Surgery - T&O Flashcards
How long is traction applied for and why?
Causes ligamentous laxity - 3 mins 30 secs applied
Describe the steps of secondary bone healing.
Why is primary bone healing preferred in intra-articular fractures and why?
Secondary bone healing = Haematoma, Inflammation, Angiogenesis, Soft Callus, Hard Callus, Lamellar Bone, Remodelling
Primary leads to osteoclast/blast based healing using compression eg. from a plate. Avoids the production of calluses, which interfere in the joint.
Paediatric fractures
What is the process by which child bone grow?
What is an easy way of determining child age?
Name the two types of paediatric fracture
Endochondral ossification from the physis
Can determine a child’s age via the carpal bones of the hand
Greenstick fracture (bendy fracture) and Torus fracture (crushing fracture)
Define the Salter Harris Classification
Type 1 - Separation of the physis from the bone Type 2 - Fracture above the physis Type 3 - Fracture below the physis Type 4 - Through the physis Type 5 - Crushing injury of the physis
Developmental Hip Defects
Name the 4 types of Hip Defect
Perthes Disease, DDH (developmental dysplasia of the hip), SUFE (slipped upper femoral epiphysis), Congenital Talipes Equinovarus
Perthes Disease Pathophysiology: Symptoms: Investigations: Management:
Pathophysiology: Blood supply disrupted, causing AVN
Symptoms: Hip pain, knee or groin, difficulty walking, limp
Investigations: X-ray to show AVN
Management: Can do conservative management with NSAIDs, physio and braces, or osteotomy to keep hip in acetabulum
SUFE (Slipped Upper Femoral Epiphysis) Pathophysiology: Symptoms: Investigations: Management:
Pathophysiology: Head of femur (metaphysis) slips backwards off the femur. Normally occurs at puberty.
Symptoms: Pain in hip, knee or groin, difficult walking, limp.
Investigations: X-ray
Management: Screw insertion and avoid weight bearing for 6 weeks
Congenital talipes equinovarus
Pathophysiology:
Management:
Pathophysiology: Tendons shortened, leading to feet rotated inward
Management: Tendon cutting (eg. achilles tendon) and adding pins and casting
Developmental dysplasia of the hip (DDH) Pathophysiology: Risk factors: Symptoms: Investigations: Management:
Pathophysiology: Acetabulum is too shallow, leading to consistent hip dislocations and subluxation
Risk factors: Breach birth, FH
Symptoms: Hip pain, restrictive movement in 1 leg, uneven skin folds/abnormal leg length
Investigations: 6-week baby checks (Barlow and Ortolani tests)
Management: Pavlik harness to secure the hips
What is the bone at the base of the thumb? What is it associated with?
Trapezium, OA of the thumb
Where should: Radial nerve Median nerve Ulnar nerve Innervations be tested?
Radial - snuffbox/1st dorsal webspace
Median - palmar aspect of tip of index finger
Ulnar - ulnar border of hand
How should Radial nerve Median nerve Ulnar nerve Motor functions be tested?
Radial: Extend the wrist, extend the thumb
Median: OK sign + Thumb to little finger
Ulnar: Spread fingers against resistance, adduction of the thumb
What does the cubital fossa contain?
What are its borders?
Really need beer to be at my nicest: Radial nerve Biceps tendon Brachial artery Median nerve
Superior: Imaginary line between epicondyles
Medial: Pronator teres
Lateral: Brachioradialis
What are the stabilisers of the shoulder?
Name the 4 rotator cuff muscles
Static - Glenoid Labrum, Bony anatomy
Dynamic - Rotator cuff muscles, long head of biceps tendon
Rotator cuff: Supraspinatus, Infraspinatus, Teres minor, Subscapularis
What are the separate sections of the Brachial Plexus?
Real teenagers drink cold beer
Roots Trunk Division Cords Branches
What are the nerve roots for each of the nerves of the brachial plexus?
Musculoskeletal -3 musketeers - C5, C6, C7 Axillary - Assassinated - C5, C6 Radial - By 5 rats - C5, C6, C7, C8, T1 Median - 4 mice - C6, C7, C8, T1 Ulnar - 2 unicorns - C8, T1
What is the main blood supply to the neck of the femur?
Medial circumflex femoral artery
Which side of the tibia is wider?
Where are the menisci sat?
Medial side is wider
Menisci sit on the tibia
What are the components of the foot? (both the triad and the individual bones)
In which configuration is the ankle most stable and why?
