of open fractures
Save life first w ATLS Document NV status Photo of soft tissue Cover w gauze and saline IV abx co-amoxiclav and tetanus Splint w backslab POP cast Xrays and plan for theatre
What is the general approach to interpreting a MSK radiograph?
The usual details + whether the pt is skeletally mature/immature
The ABCS Approach
Alignment: sublux or discl
Bones: cortex, fragments, quality
Cartilage: joint spaces, contour, arthritic/gout changes
Soft Tissues: disruption, swelling, foreign bodies
What does a fat pad on x-ray indicate?
An occult fracture that has caused swelling: ant can be normal but post is abnormal
What is a Jefferson #?
Multiple fractures at different points in C1 ring due to compressing vertical force
What is a Hangman’s #?
Fractures of both pedicles of C2 due to hyperextension injury
Colles v Smiths v Bartons
Colles Type - extension # of distal radius w dorsal angulation
Smiths Type - flexion # of distal radius w volar angulation
Bartons Type - intra articular distal radius #
Monteggia v Galeazzi
MUgGeR
Monteggia - ulna # w dislocation of radial head
Galeazzi - radius # w dislocation of distal radioulnar joint
What are the clinical signs of a scaphoid #?
Any tenderness in the anatomical snuffbox, scaphoid tubercle, thumb telescoping
What if there’s no visible fracture on xray but there’s clinical suspicion of a scaphoid #?
Treat and repeat xray in 10 days
Why is it important not to miss scaphoid fractures?
Retrograde blood supply and avasc necrosis risk
What is the Weber classification of lateral malleolus fractures?
A - below ankle joint
B - at ankle joint
C - above ankle joint
What is the Salter-Harris grading for growth plate fractures?
I - Separated II - Above III - beLow IV - Through V - Rammed
Mx of OA
Confirm dx w hx, exam, ix
Take an MDT approach w PT, OT, podiatrist
Consrv: manage RFs ie optimise weight, diet, low impact exercise, ensure other medical conditions are well controlled + consider applying warm/ice packs and use of arthritis gloves if the hands are affected
Med: analgesia up WHO pain ladder + intra-articular steroid injections
Surg: referral to ortho for osteotomy, arthrodesis and more likely arthroplasty
OA: DISGAPMMSSP
A multifactorial degenerative disease process involving degradation of articular cartilage, cellular changes and biomechanical stresses
It’s the sixth most prevalent cause of disability globally affecting predominantly elderly females esp from low income countries
Usually 1° but can be 2° to infection, inflam RA, trauma #/meniscal tear
Sx: pain, stiffness, swelling; Signs: tenderness, crepitus, dec ROM, Heberden’s, Bouchard’s; Ix: x-ray
The prognosis depends on the joints affected and disease severity and surgical mx appears to yield the best long term outcome
What are the features of OA on an x-ray?
LOSS: loss of joint space (trendelenburg), osteophytes, subchondral sclerosis, subchondral cysts (late sign)
If it’s a WB joint take the x-ray standing
What is the unhappy triad?
ACL, MCL, medial meniscus
Which nerve innervates the gluteus medius/minimus and tensor fascia lata?
Superior Gluteal Nerve
Which nerve innervates the gluteus maximus?
Inferior Gluteal Nerve
What is a crude way of assessing A-E in ATLS?
Ask for their name + to wiggle their fingers/toes
What are the types of lamellar bone?
Cortical: hard concentric Haversian systems that communicates w medullar canal
Cancellous: soft trabecular honeycomb structure around metaphysis oriented in direction of most stress which allows for meta/epiphyseal vessels
What happens to the blood supply to a bone after fracture?
The nutrient artery is disrupted and inc supply to periosteum unless open
What are the stages of secondary bone healing?
- Haematoma 0-2w
- Soft Callus 2-3w
- Hard Callus 3-6w
- Remodelling <2yr
When do you try and operate on a #?
