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year 3 surgery > T&O (Upper) > Flashcards

T&O (Upper) Flashcards

1
Q

Describe the pathophysiology of a Clavicle Fracture

A

Normally caused by a FOOSH

Medial segment displaced superiorly, inferior segment dislaced inferiorly

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2
Q

Describe the Allman classification of Clavicle Fractures

A

I - Fractured middle 1/3
II - Lateral 1/3
III - Medial 1/3 (associated with polytrauma, pneumothorax/haemothorax)

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3
Q

How do clavicular fractures present?

A

Sudden onset localised severe pain (worsened by movement)

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4
Q

How are claviular fractures managed?

A
  • Conservatively as too superficial for metal work
  • Sling until patient regains movement of shoulder (try to
    early to avoid frozen shoulder
  • Generally heals in 4 to 6 weeks

Surgery indicated if not healed, comminuted or open

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5
Q

Name the four Rotator Cuff muscles and their innervation

A

Supraspinatus (Suprascapular Nerve)
Infraspinatus (Suprascapular Nerve)
Teres Minor (Axillary Nerve)
Subscapularis (Subscapular Nerve)

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6
Q

Describe the movements of the Rotator Cuff muscles

A

Supraspinatus - Abduction
Infraspinatus and Teres Minor - Lateral Rotation
Subscapularis - Medial Rotation

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7
Q

Name two ways Rotator Cuff Tears can be classified

A
  • Acute or Chronic (>3 months)

- Can be full or partial thickness

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8
Q

Describe three features of a Rotator Cuff Tear

A
  • Pain over lateral aspect of shoulder
  • Inability to abduct arm over 90 degrees
  • Tenderness over Greater Tuberosity
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9
Q

How can you test the integrity of each Rotator Cuff Muscle?

A

Supraspinatus - Empty Can Test
Subscapularis - Gerber’s Lift Off (dorsum on back and pushing against resistance)
Infraspinatus and Teres Minor - Posterior Cuff (abducting fists against resistance)

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10
Q

How do you manage Rotator Cuff Tears?

A

Conservative - Analgesia, Physiotherapy, Corticosteroid Injections
Surgery - If conservative has failed or if presenting after 2 weeks (can be done arthroscopically or open)

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11
Q

What is the main complication of Rotator Cuff Tears?

A

Adhesive Capsulitis

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12
Q

Describe the cause of an Anteroinferior and Posterior Shoulder Dislocation respectively

A

Anteroinferior - Force applied to extended/abducted/externally rotated arm

Posterior - Seizures/Electrocution

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13
Q

Describe three clinical features of Shoulder Dislocation

A

Pain and Reduced Mobility
Instability
Asymmetry/Flattened Deltoid

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14
Q

Give 3 associated injuries of Shoulder Dislocations

A

Bankart - Fracture of anteroinferior Glenoid
Hill Sachs - Impaction fracture to Humeral Head
Rotator Cuff Tears

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15
Q

Name the three XRay views used in a Shoulder Dislocation

A

AP
Axial
Y Scapular (useful for differeniating between anterior and posterior)

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16
Q

How would an Anterior and Posterior Dislocation present on an Xray?

A

Anterior - Humeral head is out of glenoid fossa

Posterior - Lighbulb sign

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17
Q

How would you manage a Shoulder Dislocation?

A

A to E
Analgesia
Reduction/Immobilisation (broad arm sling for two weeks)/Rehabilitation

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18
Q

How would a Humeral Shaft Fracture present?

A

Pain and Deformity (commonly after a FOOSH)

Radial Nerve Involvement (Reduced sensation in dorsal web space, weakness in wrist extension

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19
Q

What is a Holstein Lewis Fracture?

A

Fracture of distal 1/3 of Humerus

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20
Q

How are Humeral Shaft Fractures investigated?

A

AP and Lateral X-Ray films

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21
Q

Describe the conservative and surgical management of Humeral Shaft fractures

A

Conservative - Realignment and Humeral/Over elbow cast

Surgical - ORIF Plating, IM Nails

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22
Q

What is Biceps Tendinopathy?

