Surgery - Orthopaedics (too much to learn for me) Flashcards
In the major haemorrhage protocol, what baseline bloods should be taken pre-transfusion?
FBC
Group and save
Clotting
Clauss fibrinogen assay (measures function of fibrinogen)
In which major haemorrhage scenarios can tranexamic acid be given, and how should it be prescribed?
If trauma within 3 hours
Dose is 1g bolus over 10 mins followed by 1g infusion over 8 hours
When examining a joint, what 3 things should you assess for?
Pain
Effusion
Temperature
What are the 3 main tests to do when examining any joint?
Look
Feel
Move
Describe the tests for each muscle of the rotator cuff
Supraspinatus tendon: Empty can test
Infraspinatus: External rotation against resistance
Teres minor: Hornblower test
Subscapularis: Internal rotation against resistance
What 2 special tests can be doe on examination for carpel tunnel syndrome? Describe them
Tinel’s test: tap along nerve from index finger down through wrist towards antecubital fossa, is positive if tingling or paraesthesia down median nerve as is tapped
Phalen’s test: put hands in like a downwars pray position with backs of hands together, positive if tingling/ paraesthesia in distribution of median nerve
What does the Trendelenburg test assess?
Abductor (gluteus medius and minimus) abnormality
What is a positive trendelenburg test?
Dip in hip when lifting GOOD side leg
How do you perform Thomas’ test, and what does it assess?
Ask pt to lie down, and to bring their knee up to their chest to ‘hug’ it
Positive test = other leg lifts off bed
Tests for fixed flexion deformities eg iliopsoas tightness, ACL tear, osteoarthritis…
How can you identify if leg shortening is tibial or femoral in nature?
Galeazzi test
Get pt to lie down, flex hips to 45 degrees and knees to 90 degrees
Test is positive when knees are a different heights
If lower knee displaced towards foot = shortened tibia, if displaced towards body = shortened femur
What can you do on examination to test for Achilles tendon rupture?
Simmond’s test
Calf squeeze –> foot movement
What can you do on examination to test for Morton’s neuroma?
Mulden’s test
Clasp metatarsals and poke plantar side of foot - positive test will be pain/ tingling
After an orthopaedic examination in PACES, what can you say you would like to do to finish your examination?
Assess neurovascular status
Assess joints above and below
Test the contralateral joint
What % of bone matrix is organic vs inorganic?
40% osteoid (organic matrix)
60% inorganic
What is osteoid matrix made up of?
Protein mix secreted by osteoblasts
Recall the 2 subtypes of lamellar bone
Cortical (compact)
Trabecular (cancellous)
What is woven bone?
Disorganised bone that forms the embryonic skeleton and fracture callus
What are the 2 types of bone formation?
- Intramembranous ossification - direct ossification of mesenchymal bone models formed during embryonic development (skull bones, mandible and clavicle for example)
- Endochondral ossification - mesenchyme –> cartilage –> bone: most bones ossify this way
What are the 4 stages of fracture healing and how long does each one last?
- Reactive: first 48 hours
Reparative phase = 2 days - 2 weeks - Proliferation (reparative phase part 1)
- Consolidation (reparative phase part 2)
- Remodelling = 1 week - 7 years
Describe the reactive phase of fracture healing
Bleeding into the fracture site –> haematoma
Inflammation –> cytokine release –> recruitment of leukocytes and fibroblasts –> granulation tissue
Describe the reparative phase of fracture healing
Proliferation of osteoblasts/ fibroblasts –> cartilage and woven bone forms –> callus formation
Consolidation = endochondrial ossification of woven bone to turn it into lamellar bone
Recall the approx healing time for different types of fracture
Closed/ paediatric/ metaphyseal/ upper limb = 3 weeks
Open/ adult/ diaphyseal/ lower limb = 6 weeks
Recall some examples of traumatic, stress and pathological fracture
Traumatic: direct (assault with metal bar), Indirect (fall on outstretched hand, clavicle #), avulsion
Stress: Foot fracture in marathon runners (particularly 2nd metatarsal)
Pathological: local (tumours), general (osteoporosis, Cushing’s, Paget’s)
What is an avulsion fracture?
When small chunk of bone attached to a tendon/ligament gets pulled away from the main part of the bone. Common in young athletes
What radiographs do you need to image a fracture properly?
Orthogonal radiographs (at right angles) –> request AP and lateral films
What is an open vs closed fracture?
Open breaks the skin, closed doesn’t
What is an extraarticular fracture?
One that doesn’t cross the surface of a joint
What is fracture angulation?
Where the normal axis of the bone has been altered such that the distal portion of the bone points off in a different direction
What is fracture translation?
Movement of the fractured bones away from each other
What are the 4 elements of fracture ‘deformity’ you might comment on?
