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Year 3 Surgery > T&O (Lower) > Flashcards

T&O (Lower) Flashcards

1
Q

Describe the three stages of Degenerative Disc Disease

A

Dysfunction - outer annular tears, cartilage destruction
Instabiity - Sublaxation & Spondylolisthesis
Restabilisation - Osteophytes and canal stenosis

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2
Q

State the three types of intracapsular fracture

A

Subcapital
Transcervical
Basocervical

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3
Q

State the two types of extracapsular fracture

A

Intertrochanteric

Subtrochanteric

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4
Q

Describe the blood supply of the Neck of Femur

A

Retrograde flow primarily through medial circumflex
branch of femoral artery
Very minor supply through ligamentum arteriosum (running through ligamentum teres in head of femur)
Minor supply through intramedullary vessels

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5
Q

Describe the Garden Classification of Intracapsular #NOF

A

I - Incomplete Fracture
II - Complete Fracture
III - Partial Displacement
IV - Complete Displacement

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6
Q

Give 3 clinical features of #NOF

A

Pain
Inability to weight bear
Shortened and Externally Rotated

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7
Q

What X-Ray planes are needed for suspected #NOF?

A

AP and Lateral of Hip

AP of Pelvis

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8
Q

How would you surgically manage a non displaced intracapsular #NOF

A

IE Garden Classification I or II

Cannulated Hip Screw

Very dependent on blood supply interruption

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9
Q

How would you surgically manage a displaced intracapsular #NOF

A

Low Activity level pre fracture - HemiArthroplasty (ideally cemented)

Active Individual - Total Hip Replacement

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10
Q

How would you surgically manage an extracapsular #NOF

A

Intertrochanteric - Dynamic Hip Screw

Subtrochanteric - IM Femoral Nail

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11
Q

Describe how OA of the Hip would present on examination

A
  • Passive movement is painful
  • If severe ROM is reduced
  • At end stage the patient may have a fixed flxeion deformity and may walk with a Trendelenberg Gait
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12
Q

How is OA of the Hip classified?

A

WOMAC classification (based on pain stiffness and function)

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13
Q

The definitive management for OA of the Hip is a hip replacement. Describe the three approaches.

A
  • Posterior Approach (most common, quick recovery as abductors intact, may damage sciatic nerve)
  • Anterolateral Approach (Abductor mechanisms are detached, allowing excess abduction and exposure of acetablum, risk of superior gluteal nerve damage)
  • Anterior Approach
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14
Q

Describe the blood supply of the femur

A

Highly vascularised due to it’s role in Haemopoiesis

Supplied by penetrating branches of profunda femoris

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15
Q

How might a Femoral Shaft fracture present

A

Pain and Inability to weight bear

May have obvious deformity (proximal segment flexed and externally rotated)

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16
Q

Give three risk factors for Femoral Shaft Fractures

A

Bisphosphonate
Metastatic Deposits
High Energy Trauma

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17
Q

How are Femoral Shaft Fractures classified?

A

Winquist and Hansen Classification (0-4 with increasing communition)

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18
Q

What two managements would you carry out for an OPen Fracture

A

Antibiotic Prophylaxis

Tetanus Injection

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19
Q

How would you immobolise a Femoral Shaft Fracture?

A

Potentially traction splinting is required if it is an isolated fracture due to strong force of the quads

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20
Q

Describe the surgical management of a Femoral Shaft Fracture

A 
IM Nail (usually anterograde although if other lower limb fractures may use retrograde)
Ex-Fix (if open fracture or polytrauma)
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21
Q

Describe the aetiology of an ACL tear

A

Aims to prevent anterior movement of tibia on fibula

Caused by sudden twisting on weight bearing knee

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22
Q

Give three presenting features of an ACL tear

A

Rapid Joint Swelling (as ligament is highly vascular)
Significant Pain
Leg may feel like it’s giving way

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23
Q

Give 3 investigations of a suspected ACL tear

A

MRI
X-Ray (rule out bony injuries)
Lachmans Test (pulling tibia forward when leg is bent at a 30 degree angle)

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24
Q

Describe the management of an ACL tear

A

RICE
Rehab and Strength training
Surgical (uses tendon as a graft)

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25
Q

Describe two mechanisms of PCL tear

A
  • Direct blow to proximal tibia

- Fall with hyperflexion of the knee and plantar flexed foot

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26
Q

How does a PCL tear present?