A

Encompasses a variety of pathological changes resulting in a weaker tendon and greater risk of rupture

Presenting with pain/associated stiffness/weakness

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23
Q

Describe the two tests for Biceps Tendinopathy?

A

Speed Test - Proximal Biceps Tendon

Yergason’s Test - Distal Biceps Tendon (Queens Wave against resistance)

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24
Q

Describe the conservative and surgical management of Biceps Tendinopathy

A

Conservative - Analgesia/Ice/Physio

Surgical - Arthroscopic Tenodesis (cut and reattached) and Tenotomy (Division of Tendon)

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25
Q

One of the main complications of Biceps Tendinopathy is Biceps Rupture. How does this occur?

A

After forced extension of a flexed elbow

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26
Q

Describe the clinical features of Biceps Rupture

A

Sudden pop followed by pain and swelling

Reverse Pop-Eye feature as muscle belly retracts

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27
Q

Describe the surgical management of Biceps Rupture

A

Anterior single incision, forming a bone tunnel in radius and reinserting ruptured end

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28
Q

Define Adhesive Capsulitis

A

Glenohumeral Joint becomes contracted and adherent to Humeral Head

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29
Q

What are the three stages of Adhesive Capsulitis?

A

Initial Painful
Freezing
Thawing

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30
Q

Adhesive Capsulitis can be Primary (Idiopathic) or Secondary. Give 3 Secondary causes.

A

Rotator Cuff Tendinopathy
Subacromial Impingment
DM

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31
Q

Give two clinical features of Adhesive Capsulitis

A

Pain (deep and constant pain that may disturb sleep)

Reduced ROM

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32
Q

Give two differentials for Adhesive Capsulitis

A

Subacromial Impingment - preserved passive movement

Muscular Tear - Weakness persists when pain resolve

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33
Q

How would you manage Adhesive Capsulitis?

A 
Self limiting (Physio and Shoulder Exercises)
Pain management (Paracetamol/NSAIDs/Intra-articular Steroids
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34
Q

Describe the surgical management of Adhesive Capsulitis

A

If no improvement after 3 months of Conservative Treatment/Symptoms affect QoL

Joint manipulation under General Anaesthetic and removal of capsular adhesions

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35
Q

What is Sub-Acromial Impingement Syndrome?

A

Inflammation and irritation of the tendons as they pass through subacromial space
Encompasses Rotator Cuff Tendinosis/Subacromial Bursitis/Calcific Tendinitis

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36
Q

The Coracoacromial Arch is formed of the Coracoid Process, Acromian and Coracoacromial Ligament. Name three structures running through the space

A

Rotator Cuff Tendons
Long Head of Biceps Tendon
Coraco-acormial Ligaments

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37
Q

State two Intrinsic and two Extrinsic causes of Sub-Acromial Impingement Syndrome

A

Intrinsic - Muscle Weakness, Overuse Microtrauma

Extrinsic - Anatomical abnormalities, Weak Scapular Musculature

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38
Q

How does Sub-Acromial Impingement Syndrome present?

A

Progressive pain in anterior and superior shoulder (exacerbated by abduction, relieved by rest)

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39
Q

Name a test for Sub-Acromial Impingement Syndrome

A

Hawkin’s Test - passive internal rotation of flexed arm

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40
Q

Describe the surgical management of Sub-Acromial Impingement Syndrome

A

If ongoing for 6 months without improvement

Usually arthroscopic

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41
Q

Supracondylar Fractures are normally a paediatric injury, how would they present?

A

Recent Trauma/FOOSH resulting in sudden onset severe pain
Gross Deformity
Bruising in cubital fossa

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42
Q

Name four nerves at risk in Supracondylar Fracture

A

Median Nerve
Anterior Interosseous Nerve
Ulnar Nerve
Radial Nerve

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43
Q

What X-Ray planes would you use to image a Supracondylar Fracture? What would they show?

A

AP and Lateral

Posterior Fat Pad Sign

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44
Q

Describe the Gartland Classification of Supracondylar Fractures

A

I - Undisplaced
II - Displaced with intact posterior cortex
III - DIsplaced in two or three planes
IV - Displaced with complete periosteal disruption

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45
Q

How would you manage Supracondylar Fractures?