Within 2wks before callus formation makes the procedure more difficult
Which clinical situation would 2° bone healing be problematic?
Intra-Articular + Displaced #: operate to promote 1° bone healing and minimise the joint surface becoming uneven
How do you dx a fracture?
Hx, o/e (tenderness + swelling), xray
Why might a fracture displacement in a cast?
As the swelling reduces therefore we take xrays to ensure it remains in place
: Replace>Fix
Comminuted
Intra-Articular
Avasc Necrosis
: ExFix>Cast
If you’re worried about infection
: Backslab>Full Cast
Allow for swelling therefore red risk of compartment syndrome
: Full Cast>Backslab
When seen in 2wk # clinic, more stable, if fibreglass also lighter weight
When would traction be used?
Midshaft femur # before operating where a cast would be inappropriate
How long do you have if there’s damage to the blood supply?
Check pulses, cap refill, doppler -> limited 3-6hrs to revascularise
What needs immobilising in a midshaft fracture?
The joint either side so above knee/elbow casts required
Why do pts die following a RTA?
Immediate: brain injury + catastrophic bleeding
Early: bleeding, DIC, ARDS
Late: comps from surgery
Mx of Open Fracture
ATLS NV Status Photograph Soaked Gauze Abx + Tetanus Restrict Xrays Theatre Rehab
What muscles sit in the lateral compartment of the lower leg? (2)
Peroneal Longus + Brevis
What muscles sit in the posterior compartments of the lower leg?
Deep: tibialis posterior, popliteus, flexor hallucis longus, flexor digitorum longus
Superficial: gastrocnemius, soleus, plantaris
What muscles sit in the anterior compartment of the lower leg? (4)
Tibialis anterior, fibularis tertius, extensor hallucis longus, extensor digitorum longus
What are the 6P’s of compartment syndrome?
Pain x6
Dx of Compartment Syn
Clinical
When would you measure the pressure of a compartment?
Unconscious or pt w severe learning disabilities to see if delta p >30 (within 30mmHg of diastolic pressure or absolute pressure above 40mmHg)
Why do pts die following a NOF#?
Mechanical fall due to slow decline and degeneration of reflex pathways
Plus stroke, MI, UTI
Workup for NOF#
Full/collateral hx to identify cause inc pre-injury mobility, DHx, SHx
Examination inc NV status, cvs, resp
Special tests inc bloods, G+S, ECG, CXR, AP pelvis and lateral hip
What bones make up the acetabulum?
Ileum, Ischium, Pubis
Why don’t we mx NOF# non-operatively?
Dec Pain, VTE, Pneumonia, UTI, Sepsis
Which group of elderly pts would you worry about giving a THR to?
Alcoholics or demented pts who forget to follow the restrictions and result in dislocation
Hemi vs Total
The risk of dislocation is less for a hemi because of the larger head but initial immobilisation isn’t as good and it won’t last as long due to wearing of the acetabulum
Which OA is most common in the hip, knee, ankle?
Hip 1°, Knee 1°, Ankle 2°
Which pts classically get valgus knee OA?
RA
Why would you perform a unicondylar knee replacement > TKR?
Operatively: quicker op + preserve as much native bone making future revisions easier w less comps
Postop: faster recovery, less pain, feels more like a real knee
What are the main comps specific to a THR?
Immediate - bleeding + nerve injury
Early - infection + VTE
Late - leg length discrepancy, dislocation, loosening
What is a potential cause for a trendelenburg gait?
An anterolateral approach to hip surgery resulting in superior gluteal nerve injury
What are the hip approaches? (3)
Anterior, Anterolateral (hemi), Posterior (total)
Where does AVN typically occur? (3)
Scaphoid, Navicular, NOF
What are the most common causes or AVN? (5)
Idiopathic Trauma Alcohol Steroids Sickle Cell
Mx of AVN
Dx: exclude other causes and xray/MRI
Tx: remove cause, revascularise, arthroplasty
Where does the spinal cord end? And what is a useful landmark?