Tarsals, metatarsals, phalanges
Talus, calcaneus, navicular, cuboid, cuneiforms
The talus is wedge shaped - narrower at the back. This means it is most stable in dorsiflexion.
What are the 4 principles of fracture management?
Resuscitate
Reduce
Immobilise
Rehabilitate
Why is reduction carried out?
Tamponades any bleeding, reduces traction from surrounding tissues and inflammation (which increases complications), reduces risk of nerve entrapment, reduces pressure on blood vessels
Plaster casting
What 2 key concepts must be remembered with regards to a new cast being put on?
What is an important risk of plaster casting?
- Must not be a fully circumferential cast, to allow the fracture to swell
- Must cast joint above and below if axial instability - for most, only needs to cross distal joint
Compartment syndrome is a risk
Open Fractures
What is the classification for open fractures?
Define the types of this classification
Management of an open fracture
Classification: Gustillo-Anderson
Type 1 - <1cm clean
Type 2 - 1-10cm clean
Type 3a - > 10cm with good soft tissue coverage (orthopaedic)
Type 3b - >10cm but not good tissue coverage (plastics)
Type 3c - >10cm with vascular impairment
Management: Urgently realign and splint, neurovascular exam, antibiotics and tetanus vaccine, photograph of the wound
Must eventually debride and wash out the wound
Scaphoid fracture Pathophysiology: Target demo: Symptoms: Signs: Risk factors: Investigations: Management: Complications:
Pathophysiology: Scaphoid has 3 parts (proximal pole, waist, distal pole) and blood supply is from radial artery. Enters distal pole and supplies proximal in retrograde fashion. Proximal scaphoid fractures = higher risk
Target demo: Men, Age 20-30, fall on hyperextended wrist
Symptoms: Wrist pain, bruising in anatomical snuffbox, pain on telescoping (pushing inwards) of the thumb
Signs:
Risk factors:
Investigations: Plain radiograph - “Scaphoid series” (AP, lateral, oblique) - not amazing at diagnosing, may need MRI
Management:
Un-displaced: Thumb spica splint
Displaced/proximal: Percutaneous compression screw
Complications: Degenerative wrist disease, AVN, non-union due to poor blood supply
What are the contents of the anatomical snuffbox?
Radial artery, radial nerve, cephalic vein, scaphoid
Distal Radius Fractures Pathophysiology: Target demo: Types: Symptoms: Risk factors: Investigations: What is the rule of 11s? Management: Complications:
Pathophysiology: Distal metaphysis fracture with or without articular involvement. FOOSH.
Target demo: 25% of all adult fractures. Increasing age (osteoporosis), but also children.
Types:
Colles’ - extra-articular, dorsal angulation
Smith’s - extra-articular, volar angulation
Barton’s - intra-articular fracture with associated dislocation of radiocarpal joint (usually volar)
Risk factors: Increasing age, female, early menopause, smoking/alcohol excess, prolonged steroid use
Investigations: Must evaluate neurovascular status, particularly muscle involvement. X-ray (rule of 11s).
Rule of 11s: Radial height > 11cm, Radial inclination <22 degrees, Radial volar tilt > 11 degrees
Management: Closed reduction using haematoma block, below elbow backslab cast, physio
Surgical: Intra-articular, young, or high-demand occupation - ORIF/K-wire fixation
Complications: Mal-union (would need osteotomy to repair shortened radius), median nerve compression, OA
Define Monteggia and Galeazzi fractures
Monteggia = Manchester United = Ulnar fracture, proximal, with radio-ulnar joint dislocation Galeazzi = Glasgow Rangers = Radial fracture distal, with radio-ulnar joint dislocation
Radial Head Fractures Pathophysiology: Symptoms: Investigations: Classification: Management:
Pathophysiology: Most common elbow fracture. Usually FOOSH with arm pronated.
Symptoms: Pain on supination/pronation
Investigations: AP and lateral elbow X-ray. Can see “Sail Sign”, which is elevation of the anterior fat pad.