A

I and II - Above Elbow Cast

Very Displaced II,III,IV or NV Compromise - Closed Reduction and K Wire

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46
Q

Describe three complications of Supracondylar Fractures

A 
Nerve Palsies (Anterior Interosseous Nerves)
Malunion (Cubitus Varus Deformity)
Volkmann's Contracture - Ischaemia and necrosis of flexor muscles cause fibrosis and contraction
47
Q

What is the Olecranon?

A

Proximal Ulna to Coronoid Process, articulating with the Trochlea of the distal Humerus
Site of insertion for Triceps Tendon

48
Q

How does an Olecranon Fracture present?

A

FOOSH followed by elbow pain/swelling/lack of movement
Inability to extend at elbow against gravity
Generally easy to recognise clinically as the triceps displace the joint

49
Q

Describe the Non-Operative Management of Olecranon Fractures

A

Suitable when the displacement < 2mm

Immobilised at 60-90 degrees with introduction of movement after two weeks

50
Q

Describe the Operative Management of Olecranon Fractures

A

Proximal To Coronoid - Tension Band Wiring

Distal to Coronoid - Olecranon Plating

51
Q

Describe the pathophysiology of a Radial Head Fracture

A

Normally a FOOSH causing Radial Head to impac against Capitulum

52
Q

What is an Essex Lopresti Fracture?

A

Fracture of Radial Head and disruption of distal radio-ulnar joint

53
Q

What planes would you XRay for a suspected Radial Head Fracture, what signs would you see?

A

AP and Lateral

‘Sail’ Sign due to elevation of anterior fat pad (from effusions)

54
Q

Describe the Mason Classification of Radial Head Fractures

A

I - Non Displacement or Minimally Displaced
II - Displacement > 2mm or Angulation
III - Complete Fracture/Displaced/Comminuted

55
Q

Describe the management of Radial Head Fractures

A

Mason I - Immobilisation with sling for a week
Mason II - No mechanical block then treated as I, if mechanical block then ORIF
Mason III - ORIF/Radial Head Excision

56
Q

Give two static and two dynamic stabilisers of the Elbow Joint

A

Static - Humeroulnar Joint, Medial/Lateral Collateral Ligaments
Dynamic - Anconeus, Triceps Brachialis

57
Q

What planes would you XRay for a suspected Elbow Dislocation, what signs would you see?

A

AP and Lateral
Loss of congruence of radiocapitellar and ulnotrochlear
90% Posterior

58
Q

How are Elbow Dislocations (without soft tissue damage) managed?

A

In line traction

Immobilisation (around 2 weeks) with an above elbow backslab at 90 degrees fixed flexion

59
Q

How are Elbow Dislocations (with soft tissue damage) managed?

A

LCL Damage - Elbow more stable in pronation

MCL Damage - Elbow more stable in supination

60
Q

Give two complications of Elbow Dislocations

A

Early Stiffness

Stretching of Ulnar Nerve

61
Q

What is the ‘Terrible Triad’?

A

Elbow dislocation with LCL injury
Radial Head Fracture
Coronoid Fracture

As a result of fall on an extended arm with rotation (resulting in posterlateral dislocation)

62
Q

Olecranon Bursitis can have an infective or non infective aetiology. Give two non infective causes

A

Repetitive Flexion

Gout

63
Q

How does Olecranon Bursitis present?

A

Pain and Swelling

Generally doesn’t affect ROM

64
Q

Give 3 investigations for Olecranon Bursitis

A

Bloods
XRays (rule out bony injuries)
Aspiration (microscopy and culture, needle SHOULDN’T enter joint capsule as to avoid seeding)

65
Q

How would you manage a Non - Infective Bursitis?

A

Analgesia and Rest

If swelling is large and causes enough discomfort - washout in theatre

66
Q

How would you manage Infective Bursitis

A

IV antibiotics and surgical drainage

Potentially even Bursectomy

67
Q

What is Lateral Epicondylitis (AKA Tennis Elbow)?

