TNO common presentations Flashcards
Shoulder dislocation can be
anterior, posterior or inferior
cause and presentation of anterior shoulder dislocation
Cause: arm forced backwards whilst abducted and extended at the shoulder e.g. someone reaching up and out to try and acth a heavy rock travelling towards
Presentation:
- arm held to body
- deltoid flattened
- humerus will cause a bulge
cause of posterior dislocation
electric shocks and seizures
damage associated with shoulder dislocation
- Bankart lesion
- Hill-sachs lesion
- Axillary nerve damage
bankart lesion
tears to the anterior portion of the labrum
These occur with repeated anterior subluxations or dislocations of the shoulder.
Hill-sachs lesion
are compression fractures of the posterolateral part of the head of the humerus. As the shoulder dislocates anteriorly, the posterolateral part of the humeral head impacts with the anterior rim of the glenoid cavity. Part of the humeral head is damaged, making the shoulder less stable and at risk of further dislocations.
investigation for shoulder dislocation
- X-ray (AP, lateral, axillary view)
- Confirm dislocation
- exclude fracture
- MRI
- look for Hill-sachs and Bankart lesions
- prep for surgery
- Arthroscopy
acute management of shoulder dislocation
Relocate ASAP- heres the step
Shoulder muscles goes into spasm making it harder to relocate as time goes on
- Analgesia, muscle relaxant and sedation as appropriate
- Gas and air (Entonox)
- Broad arm sling
- Reduce
- if associated fracture- surgery
- Post reduction x-ray
- immobilisation after relocation of shoulder
Ongoing management after shoulder disloation
to help reduce recurrent dislocations
- physiotherapy
- shoulder stabilisation therapy
Wrist fractures
-
Distal radial fracture
- Colles
- Smiths
- Bartons
- Scaphoid
Colles fracture summary
- Extra, articular transverse distal radius fracture
- may not mention but will include avulsion fracture of ulnar styloid
- Cause
- forward FOOSH
- fragility fracture e.g. think osteoporosis RF
- Presentation
- Dinner fork deformity
- Distal radius is dorsally displacement
Smith fracture
- Extra, articular transverse distal radius fracture
- less common
- think of as reverse of colles
- Cause
- Backwards FOOSH
- Presentation
- Palmar/volar angulation of distal radial fragment, with or without palmar displacement
Bartons fracture
This is an intra-articular fracture of the distal radius with associated dislocation of the radio-carpal joint.
A Barton fracture can be described as volar (more common) or dorsal (less common), depending on whether the volar or dorsal rim of the radius is involved.
The main risk factors for distal radius fractures are related to osteoporosis:
- Increasing age
- Female gender
- Early menopause
- Smoking or alcohol excess
- Prolonged steroid use
Investigation for distal radius fracture
- Neurovascular examination before and after any procedure
- Investigations
- X-ray (AP and lateral)
- Radial height <11mm
- Radial inclination <22 degrees
- Radial (volar) tilt >11 degrees
- CT or MRI more complex fractures
- X-ray (AP and lateral)
management of distal radius fractures: undisplaced
- ATLS
- Closed reduction
- Haematoma block (lidocaine)
- Traction and manipulation
- Below-elbow backslap
- allows for swelling
- Radiography repeated after 1 week to check for displacement
- Physio
management of distal radius fractures: displaced
Surgical management if
- displaced
- intra-articular
Options
- :open reduction and internal fixation with
- plating or
- K-wire fixation
- Back-slab cast to ensure immobility
mortality rate of hip fracture
5-10%
Hip Fracture Presentation
The typical scenario is an older patient (over 60) who has fallen, presenting with:
- Pain in the groin or hip, which may radiate to the knee
- Not able to weight bear
- Shortened, abducted and externally rotated leg
Hip fractures can be categorised into:
*
- Intra-capsular fractures
- Extra-capsular fractures
blood supply to the femoral head
- retrograde
- Deep femoral artery: medial and lateral circumflex supply the femoral head
- branches of circumflex arteries supply the top of the head
- If intracapsular fracture the neck of the of the femur can damage these blood vessels- removing blood supply to the femoral head→ Avascular necrosis
Intra-capsular fractures
- Break in femoral neck
- Classification : Garden
- displaced
- non- displaced
investigations for hip fracture
- X-ray (AP and lateral)
- look for Shentons line
- MRI or CT if x-ray negative, but fracture still investigated
Non-displaced intra-capsular fracture management
internal fixation (with screws)
Displaced intra-capsular fracture management
Total hip replacement (head and socket): if patient walk independently
Hemiarthroplasty (head): limited mobility or significant co-morbidities
why replacement for displaced intra-capsular and not non-displaced
Intra-capsular fractures may have an intact blood supply to the femoral head, meaning it may be possible to preserve the femoral health without avascular necrosis occurring.
extra-capsular fractures can be split up into
Intertrochanteric fractures- between greater and lesser trochanter
Subtrochanteric fractures- occurs distal to lesser trochanter (within 5cm)
management of intertrochanteric fracture
dynamic hip screw (AKA sliding hip screw).
management of Subtrochanteric fracture
intramedullary nail (a metal pole inserted through the greater trochanter into the central cavity of the shaft of the femur).
non surgical management of hip fracture
On admission, patients will have:
- Appropriate analgesia
- Investigations to establish the diagnosis (e.g., x-rays)
-
Venous thromboembolism risk assessment and prophylaxis (e.g., low molecular weight heparin)
- 28 days
- knee- 14 days
- Pre-operative assessment (including bloods and an ECG) to ensure they are fit and optimised for surgery
- Orthogeriatrics input
An ankle fracture* is a
fracture of any malleolus (lateral, medial, or posterior), with or without disruption to the syndesmosis.