Classification: Mason classification - <2mm displacement, >2mm displacement, complete displacement (Types 1-3)
Management: Type 3 needs ORIF or radial head replacement
Olecranon fracture Pathophysiology: Ages affected: Symptoms: Investigations: Management:
Pathophysiology: Fracture of the olecranon, site of insertion for the triceps muscles
Ages affected: Bimodal
Symptoms: Inability to extend elbow against gravity, elbow swelling
Investigations: AP and lateral
Management: Based on degree of displacement due to triceps -
<2mm = immobilisation at 60 degrees flexion
>2mm = olecranon plating
Supracondylar Humerus Fractures Target demo: Symptoms: Classification: Investigations: Management: Complications:
Target demo: Almost only children 5-7 years old
Symptoms: Limited range of elbow movement with ecchymosis of the anterior cubital fossa
Classification: Gartland, based on displacement
Investigations: Must examine nerves, AP and lateral - will see “Sail sign”
Management: Type 1 and 2 = Above elbow cast in 90 degrees flexion
Surgical: Closed reduction and K-wire fixation
Complications: - Neurovascular injury and vascular compromise is common:
Anterior interosseous nerve most commonly affected, ulnar nerve can be damaged by K-wire
- Malunion - “Gunstock deformity” (varus deformity of forearm)
- Volkmann’s ischaemic contracture - vascular compromise causes flexor muscle necrosis/fibrosis/contraction, leading to hand held in permanent “claw” flexion
Clavicle Fracture Target demo: Symptoms: Classification: Investigations: Management: Complications:
Target demo: Usually young people
Symptoms: Medial fragment will displace superiorly due to SCM, lateral fragment will displace inferiorly due to arm
Classification: Allman - Type 1 - Middle third (75%), Type 2 - Lateral third (unstable, malunion risk), Type 3 - Medial third (Neurovascular risk/pneumothorax risk)
Investigations: Must do neurovascular assessment (brachial plexus) and look for open fractures/tented/white/non-blanching skin
AP and modified axial X-ray
Management: Most treated conservatively with a sling supporting the elbow
If open, needs ORIF
Complications: Non-union, neurovascular injury, pneumothorax
Humeral shaft fracture Target demo: Symptoms: Risk factors: Investigations: Management: Complications:
Target demo: Bimodal
Symptoms: Pain, history of falling on adducted limb, ?wrist drop due to radial nerve damage
Risk factors: Osteoporosis, increasing age, previous fracture
Investigations: AP and lateral
Management: Functional Humeral Brace for most, can do ORIF/IM nailing
Complications: Radial nerve damage due to its presence in the spinal groove, leading to wrist drop
Holstein-Lewis fracture - distal 1/3rd humerus fracture, leading to radial nerve entrapment
What is a C1 fracture?
What is a C2 fracture?
C1 = Jefferson's, Atlas, rarely causes spinal issues, diving C2 = Hangman's, Axis, unstable fracture with spinal cord damage
Proximal Humerus Fracture Pathophysiology: Target demo: Classification: Symptoms: Investigations: Management: Complications:
Pathophysiology: Can occur at either surgical (below tubercles) or non-surgical neck
Target demo: Older
Classification: Neer
Symptoms: Will present with externally rotated and anteriorly displaced arm due to pec major and rotator cuff muscles
Investigations: AP, Y-scapular, axillary
Management: Mostly conservative with sling immobolisation
Complications: AVN due to posterior circumflex humeral artery
Neck of Femur Pathophysiology: Target demo: Classification: Symptoms: Investigations: Management: Complications:
Pathophysiology: Between the femoral head and 5cm below the lesser trochanter. Can be affected by mets.