L1 @ bottom of ribcage
Cord Compression vs Cauda Equina Syndrome
CC: presynaptic, inc tone, red power, brisk reflexes, clonus, upgoing plantars, reduced PR tone, incontinence, sensory level loss of sensation
CES: postsynaptic, dec tone, red power, red reflexes, no clonus, downgoing plantars, reduced PR tone, incontinence, patchy loss of sensation
Myelopathy vs Radiculopathy
Compression of cord + root
What happens if CES is left untreated?
Lower limb weakness and paralysis + long term incontinence
Where is the T10 sensory level?
Umbilicus
Where is the T4 sensory level?
Nipples
What are the causes of cord compression?
Tumour (Mets)
Trauma
Infection (Epidural Abscess + Discitis)
Disc Prolapse
Degeneration (Spondylolisthesis)
Congenital (Scoliosis + Syringomyelia)
What are the causes of CES?
The same pathology as for cord compression however it’s the level where it occurs that’s differs as does the order of most common causes: disc prolapse, degeneration, infection, tumour
What is the most common cause of CC + CES?
CC: Tumour + CES: Central Disc Prolapse
What are the red flags for impending CES?
Bilateral sciatica, progressive evolving neurology, saddle anaesthesia, urinary/bowel sx, sexual dysfunction
Mx of CES
Confirm dx w urgent MRI + emerg discectomy/laminectomy within 48hrs of onset of sx
What joins the lamina to the vertebral body?
Pedicle
How do you reduce a patella that’s dislocated laterally?
Extend the knee
Paeds: Septic Arthritis vs Transient Synovitis
The hx and symptomatology are similar: not moving, ?temp/tachy, ?recent viral illness, use Kocher criteria
Why do children w an inflam hip find externally rotating their hip and flexing the knee more comfortable?
It puts the least amount of tension on the capsule
What are the Kocher criteria for a child w an inflamed hip?
NWB
Temp >38.5°
ESR >40mm/hr
WBC >12,000cells/mm^3
It’s a point for each w more points making septic arthritis and need for aspiration/surg drainage more likely: 1=3%, 2=40%, 3=93%, 4=99%
What would you do if a child’s limping and only has one of the Kocher criteria?
Start NSAIDs to see if it settles down as an irritable hip is self limiting
If there’s no improvement consider US looking for an effusion +/- aspiration
What is Perthes disease?
Idiopathic transient AVN of the hip usually 4-8yo w the older they px the worst the prognosis as less potential for remodelling
What should you consider if a suspected transient synovitis is not improving after a few days?
Perthes
Mx of Perthes
Dx: initially w MRI and may be found later on xray
Tx: aim to preserve shape of femoral head until revascularisation to red future arthritis
Consrv: avoid contact sports and consider crutches during painful stages
Surg: when older osteotomy/THR left as late as possible
What are the stages of Perthes disease? (3)
Precollapsed, Collapsed, Remodelling
What is a SUFE?
Idiopathic head of femur slips backwards usually 9-15yo undergoing puberty px w groin or referred knee pain
What should you consider as a potential cause of a pre-pubertal boy px w SUFE?
Likely to be due to hormonal changes: obesity, hypogonadal, thyroid disease
Also more likely to end up w bilateral disease and could be a ~yr b/w each px
Mx of SUFE
Dx: have a low threshold to ask for AP pelvis and frog lateral xrays
Tx: aim to fix epiphysis in current position w a screw to prevent further slippage and development of 2° AVN, nonunion, arthritis +/- prophylactically tx other side in young pts
What are the DDH screening tests for all children?