A

Immediate pain and joint instability

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27
Q

MCL tears are the most commonly injured ligament of the knee. What is its normal role?

A

Acts as a valgus stabiliser of the knee

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28
Q

How is the MCL normally torn?

A

When external force is applied to the lateral knee

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29
Q

How does an MCL tear present clinically?

A

Pain at joint line following trauma to lateral knee
Swelling may occur a few hours later
May be able to weight bear

Can be graded I-III

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30
Q

Give two investigations for MCL tear

A

MRI

Valgus Stress Test (Grade II - lax in 30 degree flexion but not in extension, Grade III - Lax in flexion and extension)

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31
Q

How would you manage MCL tears?

A

Grade I - RICE and Strength Training
Grade II - Knee Brace and Strength Training
Grade III - Knee brace and consider of surgical repair

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32
Q

The Menisci of the Knee are two C shaped fibrocartilages resting on the tibial plateau. State two of their roles

A
  • Shock absorbers

- Increasing articular surface area

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33
Q

Meniscal Tears are often caused by twisting on a weight bearing knee. State the four types of tear.

A
  • Bucket Handle (longitudinal where medial becomes separated from lateral)
  • Vertical (longitudinal with no separation)
  • Transverse (Parrot Beak)
  • Degenerative
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34
Q

Give three clinical features of Meniscal Tears

A
  • Tearing sensation associated with sudden pain
  • Swelling over 6-12 hrs
  • Part of it may be trapped in the joint giving the feature of knee locking
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35
Q

Surgery is generally only required for Meniscal Tears greater than 1cm. Describe the two arthroscopic managements

A

If outer 1/3 - rich vascular supply allows for healing via sutures
If inner 1/3 - trimmed

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36
Q

Give three risks of Arthroscopic Meniscal Repairs

A

DVT
Saphenous Nerve/Vein Damage
Peroneal Nerve Damage

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37
Q

What region of the Tibial Plateau is more damaged in a Tibial Plateau fracture?

A

Normally the lateral Tibial Plateau resulting in a varus deformity

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38
Q

What would an X-Ray of a Tibial Plateau fracture show?

A

Lipohaemarthroses

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39
Q

How are Tibial Plaeau Fractures classified?

A

Schatzker Classification (from I-VI)

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40
Q

How are Tibial Plateau Fractures managed?

A

Conservative - Hinged knee brace, minimal weight bearing, physio
Surgical - ORIF or Ex-Fix

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41
Q

What is the IT band?

A

Longitudinal fibres from shared aponeuroses of TFL and Gluteus Maximus
Iliac Tubercle to the Anterolateral Tibial Tubercle

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42
Q

What is IT Band Syndrome?

A

The most common cause of lateral knee pain in athletes

Inflammation from repeated flexion and extension of the knee causing impringement against lateral femoral condyle

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43
Q

Give three risk factors for IT Band Syndrome

A

Athletic
Genu Varum/Bow Legged
Weak Abductors

44
Q

How does IT Band Syndrome Present?

A

Lateral knee pain (worse downhill or on a camber)

45
Q

IT Band Syndrome is a clinical diagnosis, explain a clinical test.

A

Nobles Test - Patient lays supine, palpate lateral femoral condyle as patient bends leg. Pain should be felt at 30 degrees as the IT band slides over condyle.

46
Q

How would you manage IT Band Syndrome?

A 
Modify Activity
Simple Analgesia
Steroid Injections
Physio
Surgery - release of IT band at its insertion
47
Q

What forms the ankle joint?

A

Talus and Mortise (formed of lateral malleolus/medial malleolus/tibial plafond)

48
Q

Describe the Syndesmosis bonding the tibia and fibula together

A

Interosseous Membrane
Anteroinferior Tibiofibular Ligament
Posteroinferior Tibiofibular Ligament

49
Q

What is an ankle fracture?