Target demo: Low energy in old (1/3rd death within 1 year), RTA in young
Classification:
Intra or extracapsular (with inter and sub trochanteric)
Garden classification for intracapsular:
Type 1 - Incomplete, non-displaced fracture
Type 2 - Complete, non-displaced fracture
Type 3 - Complete, partially displaced fracture
Type 4 - Complete, fully displaced fracture
Symptoms: Shortened and externally rotated leg due to gluteus minimus and medius and iliopsoas, inability to weight bear
Investigations: AP, Lateral, AP pelvis - look for Shenton’s line
G+S, CK for rhabdo, Urine dip, CXR, ECG
Management:
Intra: “Bin it” - emergency ORIF + total hip arthroplasty (1 stick or less) or hemiarthroplasty (immobile)
Extra OR young: “Pin it” - Dynamic hip screw or IM nail
Complications: Retrograde blood supply via medial circumflex femoral artery - AVN risk
PE risk from hip surgery
Femoral Shaft Fracture Pathophysiology: Causes: Target demo: Classification: Symptoms: Investigations: Management: Complications:
Pathophysiology: High energy trauma - highly vascularised bone supplied by deep femoral artery - 1.5L of blood loss possible
Causes: High-energy trauma, fragility in elderly, metastases, bisphosphonates
Symptoms: Pain, inability to weight bear, proximal fragment flexed and externally rotated
Investigations: Assess skin integrity (tether, white, non-blanching), X-ray
Management: Immediate reduction with fascia iliaca block, immobilisation with in-line traction
Must be fixed within 24-48 hours via Antegrade IM nail
Complications: Pudendal nerve injury, mal-union (avoid NSAIDs and smoking post-op), fat embolism
Distal Femur Fracture Target demo: Symptoms: Investigations: Management:
Target demo: Bimodal (old due to osteoporosis/mets) or those with knee replacements (peri-prosthetic fracture)
Symptoms: Inability to weight bear, ecchymosis, knee effusion (lipohaemarthrosis) if intra-articular
Investigations: AP and lateral knee, plus femur
Management: Reduction and traction, Retrograde IM nailing/ORIF
Tibial Shaft Fracture
Investigations:
Management:
Complications:
Investigations: AP and lateral of tibia and fibula
Management: Re-alignment, above knee backslab, elevate knee and look for signs of compartment syndrome
Most managed surgically via IM nailing (or ORIF if proximal/distal)
Complications: High risk of open fracture/ compartment syndrome, mal-union
Patella Fracture What is the common method of injury? How is this tested for? What is important to identify? What complications can occur?
MOA: Blunt force injury
Test: Straight leg raise
Identify: Displacement due to patella tendon and quadriceps tendons
Complications: Post-traumatic OA
Tibial Plateau Fracture Pathophysiology: Classification: Symptoms: Investigations: Management: Complications:
Pathophysiology: High energy trauma eg. RTA or fall from height, usually varus deforming force causing lateral tibial plateau fracture
Classification: Schatzker
Symptoms: Lipohaemarthrosis (indicates intra-articular fracture), inability to weight bear
Investigations: Check peripheral vascular status, AP and lateral, CT scan almost always needed
Management: Hinged knee brace (8-12 weeks)
Surgical (since intra-articular) - ORIF, then hinged-knee brace
May need external fixation prior if significant deformity
Complications: Rapid degenerative change (post-trauma OA)
Ankle Fracture Pathophysiology: Target demo: Classification: Symptoms: Investigations: Management:
Pathophysiology: Fracture of any malleolus, with or without syndesmosis disruption, Talus, tibia and fibula involved.
Target demo: Young males, older females
Classification: Weber classification:
A - below the syndesmosis
B - at the syndesmosis - check for talar shift too though
C - above the syndesmosis
Symptoms: Pain, deformity (requires urgent reduction), ecchymosis
Investigations: AP, lateral, mortise views. Assess mortise joint space/medial clear space and check for talar shift. 4mm = normal, 5mm is not normal.
Check for Maisonneuve fracture if solo medial malleolar fracture - upper third fibula fracture associated.
Management: Immediate reduction, below knee back slab, neurovascular examination
Weber A/B without talar shift = conservative, walking boot
Weber B with talar/C = ORIF, non-weight bearing for 6 weeks, then walking boot
What is the syndesmosis?
What are the main stabilisers of the ankle joint?
Anterior and posterior tibial ligaments + interosseous membrane
Medial: Deltoid ligament
Lateral: Syndesmosis, talofibular ligaments
Calcaneal fracture Pathophysiology: Classification: Investigations: Management:
Pathophysiology: Most commonly injured tarsal bone, usually fall from height. 15% open fractures.
Classification: Intra-articular can be classified by Sanders classification. Can also be extraarticular.
Investigations: AP, lateral, oblique views. May see varus deformity. Should do CT, as gold standard.
Management: ORIF, especially if intra-articular
Talar fracture
Pathophysiology:
Investigations:
Management:
Pathophysiology: High energy trauma in which the ankle is forced into dorsiflexion. High AVN risk.
Investigations: Need both dorsiflexed and plantarflexed views.
Management: Plaster and on weight-bearing crutches for 3 months.
Radiculopathy Pathophysiology: Causes: Symptoms: Red-flag symptoms: Signs: Risk factors: Investigations: Management: Complications:
Pathophysiology: Conduction block in the axons of a spinal nerve, causing neurological loss/pain.