classification of ankle fracture
- Anatomically: isolated, bimalleolar, trimalleolar
- Webers
Weber classification is for
lateral maellolus fracture
Weber classification for lateral malleolus fractures
- Type A = below the syndesmosis
- Type B = at the level of the syndesmosis
- Type C = above the level of the syndesmosis
which kind of ankle fracture is the worst
Type c- above level of syndesmosis
- higher likelihood of ankle instability
rules to suggest ankle fracture or sprain
Ottawa Ankle Rules
Where there is diagnostic uncertainty, for example where the patient is able to mobilise and has no deformity, the ‘Ottawa rules’ can be employed.
These state that in the presence of any of the below features, plain radiographs must be undertaken:
- Bone tenderness at the posterior edge or tip of the lateral malleolus, OR
- Bone tenderness at the posterior edge or tip of the medial malleolus, OR
- An inability to bear weight both immediately and in the emergency department for four steps
Whilst useful, they cannot be used in cases if the patient is intoxicated or uncooperative, has other distracting painful injuries, has diminished sensation in their legs, or has gross swelling.
investigation for ankle fracture
- X-ray
- Ap and lateral
- ensuring no talar shift
- ankle should be in full dorsiflexion
management of ankle fracture general
- STAT reduction
- under sedation in ED
- below knee back slab
- repeat neurovascular exam and X-ray
conservative management for ankle fracture
- Non-displaced medial malleolus fractures
- Weber A fractures or Weber B fractures without talar shift
- Those unfit for surgical intervention
surgical management fo ankle fracture
Open reduction and internal fixation (ORIF) is often required in ankle fractures to achieve stable anatomical reduction of the talus within the ankle mortise. Ankle fractures that require an ORIF include:
- Displaced bimalleolar or trimalleolar fractures
- Weber C fractures
- Weber B fractures with talar shift
- Open fractures
The type of operative procedure performed depends on the specific type of ankle fracture sustained.
anterior ligament limits
anterior movement of the tibia
anterior ligament tear mechanism of injury
- sudden change of direction twisting the flexed knee
- an athlete history of twisting* knee whilst weight bearing
Anterior cruciate ligament (ACL) tear presentation
- rapid joint swelling
- signif pain
- if delayed presentation- instability ‘leg giving way’
special tests for ACL tear
Lachman Test and Anterior Draw Test
investigation for ACL tear
X-ray (AP and lateral) to exclude bony injury, any joint effusion or lipohaemarthrosis
MRI is gold standards for ACL diagnosis (also picks up meniscal tear)
which fracture is pathognomic of ACL injury
Segond fracture- bony avulsion of the lateral proximal tibia
immediate management of ACL tear
RICE
rest
ice
compression
elevation
conservative management of ACL tear
- rehabilitation- strengthening of quadriceps to stabilise the knee
- cricket pad knee splint for comfort
surgical management of ACL tear
- reconstruction of ACL using a tendon or artificial graft
- not performed acutely
- months of physio before
- Acute surgical repair of ACL (only possible in some cases)
- GA knee arthroscopy, proceeding to an acute repair
- suturing ends of torn ligament together
role of PCL
the PCL is the primary restraint to posterior tibial translation and works to prevent hyperflexion of the knee.
PCL tear mechanism of injury
high energy trauma
proximal blow tot he tibia during a RTA
presentation of PCL
- immediate posterior knee pain
- instability of the joint
- posterior draw test
*
- posterior draw test
investigations for PCL tear
As with ACL tears, the gold-standard for diagnosis for PCL tears is via MRI scanning.
management of PCL tear
conservatively
- brace
- physio
if symptomatic and recurrent instability → surgery with insertion of a graft
which is the most commonly injured ligament
medial collateral ligmanet
role of the MCL
valgus stabiliser
MCL injury mechanism of injury
VALGUS trauma
direct impact to the outside of the knee
presentation of MCL tear
- patient may report hearing a pop
- immediate medial joint line pain
- swelling starts a few hours after
- increased laxity when testing the MCL
- pt may be able to weight bear
investigations for MCL tear
x-ray to exclude fracture
MRI= gold standard
The main complications following a MCL tear
are instability in the joint and damage to the saphenous nerve.
meniscus
The medial meniscus is less circular than the lateral and is attached to the medial collateral ligament,
The lateral meniscus is not attached to the lateral collateral ligament.
cause of meniscal teats
trauma-related injury and degenerative disease (the latter more common in older patients).
traumatic tears
- young patients who has twisted their knee whilst it is flexed and weight bearing
types of meniscal tear
- Vertical
- Longitudinal(Bucket-Handle)- most common
- Transverse(Parrot-Beak)
- Degenerative
presentation of meniscal tear
*
- tearing sensation
- intense sudden onset pain
- swells slowly
- may be locked in flexion and unable to extend
- joint line tenderness
- significant joint effusion
- limited knee flexion
special tests for meniscal tear
McMurray’s Test* and Apley’s Grind Test*
investigation for meniscal tear
X-ray to exclude fracure
MRI scan gold standard to confirm tear
management of menisceal tear
small: rice
large: arthrosocpic surgery
complications of knee arthroscopy
- DVT
- damage to saphenous nerve and vein
- peroneal nerve
- popliteal vessel