Barlow -> Ortolani
Which children are at a high risk of DDH? (3)
FHx
Breech
Oligohydramnios
Mx of DDH
Dx: initially w US if RF/pos screening and may be found later on xray
Tx: aim to keep the hip joint in place
Consrv: Pavlick harness + serial USS
Surg: MUA, spica cast, open reduction, when older osteotomy/THR
What results in a break in shentons line?
DDH
NOF#
How do you describe translation?
The fixed point is your proximal bone and it’s the lateral bone that’s described
What NV can be damaged following a supracondylar fracture?
Median Nerve + Brachial Artery
What is the indication for urgent surg tx of a supracondylar fracture?
Absent radial pulse, clin signs of impaired perfusion, evidence of threatened skin viability
What is the surg tx of a supracondylar fracture according to BOAST?
Stabilise w bicortical wire fixation: crossed wires lower risk of loss of fracture reduction + divergent lateral wires lower risk of ulnar nerve injury
Postop radiographs @ 4-10d + wire removal and mobilisation @ 3-4w
Which rotator cuff muscle does the axillary nerve innervate?
Teres Minor
What is Sir Herbert Seddon’s classification of peripheral nerve injury?
Mild-Sev: neurapraxia, axonotmesis, neurotmesis
Why is it so important to clinically distinguish b/w CC + CES?
To MRI the correct part of the spine to confirm dx vs the wrong part of the spine and falsely reassure
What is a crude way to examine the peripheral nerves of the upper limb in a child?
Play rock (median), paper (radial), scissors (ulnar)
What are the comps of a distal radius fracture?
Immediate: soft tissues, haemorrhage, shock
Early: infection, compartment syn, VTE, ARDS
Late: malunion, nonunion, scarring, stiffness, CRPS
Fat Embolism vs PE
You have a petechial rash w fat embolism
Where is true hip pain?
Groin
What are the three compartments of the knee joint?
Patellofemoral
Medial Femorotibial
Lateral Femorotibial
What is the ASIA score?
The minimal elements of neurological assessment for all pts w spinal injury: strength of 10 muscle groups each side + pin prick discrimination at 28 sensory locations each side
Mnemonic to remember the carpus: thumb + pinky
Here Comes The Thumb: Hamate Capitate Trapezoid Trapezium
Straight Line To Pinky: Scaphoid Lunate Triquetrum Pisiform
What are the boundaries of the anatomical snuffbox? (3)
EPL + EPB/APL
What passes through the anatomical snuffbox? (3)
Radial artery, cephalic vein, superficial branch of the radial nerve
What passes through the carpal tunnel? (4)
FDSx4, FDPx4, FPL, Median Nerve
What are the boundaries of the carpal tunnel? (2)
Superficial flexor retinaculum + deep carpal arch
What are the boundaries of Guyon’s canal? (4)
Volar and transverse carpal ligaments, pisiform, hook of hamate
What passes through Guyon’s canal? (3)
Ulnar artery, vein, nerve
What is the sensory distribution of the median + ulnar nerves?
Median: lateral three 1/2 digits inc nail beds + palmar cutaneous
Ulnar: medial one 1/2 digits, palmar cutaneous, dorsal branch
What does the anterior interosseous branch of the median nerve supply?
FDP, FPL, Pronator Quadratus
What is the Kapandji score?
Assessment of thumb opposition: 1 (radial side of proximal phalanx of index finger) to 10 (distal palmar crease)
How does conus medullaris syndrome differ to CC + CES?
It presents w a mixture of UMN + LMN signs
What is the vertebral level of the inferior angle of scapula?
T7
What are the borders of the femoral triangle? (3)
Inguinal ligament, adductor longus, sartorius
Where in the ankle do the long + short saphenous veins pass?
Long: in front of the medial malleolus
Short: behind the lateral malleolus
Ddx for a hot swollen knee
Trauma Septic Gout Bursitis Reactive Haemarthrosis Flare up of RA
What are hints that the joint could be septic?