Causes: Disc prolapse, degenerative spine disease (spinal stenosis, mainly cervical), fracture, malignancy, infection eg. osteomyelitis of the spine (Pott’s disease - TB)
Symptoms: Paraesthesia and numbness, weakness, radicular pain (burning, strap-like)
Red-flag symptoms: Saddle anaesthesia, urinary frequency, faecal incontinence, ED, bilateral sciatica
Risk factors:
Investigations:
Management: Analgesia - Amitriptyline/Gabapentin, give Benzodiazepines eg. Lorazepam for muscle spasms
Physio
What nerve roots belong to the sciatic nerve?
L4, L5, S1, S2, S3
Degenerative disk disease Pathophysiology: Steps of herniation: Stages of degenerative disc disease: Special test for disc herniation: Investigations:
Pathophysiology: Degeneration of the annulus fibrosus, leading to leading to leakage of the nucleus pulposus
Steps: DPES - Degeneration, Prolapse, Extrusion, Sequestration
Stages: Dysfunction (Herniation), Instability (Loss of disc height/resorption), Restabilisation (with canal stenosis and osteophyte formation)
Special test: Lasegue - Straight leg raise causes pain
Investigations: Only MRI if:
> 6 weeks radicular pain, red flags, imaging would influence management
Management: Analgesia - Amitriptyline, Lorazepam (for muscle spasms)
Special tests for shoulder exam:
Empty can test - Supraspinatus
Painful arc test - Supraspinatus (Impingement syndrome)
External rotation of the shoulder against resistance - Infraspinatus
Lift-Off test - Subscapularis
Scarf Test - OA of the acromioclavicular joint
Trigger Finger Pathophysiology: Symptoms: Risk factors: Management:
Pathophysiology: Finger or thumb clicks when in flexion, preventing further extension. Inflammation of the tendon and sheath, leading to node development distal to the pulley.
Symptoms: Painless clicking/snapping/catching
Risk factors: Prolonged gripping, RA, diabetes, female, increasing age
Management: Can be released via percutaneous needle, or just splinted at night. Maybe steroid injections.
RA of the fingers What joints are affected? When is the stiffness worst? What are the X-ray signs of RA? Name and the describe the deformities seen in late stage RA
Joints: MCPJ/PIPJ
Worst: Morning
X-ray signs: Loss of joint space, Subluxation, Marginal bony erosions, Periarticular osteopenia
Deformities:
Swan neck - PIPJ hyperextends, DIPJ/MCPJ flexed
Boutonniere’s - PIPJ flexed, DIPJ/MCPJ hyperextended
OA of the hand
What is the most commonly affected bone by OA in the hand?
Name 3 late stage complications of hand OA
Bone: Trapezium
- Squaring of the hand
- Heberden’s - DIPJ
- Bouchard’s - PIPJ
Carpal Tunnel Syndrome Pathophysiology: Symptoms: Tests: Risk factors: Investigations: Management:
Pathophysiology: Compression of the median nerve by the carpal tunnel
Symptoms: Pain, numbness, median nerve paraesthesia (although palmar cutaneous branch is often spared), symptoms worse at night, thenar wasting
Tests: Tinel’s test - percuss the median nerve - pain, Phalen’s test - hold wrist in full flexion for 1 minute - pain
Risk factors: Female, 45-60, Pregnancy, Obesity, Diabetes, Repetitive hand movements
Investigations: Nerve conduction studies + Tinel’s and Phalen’s tests
Management: Usually conservative - wrist splint to prevent wrist flexion, physio, corticosteroid injection into the carpal tunnel
Surgical: flexor retinaculum cut
Dupuytren's Contracture Pathophysiology: Disease progression: Special test: Risk factors: Investigations: Management:
Pathophysiology: Contraction of the longitudinal palmar fascia due to fibroplastic hyperplasia of the fascia.
Disease progression:
Painless nodules initially, fibrous cords develop at the MCPJs and PIPJs, which can limit digital movement.
Special test: Hueston’s test - cannot lay palm flat on the table.
Risk factors: Smoking, alcoholic liver cirrhosis, diabetes, male, frozen shoulder, hypercholesterolaemia
Management: Invasive only if functional disability.
