T&O - Femoral And Tibial Shaft Fractures And Knee Injuries Flashcards
Femoral and tibial shaft fractures: Mx points
◦ Must resuscitate pt and deal with life threatening injuries first (X match units of blood)
◦ Assess neurovascular status, especially distal pulses
Femoral and tibial shaft fractures: Rx
- 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
Femoral and tibial shaft fractures: specific complications/risks
◦ Hypovolaemic shock
◦ Neurovascular: sciatic nerve damage, swelling
◦ Compartment syndrome
◦ Respiratory complications: fat embolism, ARDS, pneumonia
Ankle fractures: what rules do you use?
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
Knee injuries: common presentations
◦ 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
Knee haemarthrosis: causes of primary or secondary bleeding
◦ Primary: spontaneous bleeding - warfarin, haemophilia
◦ Secondary: trauma - ACL injury, patella dislocation, meniscal injury, osteophyte fracture
Knee injuries: mechanisms of injury
◦ Collateral ligaments: torn in valgus or varus strains
◦ Twisting injuries: lead to meniscus tears or a rupture of the ACL
Knee injuries: unhappy triad
-torn medial meniscus, ACL and MCL
Mx of acutely injured knee
◦ 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
Dislocation of patella: MOI and Mx
- 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
Fractures of patella: name 7 different ways in which the patella can fracture
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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
Name a few inflammatory conditions affecting the knee
- 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
Bursitis in the knees: what are the bursae that can become inflamed in the knee?
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Bursitis in knees: Mx and Rx
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
Degenerative conditions knee: popliteal cysts
• 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
What is the commonest joint to get OA?
-Knee
Pathology of OA in the knee
-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)
Symptoms of OA in knee
- 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)
Ix for OA in knees
‣ 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)
Rx for OA in knees: Conservative and surgical
-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
Ruptured ACL: specific Mx
◦ 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.