A

Chronic symptomatic inflammation of Common Extensor origin as it inserts at Lateral Epicondyle

Caused by microtears from repetitive use (microtears - granulation tissue - fibrosis - tendinosis)

68
Q

Give four clinical features of Lateral Epicondylitis

A

Elbow Pain (radiating down forearm)
Weakened Grip
Localised Tenderness
No impact on ROM

69
Q

Name a clinical test for Tennis Elbow

A

Cozen’s Test (Elbow flexed at 90 degrees, lateral epicondyle palpated while wrist extended against resistance)

70
Q

Generally the management of Tennis Elbow is conservative, describe the surgical management.

A

Can be open or arthroscopic

If more than 50% damaged - tendon transfer

71
Q

What is Medial Epicondylitis (AKA Golfer’s Elbow)?

A

Chronic symptomatic inflammation of Common Flexor origin as it inserts at Medial Epicondyle

Caused by microtears from repetitive use (microtears - granulation tissue - fibrosis - tendinosis)

72
Q

What is a Distal Radius Fracture? State the three subtypes.

A

Fracture occurring through the distal metaphysis of the radius (with or without articular involvement)
Colles, Smiths, Bartons

73
Q

Describe the features of a Colles Fracture

A
  • Following a fall on a dorsiflexed hand
  • Dorsal angulation of distal segment
  • DINNER FORK
74
Q

Name a complication of a Colles Fracture

A

Avulsion fracture of Ulnar Styloid

75
Q

What is an Avulsion Fracture?

A

A fracture at part of the bone where a tendon/ligament inserts due to pull of it

76
Q

Describe the features of a Smiths Fracture

A
  • Following a fall on a palmar flexed hand
  • Volar/Palmar angulation of distal segment
  • GARDEN SPADE
77
Q

What is a Barton’s Fracture?

A

INTRA-ARTICULAR fracture of distal Radius and associated dislocation of Radio-Carpal joint

78
Q

How would you assess for Median Nerve damage?

A

Thumb Abduction

79
Q

How would you assess for Anterior Interosseous Nerve Damage?

A

‘Okay’ Sign

80
Q

How would you assess for Ulnar Nerve Damage?

A

Thumb Adduction

5th Digit Sensation

81
Q

How would you assess for Radial Nerve Damage?

A

Thumb Extension

Dorsal 1st Webspace

82
Q

In order to reduce a distal radius fracture, local anaesthetic is likely required. Describe two methods

A

Haematoma Block (Insert straight into fracture site, and check by withdrawing blood)

Biers Block (Use a cuff to temporarily reduce blood supply to the arm and add the LA to the venous system)

83
Q

How would you ‘Stabilise’ a distal radius fracture?

A

Stable - Below elbow backslab

Unstable - ORIF/K Wire/External Fixation

84
Q

Describe the anatomy of the Scaphoid Bone

A
  • Can be split into three parts, Proximal Pole/Waist/Distal Pole
  • Blood supply is retrograde from branches of radial artery entering at the distal pole and travelling back to proximal pole
85
Q

Why is Avascular Necrosis a risk for Scaphoid Fractures?

A

Due to the retrograde blood supply

The more proximal the fracture, the higher the risk

86
Q

State the borders of the Anatomical Snuffbox

A

Lateral Border - Abductor Pollicis Longus, Extensor Pollicis Brevis
Medial Border - Extensor Pollicis Longus
Base - Scaphoid, Trapezium, Styloid

87
Q

State the contents of the Anatomical Snuffbox

A

Radial Artery
Radial Nerve
Cephalic Vein

88
Q

How would you image a suspected Scaphoid Fracture?

A
  • AP, Lateral and Oblique XRays
  • Likely to be initially negative, so splint and repeat XRay in two weeks
  • If repeat is negative and still symptomatic
89
Q

How would you manage a Scaphoid Fracture?

A

Undisplaced - a splint is normally sufficient, but a fracture at the proximal pole may warrant surgery due to AVN risk

Displaced - Percutaneous variable pitched screw

90
Q

What is Carpal Tunnel Syndrome?