A

Any fracture to the malleoli (medial, lateral or posterior) with or without syndesmosis disruption

50
Q

Name four anatomical classifications of Ankle Fractures

A

Isolated Medial Malleolus Fracture
Isolated Lateral Malleolus Fracture
Bimalleolar
Trimalleolar

51
Q

Describe the Weber Classification of Ankle Fractures (for lateral malleoli)

A

A - Below level of syndesmosis
B - At level of Syndesmosis
C- Above level of Syndesmosis

52
Q

How would you investigate Ankle Fractures?

A

XRay - AP and Lateral

53
Q

What are the Ottawa Rules?

A

The concept that if the diagnosis is unclear, pain/tenderness over one of the malleoli and inability to weight bear for >4 steps indicates an Ankle Fracture

54
Q

How would you manage an Ankle Fracture?

A

Reduce
Below knee back slab
Surgery - If displaced B, or class C, or Open, requires ORIF

55
Q

How can you classify Ankle Sprains?

A

High Ankle - Injuries to Syndesmosis

Low Ankle - Injuries to Anterior Talofibular/Calcaneofibular

56
Q

What mechanism is likely to cause an Ankle Sprain?

A

Inversion on a plantarflexed ankle

57
Q

What is the Achilles Tendon?

A

Unites the tendons of Gastrocnemius, Soleus and Plantaris and inserts into Calcaneous

58
Q

Describe the pathophysiology of Achilles Tendonitis

A

Repetitive action causes microtears and subsequently inflammation
Over time the tendon becomes thickened/fibrotic/loses its elasticity

59
Q

Give three risk factors for Achilles Tendonitis

A

Poor Footwear Choice
Unfit Individual with sudden increase in exercise
Fluoroquinolone use

60
Q

How would Achilles Tendonitis present?

A

Gradual onset of pain and stiffness in posterior ankle (often worsened by movement and improved by heat)
Tenderness over palpation

61
Q

How would Achilles Rupture present?

A

Sudden onset severe pain following audible popping sound

Loss of power of plantar flexion

62
Q

How would you diagnose an Achilles Rupture?

A

Simmons Test - squeeze patients calf while they are knelt, normally the reaction should be plantarflexion

USS

63
Q

How would you manage Achilles Tendonitis?

A

RICE
NSAIDs
May require physio

64
Q

How would you manage Achilles Rupture?

A
  • Immobilisation (Full equinus for two weeks, semi equinus for four weeks, then neutral for four weeks)
  • If you give the patient a moonboot over the plaster they can weight bear
  • Any delayed presentation will require surgical repair
65
Q

What is a Talar Fracture?

A

Typically occurs in high energy trauma where ankle is forced into dorsiflexion
50% through Talar Neck

66
Q

Why is the Talus at risk of avascular necrosis in a fracture?

A

The talus relies on extra-osseous blood supply which is likely to be interuppted

67
Q

How would a Talar Fracture present?

A

Immediate pain and swelling

Unable to dorsiflex/plantarflex

68
Q

Describe the Hawkins Classification of Talar Neck Fractures

A

I - Undisplaced
II - Subtalar Dislocation
III - Subtalar and Tibiotalar Dislocation
IV - Subtalar, Tibiotalar and Talonavicular Dislocation

Increasing risk of AVN

69
Q

How should you image a suspected Talar Fracture?

A

X-Ray (AP and Lateral)

Taken in dorsiflexion as plantarflexion reduces any sublaxation

70
Q

How would you manage a Talar Fracture?

A

I - Conservatively in plaster for 3 months, non weight bearing
II-IV - Closed reduction and temporary cast, definitive surgical fixation

71
Q

What is Hallux Valgus (AKA Bunion)

A

Deformity of the first metatarsalphalangeal joint
Medial deviation of first metatarsal and lateral deviation of hallux
Once the metatarsal head escapes intrinsic control, tendons become a deforming force

72
Q

Give three risk factors for Hallux Valgus

A

Female
High Heel use
Hypermobility disorders

73
Q

How does Hallux Valgus present?

A

Painful Medial Prominence (aggravated by walking/weight bearing)

74
Q

What investigation could you use to diagnose Hallux Valgus?