Translation (‘translocation’)
Angulation
Rotation
Impaction
What are the ‘four Rs of fracture management?
Resuscitation
Reduction
Restriction
Rehabilitation
Recall the principles of resuscitation in fracture management
- ATLS - Trauma assessed in primary survey (C spine, chest, pelvis) with secondary survey addressing #
- Assess neurovascular status and look for dislocations
- Stabilise BEFORE imaging
Recall the ‘6 As’ of managing open fractures
Analgesia
Assess: NV status, soft tissues, photograph
Alignment: align # and splint
Anti-sepsis: wound swab, copious irrigation, cover with betadine-soaked dressing
Anti-tetanus: check status (booster lasts 10 years)
Antibiotics: flucloxacillin 500mg IV/IM, benzylpenicillin 600mg IV/IM)
What system can be used to classify open fractures?
Gustilo classification
Differentiate the 3 types of fracture in the Gustilo classification in terms of size
Type 1: <1cm
Type 2: 1-10cm
Type 3: >10cm
Which of the Gustilo classifications of fracture might involve periosteal stripping?
Type 3
If a fracture has been exposed to salt/fresh water, what extra antibiotic coverage will be needed and why?
Ciprofloxacin for pseudomonas exposure
Recall the principles of reduction in fracture management
- Displaced fractures should be reduced unless no effect on outcome (eg ribs)
- Aim for anatomical reduction (especially if articular surfaces involved)
- Alignment is more important than opposition
What are the principles of restriction in fracture management
Based on Wolff’s law
Tissue formed at fracture site depends on strain it experiences
Fixation –> less strain –> bone formation
Also
Fixation –> less pain –> increased stability –> ability to fx
What is the difference between internal and external fixation?
Internal: Physically reconnecting bones with screw/plates etc
External: Fragments held in place by pins/ wires connected to an external frame
For open soft tissue injuries, which sort of fixation is best?
External
When describing the possible complications of fracture management, under what sub-headings can you classify them? Name some complications under each subheading
Anaesthetic - anaphylaxis, damage to teeth, aspiration
Intra-operative - bleeding, damage to local structures (eg neurovascular injury), treatment failure
Early post-operative - compartment syndrome, infection (surgical site, UTI, bed sores), VTE, ABx colitis
Late post-operative - scarring, fx loss, neuropathy, pain, myositis ossificans
What is myositis ossificans?
A condition where bone tissue forms inside muscle or other soft tissue after an injury at sites of haematoma formation
Recall 3 possible neurological complications of fracture surgery
Neuropraxia (axon preserved, conduction interrupted)
Axonotomesis (Wallerian degeneration of axon, interruption of axon)
Neurotmesis (axon transected - requires surgery)
What is Wallerian degenration?
An active process of retrograde degeneration of the distal end of an axon that is a result of a nerve lesion
Describe how compartment syndrome develops
Oedema from fracture –> increased pressure –> decreased venous drainage –> increased pressure –> ischaemia
What are the signs and symptoms of compartment syndrome?
Pain on passive stretching
Warmth, erythema, swelling, weak pulses, increased CRT
Recall 2 fracture sites that are most associated with compartment syndrome
Suprachondylar fractures
Tibial shaft fractures
How should compartment syndrome be managed?
Elevate limb, remove all bandages/ splint etc – fasciotomy
Recall the ‘5 Is’ that may cause non-union
Ischaemia (poor blood supply/ AVN) Interfragmentory strain Intercurrent disease (eg malignancy) Infection Interposition of tissue between fragments
Into what 2 types can non-union fractures be classified?
Hypertrophic (bone end rounded, dense + sclerotic)
Atrophic (osteopaenic bone)
What is Pelligrini-Stieda disease?
A form of myositis ossificans where the superior MCL attachment on knee calcifies following trauma
How should myositis ossificans be managed?
Excision
What are the previous names for the 3 different types of complex regional pain syndrome?
Type 1 = Reflex Sympathetic Dystrophy/ Sudek’s atrophy
Type 2 = Causalgia (persistent pain following injury to a nerve)
Type 3 = Type NOS
Recall 2 criteria that can be used to diagnose complex regional pain syndrome
Budapest criteria
IASP criteria
What are the signs and symptoms of complex regional pain syndrome?
Affects a NEIGHBOURING area to the area affected by trauma
Hyperalgesia
Allodynia
Vasomotor disturbance (may be hot + sweaty or cold + cyanosed)
Swollen, atrophic and shiny skin
Hyperreflexia/ contractures/ dystonia
Recall some medical and surgical options for managing complex regional pain syndrome
Medical: amitriptyline + gabapentin
Surgical: regional nerve block
Recall the signs and symptoms of fat embolism
Looks like a PE but with neurological signs
Onset of dyspnoea, hypoxia and tachypnoea within 24 hours of multiple fractures
CNS signs: confusion, agitation, retinal haemorrhage
Dermatological: 25-50% develop a petechial rash
How should fat embolism be managed?