Conservative: Hand physio, injectable CCH (collagenase clostridium histiolyticum)
Surgical: Fasciectomy
De Quervain's Tenosynovitis Pathophysiology: Symptoms: Risk factors: Management:
Pathophysiology: Inflammation of the first extensor compartment tendons (extensor pollicis brevis and longus)
Symptoms: Pain at the base of the thumb with associated swelling, pinching is painful
Risk factors: Age - 30-50, Female, Pregnancy, High-intensity wrist activities
Management: Avoid repetitive actions, wrist splint, steroid injections, surgical decompression
Ganglionic Cysts Pathophysiology: Symptoms: Risk factors: Management:
Pathophysiology: Soft tissue lumps along any tendon caused by degeneration within the tendon sheath and filling with synovial fluid
Symptoms: Smooth, spherical lump, can grow over time, transilluminates, can apply pressure on nerves and cause paraesthesia
Risk factors: Female, OA
Management: Clears spontaneously, but can aspirate and give a steroid injection
Elbow dislocation Pathophysiology: Causes: Symptoms: Signs: Risk factors: Investigations: Management: Complications:
Pathophysiology: Usually occur in young adults, 90% are posterior and 50% suffer bony injury. Can lead to stabiliser damage and ongoing instability if medial and lateral collateral ligaments are damaged.
Causes:
Symptoms: Likely high energy fall history
Signs:
Risk factors:
Investigations: Neurovascular assessment, particularly ulnar nerve, AP and lateral
Management: Closed reduction via in-line traction, elbow backslab at 90 degrees, confirm reduction with X-ray
May need ORIF fixation and soft tissue repair or medial and lateral collateral ligament
Complications: Ulnar nerve damage, recurrent instability, loss of terminal extension
Define the “Terrible Triad”
Elbow dislocation with: Lateral collateral ligament injury Radial head fracture Distal humerus (coronoid) fracture Leads to a very unstable elbow
Olecranon Bursitis Pathophysiology: Causes: Symptoms: Investigations: Management:
Pathophysiology: Inflammation of the Olecranon Bursa (prone to inflammation due to superficial position)
Causes: Repetitive flexion/extension movements, Gout, RA, S. aureus infection
Symptoms: PAINFUL Swelling over olecranon, usually no change in range of motion
Investigations: RA tests, Serum urate, definitive diagnostic via fluid aspirate and microscopy
Management: Can drain and washout in theatre if large/infected, otherwise rest/splinting of the elbow
Tennis Elbow (Lateral Elbow Tendinopathy) and Golfer’s Elbow
Pathophysiology (LET):
Pathophysiology: (MET)
Management:
LET: Chronic inflammation of the tendons of the lateral (extensor) origin at the elbow. Overuse of the elbow causes microtears in the tendons.
MET: Flexor origin (medial)
Management: Activity modification, steroid injections, physio
Surgical: arthroscopic debridement of the tendinosis
Cubital Tunnel Syndrome
Pathophysiology:
Patho: Compression of the ulnar nerve between the heads of flexor carpi ulnaris (cubital tunnel) - needs decompressing.
Rotator cuff tears What are the roles of the rotator cuff muscles? Describe the size classification What are the three tests to do? Risk factors: Investigations: Management:
Supraspinatus - Abduction
Infraspinatus - External rotation
Subscapularis - Internal rotation
Classification: <1cm = small, 1-3 = medium, 3-5 = large, >5 = massive
Tests: Empty can test (supraspinatus, internally rotate and push down arm, see if there is weakness), Lift-off test (Subscapularis), Posterior cuff test aka external rotation against resistance - Infraspinatus and Teres minor
Risk factors: Age, trauma, overuse, repetitive overhead shoulder motions, obesity, smoking
Investigations: X-ray to exclude fracture, USS to identify size of tear, MRI (gold standard)
Management: Analgesia, physio, corticosteroid injection into subacromial space. If remaining symptomatic, can do arthroscopic or open surgical repair.