A

X-Ray - looking at the angle between the first metatarsal and the proximal phalanx (diagnosed if greater than 30 degrees

75
Q

Describe two surgical managements of Hallux Valgus

A

Chevron Procedure - V Shaped Osteotomy of distal metatarsal

Lapidus Procedure - fuses first metatarsal and medial cuneiform

76
Q

Plantar Fasciitis accounts for 80% of heel pain complaints. Describe the pathophysiology

A

Thick fibrous tissue from calcaneal tuberosity to proximal phalanx
Microtears cause a chronic breakdown

77
Q

Give 3 risk factors for Plantar Fasciitis

A

Obesity
Prolonged Standing
Pes Cavus

78
Q

How does Plantar Fasciitis present?

A

Sharp heel pain worse in the morning, before easing off after the first few steps

79
Q

How would you manage Plantar Fasciitis?

A

Activity Modification
NSAIDs
Steroid Injections
Plantar Fasciotomy

80
Q

What is a complication of Plantar Fasciotomy?

A

Medial Foot Instability

81
Q

Give 5 medical managements of Hip Fractures

A
  • Establish cause of fall
  • Analgesia (Nerve Block)/Antiemetics/Laxatives
  • Discuss rescucitation
  • Prevent AKI
  • Bone protection assessment
82
Q

What X-Ray feature are you looking for on lateral view of Hip Fracture?

A

‘Head off the back’

83
Q

Describe three possible X-Ray features of a #Hip

A

Obvious fracture
More proximal lesser trochanter (Also may be more prominent due to external rotation)
Disruption of Shenton’s Line
Increased density due to overlapping bone

84
Q

Why do total hip replacements last well?

A

The femoral head is replaced with metal, whereas the acetabulum is replaced with plastic. This wears well

85
Q

Describe a Dynamic Hip Screw

A

One screw into femoral shaft, and four more to keep that in place
Screw can shorten and lengthen with weight bearing (compression is good for healing)

86
Q

What is a Cephalomedullary Nail and when is it used?

A

One nail from femoral head to knee, kept in place by two more
Used if reverse oblique displacement as they are generally more unstable and not appropriate for DHS fixation

87
Q

How does a Bisphosphonate Fracture present?

A

Normally after 8-10 years of taking Bisphosphonates

Generally subtrochanteric stress fracture

Pre fracture changes include cortical expansion and black line developing on XRAY

88
Q

What is SCFE?

A

Slipped Capital Femoral Epiphyses

Perichondrial ring that normally resists shearing forces pre ossification becomes weak, allowing the femoral neck to slide from the head/epiphyses

89
Q

Name two risk factors of SCFE

A

Hyperthyroidism, Obesity

90
Q

How does SCFE present?

A

Groin or Thigh Pain

Limp

91
Q

How is SCFE imaged?

A

Frog leg XRay

92
Q

How is SCFE managed?

A

Surgical screw connecting diaphysis through the femoral neck and epiphyses to femoral head
May do prophylactic screwing of contralateral leg

93
Q

When should you weight bear after IM nail?

A

Immediately

94
Q

How would you manage an undisplaced patella fracture?

A

Aspirate any Haemarthroses

4-6 weeks leg immobilised in extension

95
Q

How would you manage a displaced patella fracture?

A

ORIF with tension banding

96
Q

How do tension bands work?

A

Convert tensile to compressive forces by shifting the centre of rotation

97
Q

How does a Patella Dislocation normally occur?

A

Sudden severe contraction of the Quads, normally in external rotation

98
Q

How is a patella dislocation managed?

A

Back slab with knee in extension

99
Q

How does a Knee Dislocation occur and what are the associated injuries?

A

Occurs in high velocity trauma

Cruciate ligaments and at least one collateral ligaments are torn

100
Q

How are Knee Dislocations managed?

A

Backslab for one week at 15 degree flexion (to allow swelling reduction)
12 week cast (with Quad exercises and weight bearing as soon as they can lift the leg)

101
Q

Name the three main ligaments of the lateral ankle

A

Anterior Talofibular, Posterior Talofibular, Calcaneofibular

102
Q

What ligament is commonly damaged in ankle fractures?

A

Deltoid

103
Q

What non radiological investigations should you consider for a #NOF?

A

Bloods (inc CK for long lie)

ECG/Urine Dip/CXR - for falls work up

104
Q

What non operative pain relief can be used for NOF

A

Opioids

Regional block (fascia iliaca)

105
Q

What anaesthesia can be used for THR?

A

General
Spinal
Epidural

Year 3 Surgery (11 decks)

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