DVT prophylaxis
What is the Salter-Harris classification used for, and what are the criteria?
It's used to classify the degree of disruption to the growth plate caused by a fracture SALT-C Straight across Above Lower Through CRUSH Type 1-5 = increasing risk of growth plate injury
What are the Ottawa rules used for?
To decide if an x ray is needed
Recall the 4 criteria of the Ottawa knee rule
- Over 55 years old
- Isolated patellar tenderness
- Cannot flex to 90 degrees
- Inability to weight bear both immediately and in A&E for >4 steps
Recall the Ottawa ankle rule (much more complicated than knee!)
LMN FUN
Malleolar zone pain +
- Lateral malleolus posterior edge tenderness
- Medial malleolus posterior edge tenderness
- No weight bearing - both immediately and for 4 steps in A&E
Mid foot zone +
- Fifth metatarsal base pain
- Unable to weight bear immediately or for 4 steps in A&E
- Navicular tenderness
Recall the risk factors for #NOF
SHATTERED Steroids Hyperthyroidism/hyperparathyroidism Alcohol/ smoking Thin (BMI<22) Testosterone LOW Erosive bone disease (eg RhA, MM) Renal failure Early menopause Dietary calcium low, DM
What is the key examination finding in #NOF?
Leg is shortened with external rotation
What is the most common form of intracapsular #NOF?
Sub-capital NOF#
What is the most common form of extracapsular #NOF?
Intertrochanteric NOF#
If someone’s leg is shortened and internally rotated, what is this indicative of?
Posterior dislocation of the hip
What are the 3 types of intracapsular NOF#?
Subcapital
Transcervical
Basicervical
What are the 3 types of extracapsular NOF#?
Intertrochanteric
Subtrochanteric
Reverse oblique
What is the best analgesia for a #NOF?
Iliofascial nerve block
What is the surgical management of intertrochanteric #NOF?
Dynamic hip screw
How should extracapsular NOF# be managed?
ORIF (although intertrochanteric # can be managed with a DHS)
How can the degree of displacement of an intracapsular NOF# be classified?
Using Garden classification (grades I-IV)
How should intracapsular NOF# be managed?
Garden 1 + 2 = ORIF with cancellous or cannulated screws
Garden 3 + 4 =
- <55 years: ORIF with cancellous or cannulated screws
- 55 - 75 years: total hip replacement
- >75 years: hemiarthroplasty
What is the difference between a total hip replacement and a hemiarthroplasty?
THR = replaces femoral head and acetabulum Hemiarthroplasty = replaces femoral head
What is the 1 year mortality for NOF#?
30%
What type of NOF# is most likely to be complicated by osteonecrosis and why?
Transcervical fracture
Retinacular artery is disrupted from medial circumflex femoral artery
What are the signs and symptoms of osteonecrosis of the hip?
Anterior hip pain on climbing the stairs
Insidious onset
What imaging needs to be requested in suspected osteonecrosis of the hip?
XR (AP, frog-lateral, contralateral)
MRI (double density appearance)
Bone scan
How can osteonecrosis of the hip be medically managed?
Bisphosphonates
Recall some surgical options for managing osteonecrosis of the hip
Core-decompression Rotational osteotomy Free-fibula transfer Total hip resurfacing/ replacement Hip arthrodesis
What is the ‘modified Kerboul angle’ used to determine?
Risk of femoral head collapse in osteonecrosis of the hip
How should femoral shaft fractures be managed?
Immediately: traction
1st line: intramedullary nailing
2nd line: ORIF
Recall 4 options for managing humeral fracture and the general indications for each one
Collar & cuff: 2 parts, minimally displaced, high surgical risk
ORIF: >2 parts but not highly comminuted
Arthroplasty: large displacement of humeral head and high risk of non-union
Reverse arthroplasty - irreprable rotator cuff/ previous unsuccessful replacement
What is the most common type of paediatric elbow fracture?
Suprachondylar humeral #
How will a suprachondylar humeral # appear on examination?
Elbow swollen and hand semi-flexed
What is the difference between the extension and flexion types of suprachondylar humeral #?
Extension = distal fragment displaces posteriorly (most common) Flexion = distal fragment displaces anteriorly
What is the most likely artery to be severed by a suprachondylar humeral #?
Brachial artery (by sharp edge of proximal humerus)
What is the most likely nerve to be damaged by a suprachondylar humeral #?
Median nerve
Recall the principles of reducing a suprachondylar humeral # if it is undisplaced vs if it is displaced
Undisplaced: Collar and cuff with fully flexed arm
Displaced: Manipulation under anaesthetic + K-wire fixation THEN collar and cuff for 3 weeks with fully flexed arm
What is the most common early sign of compartment syndrome following a suprachondylar humeral #?
