T+O Flashcards
#NOF Need adequate pain control!!
Intracapsular-
Displaced @ risk of AVN- Hemiarthroplasty
Non displaced- Cannulated hip screws (3 parallel)
Extracapsular-
Inter trochanteric- Dynamic hip screw (with side plate and 2 screws)
Sub trochanteric- Intramedullary femoral nail.
View AP and lateral hip XR, also pelvis XR. Request routine bloods inc CK- Rhabdomyolysis.
Surgery preferred to conservative. @ risk of infection, pain, bleeding, leg length discrepancies and NV damage post op. Early rehab important!!
Osteoarthritis of hip-
Presentation
DDx
2nd common joint affected by OA.
Pain (into groin/buttock), stiffness, crepitus, antalgic gait. Late stage shows fixed flexion deformity and Trendelenburg’s gait.
DDx- Trochanteric bursitis, sciatica, NOF#
Investigate with XR.
Osteoarthritis of hip-
Management
Manage pain, give lifestyle advice.
If ineffective then surgery- hemiarthroplasty or THR.
THR- Posterior- more common, fast recovery, does not interfere with abductor muscles.
Anterolateral.
Anterior- less commonly used.
Femoral shaft-
Features
Investigations
Due to high trauma- can be either open or closed, lots of blood loss!! Difficulty weight bearing.
Result in pain in the thigh, but also can be hip/knee.
Plain radiograph imagining AP and lateral.
Bloods, including clotting, G+S.
#Femoral shaft- Management
Treat with ATLS- A-E assessment, plenty of analgesia, traction splinting, open fractures need prophylactic Abx and tetanus.
Surgery- definitive management, via antegrade intermedullary screw. If open or unstable then screw delayed, start with external fixation.
Complications- Infection, malunion/non union, NV damage, fat embolism. Early mobilisation important!!
Quadriceps tendon rupture-
RF
Presentation
DDx
Commonly male, unilateral. RF- Main>40yrs, also DM, CKD, RA.
Presents with popping/tearing sensation followed by pain across knee/thigh, swelling. Can be after landing from jump. Diagnose clinically, confirm with USS.
DDX- Patella fracture, patella tendon rupture, #femoral shaft.
Quadriceps tendon rupture-
Management
Incomplete- usually extensor mechanism intact- therefore manage with knee brace and rehab.
Complete- extensor mechanism lost- manage surgically. If within the tendon (intratendinous)- end-to-end sutures. If at the point of insertion of the patella-longitudinal drill holes/anchor sutures
Distal Femur-
Presentation
Investigation
Differentials
Present with severe pain in distal thigh, following fall/trauma, can’t weight bear.
Type A- Extra-articular. Type B- partial articular. Type C- Complete articular.
Investigate with plain radiograph AP and lateral. Also bloods + G+S, clotting.
DDx- Tibial shaft fracture, hemarthrosis.
Young or old.
Distal Femur-
Management
Complications
ATLS.
Adequate analgesia.
If malalignment of the fracture then give analgesia and reduce the fracture, then immobilise with skin traction.
Extra-articular/simple intra-articular- Retrograde intramedullary nail.
Complicated intra-articular/more distal fractures- ORIF
Complications- Malunion, non union, secondary OA.
Pelvis-
Features
Investigations
Due to high trauma injury. Within pelvic ring have lumbosacral nerves, iliac vessels, bladder, uterus and rectum. So fracture can lead to bladder/rectal problems, neurovascular damage, hameorrhagic shock.
Pain and swelling around pelvis.
Need 3 plain radiograph films, in acute setting may do CT, which suffices.
#Pelvis- Management
Initial ATLS, A-E assessment, analgesia.
If haemodynamically unstable and pelvic trauma then pelvic # until proven otherwise- need pelvic binder.
Management can be conservative; unless unresponsive or HD unstable- then operative.
Complications- VTE, urological injury, long standing pelvic pain.
Acetabular-
High energy fracture, usually can be associated wiht pelvic# or hip dislocation.
Present with pain, inability to weight bear.
Gold Standard- CT.
Manage initially with ATLS.
Undisplaced/minimally displaced- non weight bearing 6-8wks.
Young pts with displacement- need surgery. May also do surgery pre-THR for some elderly pts.
Complications- VTE, secondary OA
Clavicle-
Presentation
Investigation
DDx
Due to direct trauma or indirect fall, causing localised pain, may show signs of approaching open fracture.
Type 1 (middle 1/3)>Type 2 (lateral 1/3)>Type 3 (medial 1/3)
Investigate with AP plain radiograph.
Medial fragment moves up (SCM), lateral moves down (arm weights it down).
DDx- sternoclavicular dislocation.
#Clavicle- Management
Conservative management using a sling and early mobilisation (avoid frozen shoulder), most effective.
If open fracture, bilateral fracture or comminuted then consider surgical intervention.
Failure to unit- warrants ORIF 2-3 months post injury.
Assess for non-union, neurovascular damage and puncture injury- pneumo/haemothorax.
Rotator cuff tears-
Presentation
Investigation
Management
Can be acute <3months, or chronic >3months. Tears can be full/partial thickness and will vary in size.
Pts have pain over lateral shoulder and inability to abduct >90 degrees.
Need to rule out fracture (DDx), using plain radiograph.
Then assess the tear using USS, MRI.
Manage conservatively if presents within 2 weeks of pain. Includes physio and analgesia
Surgery can be arthroscopically/open repair. Surgery if present after 2 weeks, conservative not effective, or if large tear.
Shoudler-
Presentation
MOA
Investigations
Pain across the shoulder joint, @ the upper arm, also swelling and inability to abduct shoulder.
MOA usually FOOSH with osteoporosis therefore osteoporotic RF.
Can affect the greater tubercle, lesser tubercle, surgical neck (humeral shaft), anatomical neck.
Radiograph AP, lateral scapular and axillary. May need CT.
Need to ensure no damage to axillary nerve and circumflex arteries.
#Shoulder- Management
Conservative usually preferred. Immobilise with sling, then introduce mobilising 2-4 weeks post injury.
Surgery indicated if displaced, open or NV compromise.
ORIF/intramedullary nail- Head splitting, surgical neck preferred methods respectively but can interchange.
Hemiarthroplasty- Head splitting or can’t do ORIF.
Reverse shoulder arthroplasty (TSR)- Failed previous procedures.
Shoulder dislocation-
Mainly anteroinferior (anterior) due to high trauma on extended, abducted and externally rotated arm, but also posterior (seizures/electrocutions) and inferior.
Present with joint instability, pain, reduced mobility.
Associated injuries include Bankart lesion (labrum tear) or Hill Sachs lesion.
Investigate with radiograph AP, Y scapula and axial view.
Manage with A-E for trauma. Then closed reduction, plenty of analgesia, immobilisation and rehab. Asses NV.
Complications include recurrence, NV damage, chronic pain, stiffness, reduced mobility.
Humeral Shaft-
Presentation
Investigation
RF
Affecting mainly the middle 1/3 of the humeral shaft. Presents with pain, deformity, may show loss of sensation @ 1st webspace + weak wrist extension, if radial nerve involved (runs within the groove).
Investigate plain radiograph AP + lateral.
RF- osteoporosis, age, previous fractures.
Younger pts high trauma, older pts low trauma.