Shoulder dislocation Types: Causes: Symptoms: Signs: Risk factors: Investigations: Associated injuries: Management: Complications:
Types: Anterior (95%) (extended, abducted, externally rotated humerus), Posterior (electric shock/seizures)
Causes:
Symptoms:
Signs:
Risk factors:
Investigations: Assess neurovascular status (axillary/suprascapular nerves/brachial plexus), AP, Y-scapular, Axial views
“Light bulb sign” for posterior dislocations
Associated injuries:
Bankart lesions - glenoid labrum fracture/avulsions
Hill sachs lesions - impaction injuries to the posterior and superior aspects of the humeral head
Rotator cuff injuries
Surgical neck of humerus fracture
Management: Reduction (closed, using traction and Hippocratic method), immobilise in a broad-arm sling for 2 weeks and then do physio
Complications: Recurrence, adhesive capsulitis, nerve damage, rotator cuff injury, OA
Biceps Tendinopathy Pathophysiology: Symptoms: Special tests: Management: Complications:
Pathophysiology: Overuse causing pathological changes, swelling, hypervascularisation
Symptoms: Pain worse when stressing the tendon, weakness on flexion/supination, stiffness
Signs: Speed’s, Yergason’s
Management: Conservative
Complications: Biceps rupture
Adhesive capsulitis Pathophysiology: Types: Symptoms: Risk factors: Investigations: Management:
Pathophysiology: Glenohumeral joint capsule becomes contracted and adherent to the humeral head
Types:
Primary - idiopathic
Secondary - Rotator cuff tendinopathy, impingement syndrome, biceps tendinopathy, diabetes, autoimmune conditions
Symptoms: Deep, constant shoulder pain (may radiate to bicep), disturbs sleep, stiffness and reduction of function, atrophy of deltoid muscle, external rotation will be limited
Risk factors: 40-70 years old, female, one shoulder affected
Investigations: Clinical diagnosis, but can do MRI to rule out impingement syndrome
Management: Generally self-limiting, encourage to stay active
If no improvement within 3 months, can do joint manipulation under general to remove capsular adhesions to humerus
Impingement Syndrome Pathophysiology: Age affected: What is the subacromial space? Causes: Symptoms: Special test: Signs: Risk factors: Investigations: Management: Complications:
Pathophysiology: Most common shoulder pathology, inflammation of the rotator cuff tendons that pass through the subacromial space, resulting in pain, weakness, reduced range of motion. Includes subacromial bursitis, calcific tendonitis, rotator cuff tendinosis.
Age affected: <25 years old, active individuals
Subacromial space: coracoacromial arch, formed by the coracoid process, acromion and coracoacromial ligament. Contains the rotator cuff tendons and biceps tendon.
Causes: Shoulder overuse, degenerative tendinopathy, scapular muscle weakness, anatomical variation
Symptoms: Progressive pain in the anterior superior shoulder, exacerbated by impingement syndrome painful arc test
Special test:
Neers impingement test - internally rotate arm and flex upwards
Signs:
Risk factors:
Investigations: Clinical diagnosis, can use MRI
Management: Conservative: Most cases, Analgesia, physio, corticosteroids
Surgical: >6 months without response, can co arthroscopic repair eg. bursectomy, acromioplasty, muscular repair
Complications: Rotator cuff degeneration, adhesive capsulitis, complex regional pain syndrome
Brachial Plexus injuries:
Define an upper brachial plexus injury
Define a lower brachial plexus injury
Upper (C5, C6) - Erb’s Palsy, caused by excessive angle of neck eg. shoulder dystocia at birth - Loss of external rotation, loss of elbow flexion, loss of wrist extension and shoulder abduction
Lower (T1, C8) Kulmpke’s palsy - Wrist is extended, fingers flexed, “Claw hand”
Anterior Cruciate Ligament Tear Pathophysiology: Causes: Symptoms: Tests: Investigations: Management: Complications: PCL specifics:
Pathophysiology: Restrains anterior translocation of the tibia on the femur
Causes: Twisting knee while weight bearing, usually no contact
Symptoms: Hemarthrosis forms as highly vascular, leg may give way
Tests: Lachman’s test - 30 degree knee flexion, pull tibia forward (ACL specific)
Anterior drawer test - 90 degree flexion, apply force anteriorly
Investigations: MRI scan of the knee (can also pick up meniscal tears), X-ray to exclude bony injury
Management: Must have pre-habilitation prior to surgery, then do tendon repair
Complications: Post traumatic OA
PCL: Tibia high energy trauma, will have positive posterior drawer test
Medial Collateral Ligament tear Pathophysiology: Symptoms: Tests (not named): Investigations: Management: Complications:
Pathophysiology: Most commonly injured ligament of the knee. Lateral damage leads to more instability though. External rotational forces applied to the knee eg. direct blow to one side.