RIG: recent replacement, infection risk (elderly, diabetic, immunocomp), gonococcal
Septic Arthritis vs Bursitis
ROM
Where are the diff eponymous bursitis in the knee?
Housemaids - Prepatella
Clergymans - Infrapatella
Bakers Cyst - Semimembranous
What are the potential consequences of septic arthritis? (2)
Septic Shock + OA
What’s the most common culprit for septic arthritis?
Staph Aureus
Plus ivdu mrsa, sickle cell salmonella, sexually active gonococcal
What is a red hot swollen joint until proven otherwise?
Septic Arthritis
What is a bakers cyst usually on the background of?
OA or RA
Workup for a hot swollen knee
Full hx inc recent surg/diabetic/sexual, examination inc mcmurrays/hands/obs, special tests inc bloods (wcc crp esr urate clotting) + aspiration (MCS and crystals) only if native joint
Tx of Septic Arthritis
Washout + IV Empirical Abx
What are the two causes of a trendelenburg gait in OA?
Loss of joint space + pain inhibition
What can result in ulnar nerve palsy? (3)
Dysfunction at cervical spine, cubital tunnel syndrome at elbow, guyons canal syndrome at wrist
Which muscles in the forearm does the ulnar nerve supply?
Flexor capri ulnaris + the medial half of flexor digitorum profundus
What are the subtypes of osteomyelitis?
Acute: initially nidus of infection which can spread under the periosteum
Subacute: brodies abscess in children
Chronic: walled off abscess w sequestrum (necrotic bone) inside and involucrum (reactive bone) outside +/- sinus
What are the majority of osteomyelitis you see in the community?
Chronic: young/old, immunocomp, diabetic
Tx of Osteomyelitis
Aggressive IV abx if acute + surgical drilling if sequestrum
CIs of FIB
Absolute: clinical suspicion of compartment syndrome + local anaesthetic allergy
Relative: associated crush injury, infection/burn of overlying skin at injection site, easy bruising
What is the vertebral level of the iliac crest?
L4
Most common sources of bone mets
Breast Prostate Lung Kidneys MM Lymphoma
Most common sites of bone mets
Spine Ribs Pelvis Proximal Femur Proximal Humerus
When does periprosthetic lucency occur?
Prosthetic loosening or infection
What is the imaging modality of choice in diagnosing a joint prosthesis infection?
X-rays
What xray changes are indicative of joint prosthesis infection?
Wideband of radiolucency at the cement/metal bone interface & bone destruction
Mx options for periprosthetic infection
Excisional arthroplasty, debridement and implant retention, single/two stage revision
What is arthroplasty?
The surgical creation or reshaping of a new joint to relieve pain and/or restore movement
Where is excision arthroplasty commonly performed?
The hip (Girdlestone), first carpometacarpal joint/trapezium & to correct severe hallux valgus deformity (Keller)
What is the Trendelenburg’s sign?
The pelvis drops on the side of the lifted foot during the step
When is the Trendelenburg’s sign positive?
Contralateral aBductor weakness, superior gluteal nerve palsy, subluxation or dislocation of the hip, shortening of the femoral neck, any painful hip disorder
Draw out the carpus
https://teachmesurgery.com/wp-content/uploads/2018/10/21.jpg
See iPad Photos
Draw out the tarsus
https://teachmeanatomy.info/wp-content/uploads/The-Tarsal-Bones-of-the-Foot.jpg
See iPad Photos
What are the most causative organisms of infected hip replacement?
Staph aureus & coagulase negative strept
What are the primary aBductors of the hip?
Gluteus medius & minimus
Intracapsular hip fractures
Femoral head & neck
Extracapsular hip fractures
Trochanteric, intertrochanteric and subtrochanteric
Branches of which artery can be damaged in intracapsular fractures?
The medial femoral circumflex artery
What is a/w femoral neck fractures?
Limb shortening, external rotation, fracture non-union, avascular necrosis
What is fracture non-union?