Pain on passive extension of fingers
What is the aetiology of subluxation of the humeral head?
In children the distal attachement of the annular ligament covering the radial head is weaker so is at higher risk of subluxation
What are the signs and symptoms of subluxation of the humeral head?
Elbow pain and limited supination and extension of the elbow
How should subluxation of the humeral head be managed?
Analgesia
Passively supinate elbow joint whilst elbow flexed
What is the ‘dinner fork’ deformity associated with?
Colle’s #
What is Colle’s #?
Posterior displacement and angulation of the distal radius fragment
What is Smith’s #?
Anterior displacement and angulation of the distal radius fragment
What is the typical history of Colle’s vs Smith’s #?
Colle’s = fall on an extended wrist
Smith’s fall on a flexed wrist
What are the Barton’s and Reverse Barton’s fractures?
Both are oblique intra-articular #s with dislocation at the radio-carpal joint
Barton’s: Dorsal (posterior)
Reverse Barton’s: Volar (anterior)
A Monteggia # is a type of fracture of which bone?
Ulnar
A Galeazzi # is a type of fracture of which bone?
Radius
Describe how the location of a radius/ulnar fracture guides how the cast should be applied
Proximal #: supination
Mid-shaft #: neutral
Distal #: pronation
How are intraarticular fractures of the radius/ulnar managed?
ORIF
How are extraarticular fractures of the radius/ulnar managed?
MUA + k wire
If unsuitable for k wire –> ORIF
Recall 5 signs of scaphoid fracture
[1] Pain in the anatomical snuffbox [2] Wrist joint effusion [3] Pain on telescoping thumb [4] Tenderness on scaphoid tubercle [5] Pain on ulnar deviation of wrist
Why are scaphoid fractures particularly vulnerable to avascular necrosis?
Retrograde blood supply
80% is from the dorsal carpal branch of the radial artery
What is the use of CT in tibial plateau #?
To assess whether non-operative management can be used
What is the most common long bone fracture?
Tibial
Which bone articulates with the tibia and fibula at the ankle joint?
Talus
What is Pott’s fracture?
Bimalleolar #
What is a Cotton’s fracture?
Trimalleolar #
What is a pilon fracture?
A fracture of the distal tibia involving the articular surfaces
What classification system is used to assess the extent of syndesmotic ligament damage at the tibiotalar joint?
Weber
Name 2 techniques that can be used to repair syndesmotic tears at the ankle
Syndesmotic screws
Tightrope technique
What is a Lisfranc injury?
An injury of the foot in which one or more of the metatarsal bones are displaced from the tarsus
Recall some signs and symptoms of Lisfranc injury
Medial plantar bruising
Unable to weight bear
Gross midfoot swelling with severe pain
What is the most common metatarsal to be fractured in children vs adults?
Children: 1st
Adults: 5th
Into which 3 categories can pelvic fractures be places?
- Lateral compression (hit from side)
- AP compression (Dashboard injury)
- Vertical shear (falling from height)
Recall 3 signs/symptoms of fractured patella
- Palpable patellar defect
- Significant haemarthrosis
- Loss of straight leg raise
What 3 x ray views are recommended to image a patellar fracture?
AP
Lateral
Skyline (inferior-superior)
How should patellar # be managed if the # is comminuted and ORIF is not possible?
Partial patellectomy, or total patellectomy if no salvage potential
How is ORIF performed for patellar fractures?
Tension Band Wiring
Cerclage wiring
Screw fixation
What is compartment syndrome?
Raised pressure in closed space –> compromised tissue perfusion
What are the main signs and symptoms of compartment syndrome?
Excessive use of breakthrough analgesia due to significant pain
Why might arterial pulses still be palpable in compartment syndrome?
Necrosis occurs as a result of microvascular compromise
How can a manometer be used to help diagnose compartment syndrome?
Can use to measure intracompartmental pressure (ICP)
Normal pressure = 0-10mmHg
Delta pressure <30mmHg = compartment syndrome
Absolute pressure >30mmHg = compartment syndrome
What is the ‘delta pressure’ of a compartment?
Diastolic pressure - measured intracompartmental pressure
Recall some non-operative options for managing compartment syndrome
- Fluid resuscitation to ensure normotension (as hypoperfusion accelerates tissue injury)
- Remove circumferential bandages and casts
- Maintain limb at level of heart
How can compartment syndrome be managed operatively?
Fasciotomy
Which tendon is impinged in ‘subacromial impingement’?
Supraspinatus tendon
What is Hawkin’s test used to diagnose, and how is it performed?
For shoulder impingement
90 degrees shoulder and elbow flexion
Passive internal rotation of the arm –> pain