A

Compression of the median nerve within the carpal tunnel due to raised pressure within this compartment

91
Q

Give four risk factors for Carpal Tunnel Syndrome

A

Pregnancy
Obesity
DM
RA

92
Q

Give four clinical features of Carpal Tunnel Syndrome

A
  • Pain, numbness and paraesthesia in median nerve distribution
  • Palm sparing (Palmar cutaneous branch given off pre tunnel)
  • Symptoms worse at night
  • Late stage may get weakness/wasting of thenar eminence
93
Q

Describe two clinical tests for Carpal Tunnel Syndrome

A

Tinnels (tapping on the Carpal Tunnel for 30 seconds produces sensory symptoms)

Phalens (forced flexion of wrists for one minute produces sensory symptoms)

94
Q

Describe the conservative management of Carpal Tunnel Syndrome

A

Wrist Splint (commonly worn at night)
Physiotherapy
Corticosteroid Injections

95
Q

Describe the surgical management of Carpal Tunnel Syndrome

A

Cut through flexor retinaculum under LA

96
Q

What is Dupuytren’s Contracture?

A

Contraction of the longitudinal palmar fascia

Fibroplastic hyperplasia and altered collagen matrix of palmar fascia leading to thickening and contraction

97
Q

Give four risk factos for Dupuytren’s Contracture

A

Smoking
Alcoholic Liver Disease
DM
Use of vibration tools

98
Q

How does Dupuytren’s Contracture present?

A

Thickening/Contracture commonly on ring or little finger
45% Bilateral
May have reduced ROM/complete loss of movement

99
Q

The diagnosis of Dupuytren’s Contracture is mainly clinical, name a diagnostic test

A

Hueston’s Test - Patient is unable to lie the dorsum of their hand flat on the table

100
Q

Dupuytren’s Contracture can be conservatively managed using physio exercises, or surgically managed. Describe 4 different surgical techniques

A

Regional - entire cord is removed
Segmental - Points of cord are removed
Dermofasciotomy - Cord and overlying skin are removed and replaced with graft
Finger amputation

101
Q

What is DeQuervain’s Tenosynovitis?

A

Inflammation of the tendons in the first extensor comparment of the wrist

102
Q

What does the first extensor compartment of the wrist contain?

A

Extensor Pollicis Brevis

Abductor Pollicis Longus

103
Q

Give four risk factors for DeQuervain’s Tenosynovitis

A

Age (between 30 and 50)
Female
Pregnancy
Occupations/Hobbies with repetitive wrist movements

104
Q

Give 3 clinical features of DeQuervain’s Tenosynovitis

A

Pain near the base of the thumb with associated swelling
Painful to grasp/pinch
Palpable Thickening

105
Q

Describe a clinical test for DeQuervain’s Tenosynovitis

A

Finkelstein’s Test (Pain at radial styloid process when radial traction and ulnar deviation applied)

106
Q

How would you manage DeQuervain’s Tenosynovitis

A 
Wrist Splint
Steroid Injections
Surgical Decompression (via transverse/longitudinal incision)
107
Q

What is a Ganglionic Cyst?

A

Non cancerous soft tissue lump occurring along any joint/tendon
Occurs when joint capsule/tendon sheat degenerates causing them to become filled with synovial fluid

108
Q

How do Ganglionic Cysts present?

A

Smooth spherical painless lump adjacent to affected joint

Soft and will transilluminate

109
Q

How would you manage Ganglionic Cysts?

A

Usually just monitor as they disappear spontaneously
Aspirate (+/- steroid injections)
Cyst Excision

110
Q

What is a Trigger Finger?

A

Finger/Thumb click or lock into place when in flexion, preventing return to extension

111
Q

What is the Flexor Sheath and Pulley System?

A

Ensures tendons remain in the joints axis of motion and prevents bow stringing

112
Q

Describe the pathophysiology of Trigger Finger

A

Usually preceded by flexor tenosynovitis

Superficial and deep tendons develop nodules that can pass under the pulley system on flexion, but get stuck on extension

Risk Factors include: DM, RA, Age

113
Q

Trigger Finger is generally painless, but can become painful. Describe the conservative and surgical management.

A

Conservative - Splint holding finger in extension at night, steroid injections
Surgical - Percutaneous trigger finger release (using needle), Slit in roof of tunnel

114
Q

What is a Bennett Fracture?

A

Fracture of the thumb metacarpal base

year 3 surgery (10 decks)

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