T&O - Femoral And Tibial Shaft Fractures And Knee Injuries

Question 1

Femoral and tibial shaft fractures: Mx points

Answer 1

◦ Must resuscitate pt and deal with life threatening injuries first (X match units of blood)
◦ Assess neurovascular status, especially distal pulses

Question 2

Femoral and tibial shaft fractures: Rx

Answer 2

• Intramedullary nail and/or plate and ex-fix
• If open fracture: start ABX, take pt to theatres for debridement and washout
• Sub trochanteric NOF fractures are not treated with DHS (intertrochanteric are Rx with DHS) and must be treated like a midshaft fracture - with intramedullary nail and screws

Question 3

Femoral and tibial shaft fractures: specific complications/risks

Answer 3

◦ Hypovolaemic shock
◦ Neurovascular: sciatic nerve damage, swelling
◦ Compartment syndrome
◦ Respiratory complications: fat embolism, ARDS, pneumonia

Question 4

Ankle fractures: what rules do you use?

Answer 4

Suspect ankle fracture and perform X-ray if

• Pain in malleolar (lat or med) zone
• tenderness along distal 6cm of posterior tib/fib including posterior tip of malleoli
• Inability to weight bear both immediately and in ED
• Called Ottawa ankle rules

Question 5

Knee injuries: common presentations

Answer 5

◦ Swelling: immediate (haemarthrosis = torn cruciates) vs overnight (effusion = meniscus or other ligament tear)
◦ Pain: joint line (meniscal) vs med/lar margins (collateral ligs)
◦ Locking: meniscal tear and obstruction
◦ Giving way: instability following ligament injury

Question 6

Knee haemarthrosis: causes of primary or secondary bleeding

Answer 6

◦ Primary: spontaneous bleeding - warfarin, haemophilia

◦ Secondary: trauma - ACL injury, patella dislocation, meniscal injury, osteophyte fracture

Question 7

Knee injuries: mechanisms of injury

Answer 7

◦ Collateral ligaments: torn in valgus or varus strains

◦ Twisting injuries: lead to meniscus tears or a rupture of the ACL

Question 8

Knee injuries: unhappy triad

Answer 8

-torn medial meniscus, ACL and MCL

Question 9

Mx of acutely injured knee

Answer 9

◦ Full examination of acutely swollen knee is very difficult
◦ Take X-ray to ensure no fracture
◦ If no fracture: RICE + later re-examination for pathology
◦ MRI if meniscal/crucifer injury suspected

Question 10

Dislocation of patella: MOI and Mx

Answer 10

• MOI: blow to side of knee causes lateral dislocation of patella
• Mx of 1st time traumatic dislocation is conservative unless there is osteochondral fracture or medial patellar stabilisers
• Reduce patella and put in POP for 3 weeks
• Short cast time with early mobilisation with or without brace and with physio

Question 11

Fractures of patella: name 7 different ways in which the patella can fracture

Answer 11

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◦ Communited: direct blow, likely to also have damage in underlying femoral condyles - try to reduce and fix, avoid taking patella out
◦ Transverse fracture of patella: violent contracture of quads against resistance - usually town in two horizontally - open reduction and early mobilisation

Question 12

Name a few inflammatory conditions affecting the knee

Answer 12

• Cysts of menisci: usually arises from lateral meniscus, enlarges under capsule, forms a swelling which is tense in certain positions of flexion. Is liable to tear, in which removal of meniscus s better than cyst removal.
• Other causes: OA/RA, ankylosis spondylitis, gout

Question 13

Bursitis in the knees: what are the bursae that can become inflamed in the knee?

Answer 13

INSERT PICTURE

Question 14

Bursitis in knees: Mx and Rx

Answer 14

Septic bursitis

• Admit pt if systemically unwell, is immunocompromised, severe infection in surrounding tissue or has other comorbidities such as RA and diabetes.
• Will probably need IV ABX

Primary care Mx of bursitis

• RICE and modify activities which worsen symptoms
• Compression
• Analgesia: paracetamol/NSAIDs
• Can aspirate fluid if uncomplicated septic bursitis is suspected OR there is very big swelling

Question 15

Degenerative conditions knee: popliteal cysts

Answer 15

• Popliteal cysts: common all ages, painless swellings in popliteal fossa, often fluctuate in size
◦ Only excise if cause other symptoms
◦ Larger/diffuse cysts associated with pathology of knee joint (RA esp)
◦ Should address/look at underlying cause, can do synovectomy/dissection of cyst

Question 16

What is the commonest joint to get OA?

Answer 16

-Knee

Question 17

Pathology of OA in the knee

Answer 17

-Caused by extensive wearing away of joint cartilage, fraying of menisci, marginal osteopaths and some synovial thickening (but little inflammation)
‣ Primary: no obvious underlying cause
‣ Secondary: follows pre-existing abnormality of joint (fracture, RA, haemarthrosis, meniscal tear, etc)

Question 18

Symptoms of OA in knee

Answer 18

• pain, stiffness, deformity
• Joints affected: hips, knees, DIPs, PIPs, thumb and CMC
• Pain pattern: worse with movement and at the end of the day. (RA is early morning stiffness)

Question 19

Ix for OA in knees

Answer 19

‣ Bloods: CRP may be mildly elevated + Ca/PO4 and ALP all normal
‣ X-ray changes: decreased joint space, osteophytes, subchondral sclerosis/bone cysts, evidence of previous disorders (rheumatoid/congenital defects), structural damage (late sign)

Question 20

Rx for OA in knees: Conservative and surgical

Answer 20

-Conservative methods: losing wt, using stick, modifying work, analgesics and NSAIDs, physio, heat
-Surgical Rx:
‣ Arthroscopic lavage/debridement: controversial
‣ Osteotomy: esp in younger pts, aims to correct abnormal bone alignment
‣ Arthroplasty: knee replacement - most common operation for knee OA, can be total or part

Question 21

Ruptured ACL: specific Mx

Answer 21

◦ Conservative: rest, physio to strengthen quads and hamstrings, not enough stability for many sports
◦ Surgical: autograph repair (gold standard - usually semitendinosus +/- gracilis) - tendon threaded through heads of tibia and femur and held using screws.