It fails to heal
Which fracture increases the risk of septic arthritis?
Compound
Mx of displaced intracapsular fractures
Replacement arthroplasty or total hip replacement
Mx of extracapsular fractures
Intramedullary pin and plate or extramedullary sliding hip screw for trochanteric fractures above and including the lesser trochanter & internal fixation for subtrochanteric fractures
Mx of non-displaced intracapsular fractures
Internal fixation
What are Tinel’s + Phalen’s signs?
Both test the MEDIAN nerve
Tinel’s: tapping over the median nerve causes paraesthesia
Phalen’s: downward prayer position results in flexion at the wrist producing sx
What are the Ottawa ankle rules?
Ankle x-ray is only required if there’s any pain in the malleolar zone and one of: inability to WB for four steps or bony tenderness over distal tibia or fibula
Outline the Weber classification
A: infrasyndesmotic
B1-3: usually starting at level of tibial plafond and extending proximally
C1-3: suprasyndesmotic +/- tibiofibular syndesmosis disruption, medial malleolus #, deltoid ligament injury
Mx of Weber A + C
A: remain WB as tolerated in CAM boot for 6wks
C: open reduction + external fixation
What radiographic signs are a/w POSTerior shoulder dislocation?
Rim’s: widened glenohumeral joint >6 mm
Light Bulb: fixed internal rotation of the humeral head
Trough Line: dense vertical line in the medial humeral head
What position does ANTerior shoulder dislocation result in?
Ext rotation and aBduction
What radiographic signs are a/w ANTerior shoulder dislocation?
Bankart Lesion: injuries specifically at the anteroinferior aspect of the glenoid labral complex
Hill-Sachs Defect: posterolateral humeral head depression fracture resulting from the impaction with the anterior glenoid rim
Greater Tuberosity #
Which #s are most commonly a/w compartment syndrome?
Supracondylar + Tibial Shaft
What is the most common site of metatarsal stress #s?
Second metatarsal shaft as it’s the longest
Fifth Metatarsal #s: Pseudo-Jones vs Jones
Pseudo: most common, avulsion # at proximal tuberosity, a/w lateral ankle sprain and often follow inversion injuries
Jones: less common, transverse # at metatarsal base, a/w sig aDduction force to forefoot w ankle in plantar flexion
Outline the Gustilo + Anderson classification
Open #s
1 - low energy wound <1cm
2 - >1cm w mod soft tissue damage
3 - high energy wound >1cm w extensive soft tissue damage
A: adequate ST coverage
B: inadequate ST coverage
C: associated arterial injury
How soon should open #s be debrided and lavaged?
<6hrs of injury + IV broad spec abx and tetanus prophylaxis
: Trauma v Stress v Patho
XS forces, repetitive low velocity injury, abnormal bone w normal use
Pt w snuffbox tenderness but neg x-rays next step?
Ideally MRI before discharging w splint/cast plus thumb immobilisation + 2wk review in # clinic to repeat x-ray
What are the scaphoid views?
PA
Ziter
Lateral
Oblique
What is the mx of undisplaced scaphoid #s?
Immobilisation in below elbow cast for 6-8wks
Which scaphoid #s require surgical fixation?
Displaced OR proximal scaphoid pole #s
What are the comps of discitis? (2)
Sepsis + Epidural Abscess
What other ix do you need to perform alongside spine MRI for pt w discitis?
Assess for signs of infective endocarditis
What is the FRAX score?
Estimates the 10yr risk of fragility fracture for pts 40-90yo: low reassure and lifestyle advice, med offer BMD, high offer boje protection tx
Ddx for sx ruptured bakers cyst
DVT
What is the most common 1° + 2° cause of iliopsoas abscess?
1°: staph aureus + 2°: crohns disease
Iliopsoas abscess ix + mx
CT abdomen + IV abx and percutaneous drainage
Tx for NOF
Intracapsular - internal fixation, hemi (immobile), total (mobile)
Extracapsular - DHS (intertrochanteric) or intramedullary nail (subtrochanteric)
What is the Garden classification?