Symptoms: Trauma to one side of the knee, “pop” feeling, will feel laxity when doing valgus stress test
Tests: Valgus stress test
Investigations: X-ray to exclude fracture, MRI
Management: Knee brace and crutches, with strength and weight training
Complications: Instability of the joint, saphenous vein damage
Name the components of the unhappy triad of the knee
ACL, MCL, Medial meniscus
Usually strong lateral force to the knee
Meniscal Tears What is the point of menisci? What is different about the medial meniscus compared to the later? Presentation: Investigations: Management: Complications:
Menisci: Shock absorbers, increase articulating surfaces
Medial meniscus - attached to the medial collateral ligament (LCL is not)
Presentation: “Tearing” sensation after flexion rotation injury, can be locked in flexion if free body formed, significant joint effusion, but not haemarthrosis as not vascular
Investigations: MRI
Management: RICE, arthroscopic surgery
Complications: OA, DVT/saphenous vein damage risk from arthroscopy
Compartment Syndrome
Pathophysiology:
Symptoms:
Management:
Pathophysiology: Increase in pressure within a fascial compartment, causing vein compression, oedema, increasing further pressure and causing ischaemia
Symptoms: Severe pain, disproportionate, pain worse on passive stretching, paraesthesia/6ps
Management: Urgent fasciotomy, high flow oxygen, IV fluids, remove all dressings, opioids, keep limb at neutral level
Achilles Tendonitis Pathophysiology: Symptoms: Special test for Achilles rupture: Risk factors: Investigations: Management:
Pathophysiology: Inflammation of achilles tendon (calcaneal). Can be ruptured in “weekend warriors”.
Special test: Simmond’s test - squeezing calf shoulder plantarflex
Risk factors: Unfit who suddenly increases exercise frequency, poor footwear, male, obesity, fluorochloroquine treatment
Investigations: USS
Management: NSAIDs, physio for tendonitis
Rupture: Full immobilisation, or end-to-end tendon repair
Septic Arthritis Pathophysiology: Main organisms: Symptoms: Risk factors: Investigations: Management: Complications:
Pathophysiology: Orthopaedic emergency. Infection of the joint. Causes rapid articular damage and destroys cartilage via proteolytic enzyme release.
Main organisms: Staph aureus, Streptococcus, Gonorrhoea, Salmonella in those with sickle cell
Symptoms: Cannot move the joint, swollen, pyrexia.
Risk factors: >80, joint disease, diabetes, CKD, joint prosthesis, IV drug use
Investigations: Joint aspirate must be done before giving antibiotics, X-ray, ESR/WCC/fever/inability to weight bear all assessed as part of the Kocher criteria
Management: Empirical antibiotics, irrigation and debridement (washout)
Complications: OA, osteomyelitis
Osteomyelitis
Most common organisms:
Organisms: S. aureus, streptococci, p aeruginosa (IVDU), salmonella in sickle cell
Hallux Valgus Pathophysiology: Symptoms: Risk factors: Investigations: Management:
Pathophysiology: Medial deviation of the 1st metatarsal and lateral deviation of the hallux with subluxation, due to action of extrinsic tendons on 1st metatarsal.
Symptoms: Painful medial prominence, aggravated by walking
Risk factors: Female, connective tissue disorders, anatomical variants
Investigations: X-ray to identify severity
Management: Initially conservative with orthoses, looser footwear, analgesia, then first metatarsal osteotomy
Plantar Fasciitis Pathophysiology: Symptoms: Risk factors: Investigations: Management:
Pathophysiology: Inflammation of the plantar fascia of the foot, most common cause of infracalcaneal pain - extends from calcaneum to proximal phalanges
Symptoms: Sharp pain across plantar aspect of foot
Risk factors: Anatomical factors eg. high arches, excessive running, leg length discrepancy, obesity
Investigations: X-ray, may seen a bony spur on calcaneus
Management: Activity moderation, footwear adjustment physio
What is the sign of a Radial nerve injury in the arm?
Wrist drop
Elbow extension not affected, as triceps innervation given off earlier
What is the sign of high median nerve damage?
What is the sign of low media nerve damage?
High median nerve: Loss of wrist flexion, loss of palmar abduction, loss of flexion of middle and index fingers - hand of benediction of active movement
Low median nerve: No loss of palmar sensation due to palmar cutaneous branch, Ape hand deformity - thumb adducted and externally rotated, thenar wasting
What is the sign of low ulnar nerve damage?
What is the sign of high ulnar nerve damage?
Low ulnar nerve: Claw hand, hyperextension at the MCPJ, flexed at the PIPJ/DIPJs, hypothenar wasting
High: No loss of DIPJ flexion