NOF
I: stable w impaction in valgus
II: complete but undisplaced
III: displaced but still has boney contact
IV: complete boney disruption
Tests for DDH
Barlow -> Ortolani
Perthes vs SUFE
Perthes: 4-8yo boy, hip pain stiffness red rom, widening of hip joint space due to avasc necrosis w flattening of femoral head on x-ray
SUFE: 10-15yo obese boys, distal thigh or knee pain w loss of int rotation of leg in flexion, displacement of femoral head epiphysis postero-inferiorly on x-ray
Aetiology of Dupuytren’s contracture
Manual labour, trauma, alcoholic liver disease, diabetes mellitus, phenytoin
What is Simmond’s triad?
Helps to exclude Achilles tendon rupture: palpation of tendon, angle of declination at rest, Thompson test ie calf squeeze test
De Quervain’s tenosynovitis vs Wartenberg’s syndrome
De Quervains: inflam of EPB and APL tendon sheath causing radial styloid process pain w no sensory deficit
Wartenbergs: entrapment of superficial branch of radial nerve causing rest pain regardless of position over distal radial forearm w paraesthesia over dorsal radial aspect of the hand
How long should you wait to weight bear following the placement of an intramedullary nail?
You don’t need to wait as WB is tolerated and prolonging it would just inc risk of VTE and decline in physical function
The red flags for lower back pain (5)
Age <20 or >50, night pain, sys unwell, hx of trauma, prev malignancy
What does the light bulb sign on x-ray suggest?
Posterior dislocation of the shoulder
Elbow: Golfers vs Tennis
Middle of the fairway vs sides of the court
Golfers: tenderness over MEDIAL epicondyle + medial wrist pain on resisted wrist pronation/flexion
Tennis: tenderness over LATERAL epicondyle + lateral elbow pain on resisted wrist supination/extension
What is Finkelstein’s test?
Pulling the thumb in ulnar deviation and longitudinal traction will cause pain over the styloid process and along EPB+APL in pts w tenosynovitis
Mx of Open #
Consrv: examine extent of injury, monitor and document NV status, image, dressing
Med: IV broad spec abx + tetanus prophylaxis
Surg: primary debridement within 6hrs of injury +/- temp external fixation followed by secondary debridement after 24-48hrs to ensure soft tissue recovery before def fixation
What is the main NV structure that is compromised in a scaphoid #?
Dorsal carpal arch of the radial artery
What is long term steroid use a key RF for the development of?
Avascular necrosis of the femoral head
What are the causes of AVN of the hip? (4)
Steroids, chemo, xs alcohol, trauma
What causes of lower back pain are worst in the morning?
Facet Joint + Ank Spond
What causes of lower back pain are relieved by rest?
Spinal Stenosis + Peripheral Arterial Disease
What does the straight leg raise test?
If a pt w lower back pain has an underlying lumbosacral nerve root sensitivity
How is the straight leg raise performed?
Pt lying supine raise the straight leg, place hand under the lumbar spine to ensure no compensatory lordosis, dorsiflex the foot to exacerbate the signs
What are RFs for haematogenous osteomyelitis? (5)
Sickle cell anaemia, immunosuppression, HIV, infective endocarditis, IVDU
What are RFs for non-haematogenous osteomyelitis? (4)
Diabetic foot ulcers, diabetes mellitus, peripheral arterial disease, pressure sores
What are the most common causative organisms of osteomyelitis? (2)
Staph aureus except in pts w sickle cell where salmonella predominate
What are the possible features of cauda equina syndrome? (5)
Lower back pain, bilateral sciatica, red perianal sensation, dec anal tone, urinary dysfunction
What should you check in pts with new onset back pain?
Anal Tone
Comps of cauda equina syndrome (2)
Paralysis + Incontinence
CES: ix + mx
Urgent MRI within 6hrs + surg decompression
What is the most common cause of cauda equina syndrome?
Central disc prolapse
Plus: infection, malignancy, trauma
What is the initial imaging modality for suspected Achilles tendon rupture?
USS
RFs for Achilles tendon disorders (2)
Quinolone + Hypercholesterolaemia
What is the first line tx for back pain?
NSAIDs +/- PPI
Typical LCL + MCL injuries
LCL: direct blow to MEDIAL aspect w slow developing effusion and lateral joint line tenderness
MCL: direct blow to LATERAL aspect w slow developing effusion and medial joint line tenderness
What are meniscal tears a/w? (3)
Twisting injuries, delayed knee swelling, joint locking
What does the Schatzker system classify?
Tibial plateau fractures
What is the incidence of different shoulder dislocations?
Ant >95%
Post 2-4%
Inf <1%
How is acromioclavicular joint injury graded?
Based on degree of separation: I+II conv rest w sling and IV-VI surg
What is Thessaly’s test?
Used to assess meniscal tear: weight bear at 20° knee flexion and pos if pain on twisting knee
How does lumbar spinal stenosis px?
Back pain, neuropathic pain and sx mimicking claudication however sitting>standing and uphill>downhill
Mx of lumbar spinal stenosis
MRI + Laminectomy
Adhesive Capsulitis vs Subacromial Impingement
AC: restriction of both active and passive ROM w ext rotation most marked
SI: pain on overhead activities w painful arc at the top of aBduction o/e and worse when lying on affected side
Osgood-Schlatter Disease vs Chondromalacia Patellae
OSD: inflam of insertion into tibial tuberosity worst w activity and better w rest
CMP: inflam of underside of patella typically teenage girl w knee pain on walking down the stairs + o/e wasting of quads and pseudolocking of knee
Osteochondritis Dissecans: DISGAPMMSSP
Affects subchondral bone w 2° pain, oedema, free bodies, mechanical dysfunctions
Young males
RFs trauma+genetics
Loose piece separates from end of bone
Sx: knee pain and swelling typically after exercise, locking/giving way a/w loose bodies
Signs: effusion, tenderness, Wilson’s sign
Left untx can develop degen arthritis
What is Wilson’s sign?
Used for detecting medial condyle lesion: knee at 90° flexion and tibia int rotated gradual extension leads to pain at about 30° relieved by tibia ext rotation
Ddx of Painful Arc
45-120°: Glenohumeral
170-180°: Acromioclavicular
Which group of pts typically get posterior shoulder dislocations?
Epileptics
Mx of Frozen Shoulder
Relieve Pain + Restore ROM: consrv physio, meds NSAIDs codeine steroid injections, surg MUA
What are the origins + insertions of the rotator cuff muscles?
Scapula + Humerus
What position does POSTerior shoulder/hip dislocation result in?
Int rotation and aDduction
What are the common injuries following a FOOSH?
Fractures: scaphoid, colles type, clavicle + ant shoulder dislocation
Mx of Radial Head Sublux
Analgesia and passive supination in 90° flexion
Which nerve is compressed in meralgia paresthetica?
Lateral Femoral Cutaneous
What are Kanavel’s signs of flexor tendon sheath infection?
Fixed flexion, fusiform swelling, tenderness on passive extension
Which digits are more responsible for the pincer + power grips?
Pincer: index + middle
Power: ring + little
Which knee ligament is isolated injury uncommon?
LCL
What is the sx triad of a fat embolism?
Resp, Neuro, Petechial Rash
Which biceps tendon rupture requires urgent MRI and often surgical intervention?
Distal
Achilles Tendon RFs
Ciprofloxacin + Hypercholesterolaemia
What are the key features of a ACJ dislocation?
Loss of shoulder contour and a prominent clavicle
