trauma and ortho Flashcards
What is Monteggia’s fracture?
fracture of proximal third of ulna
+
anterior dislocation of head of radius at the elbow
What is Galeazzi’s fracture?
fracture of the distal third of the radius +
subluxation (partial dislocation) of the head of the ulna at the wrist joint
What is colles fracture?
fracture, and dorsal displacement, of the distal end of the radius.
which types of bones undergo intramembranous ossification?
(direct ossification of mesenchymal bone models formed during embryonic development)
skull bones, mandible, clavicle
which types of bones undergo endochondral ossification?
mesenchyme -> cartilage -> which then ossifies into bone
most bones
e..g appendicular skeleton
what occurs during a reactive phase of fracture healing?
(injury- 48hrs)
- bleeding into # site -> haematoma
- inflammation -> cytokine, GF, vasoactive mediator release -> recruitment of leukos and fibroblasts -> granulation tissue
what occurs during the reparative phase of fracture healing?
(2 days - 2wks)
- proliferation of osteoblasts and fibroblasts -> cartilage and woven bone production: callus formation
- consolidation (endochondral ossification) of woven bone -> lamellar bone
what occurs during remodelling phase of fracture healing?
(1 wk - 7 years)
- Remodelling of lamellar bone to cope with mechanical forces applied to it.
what is the average healing time of a fracture?
around 3 weeks
for closed, paediatric, metaphyseal, upper limb #s
what are some complicating factors that could lengthen the time of fracture healing?
adult
lower limb
open fracture
diaphyseal
*doubles healing time
ortho radiographs of a fracture
- what to request for?
AP and lateral views
Images of joint above and joint below #
how to describe a fracture?
- Patient details, date radiograph taken, orientation, content of image
PAID
- Pattern
e. g. transverse, oblique, spiral, multifragmentary (comminuted), avulsion, crush, greenstick - Anatomical location
- Intra/ extra articular
Dislocation/ subluxation
- Deformity
e. g. impaction, rotation, angulation, translation - soft tissues
- ? specific type of #
e. g. colles, smiths, galeazzis, monteggia
what are the 4 Rs of fracture management?
Resuscitation
Reduction
Restriction
Rehabilitation
how would you resuscitate a patient w a fracture?
- Follow Advanced Trauma Life Support (ATLS) guidelines
- Primary survey: C-spine, chest and pelvis
- # usually assessed in secondary survey
- assess neurovascular status and look for dislocations
- consider reduction and splinting before imaging
to decrease pain/ bleeding/ risk of neurovasc injury
Xray once stable.
What are the 6As that guide the management of open fractures?
open fractures require urgent attention
Analgesia: morphine
Assess: neurovascular status, soft tissues, photograph
Antisepsis: wound swab, copious irrigation, cover with betadine-soaked dressing
Alignment: align # and splint
Anti-tetanus: check status (booster lasts 10 yrs)
Abx:
e.g. Fluclox + Benpen or Augmentin
Mx: debridement and fixation in theatre
what is the Gustillo classification of open #s?
- wound <1 cm in length
- wound ≥ 1cm w minimal soft tissue damage
- extensive soft tissue damage
what is the most dangerous complication of open #?
clostridium perfringens
leading to wound infections and gas gangrene
+/- shock and renal failure
tx of clostridium perfringens infection of open fracture?
debridement,
abx: benpen + clindamycin
principles of reduction in fracture mx?
displaced #s should be reduced
unless no impact on outcome e.g. ribs
- aim for anatomical reduction esp if articular surface involved
what does closed reduction of a fracture involve?
under local, regional or general anaesthetic
traction to disimpact
manipulation to align
what does traction of fracture involve?
not typically used now
used to overcome contraction of large muscles e.g. femoral #s
traction refers to the practice of slowly and gently pulling on a fractured or dislocated body part.
Skin traction rarely causes fracture reduction, but reduces pain and maintains the length of the bone
skeletal traction (pins in bones)
what is open reduction and internal fixation of a fracture?
balance accurate reduction vs risks of surgery (e.g. infection)
used for intra-articular #s, open #s, 2#s in 1 limb, failed conservative tx, bilateral identical #s
principles of restriction in fracture mx?
interfragmentary strain hypothesis dictates that tissue formed @ # site depends on strain it experiences
fixation -> ↓ strain -> bone formation
fixation also -> ↓ pain, ↑ stability, ↑ ability to function.
methods of restriction of fractured area?
non rigid: e.g. slings, elastic support
plaster cast: in first 24-48h use black slab or split case due to risk of compartment syndrome
functional bracing: joints free to move but bone shafts supported in cast segments
continuous traction e.g. collar and cuff
external fixation
internal fixation
what is external fixation of a fracture?
fragments held in position by pins/ wires which are then connected to an external frame
intervention is away from field of injury
useful in open #s, burns, tissue loss to allow wound access and decrease infection risk
but risk of pin-site infections
what is internal fixation of a fracture?
pins, plates, screws, Intramedullary nails
usually perfect anatomical alignment
↑ stability
aids early mobilisation
principles of rehabilitaion in fracture mx?
immobility -> decreased muscle and bone mass + joint stiffness
need to maximise mobility of uninjured limbs
quick return to function decreases later morbidity
methods of rehabilitation in fracture mx?
physiotherapy
OT: splints, mobility aids, home modification
social services: meals on wheels, home help
what is axonotmesis of a nerve?
disruption of nerve axon -> distal Wallerian degeneration
endoneurium, perineurium, epineurium remain intact
mainly follows stretch injury,
usually the result of a more severe crush or contusion than neurapraxia.
Regeneration occurs and recovery is possible
what is wallerian degeneration?
active process of degeneration that results when a nerve fiber is cut or crushed and the part of the axon distal to the injury (i.e. farther from the neuron’s cell body) degenerates.
what is neuropraxia?
Temporary interruption of conduction w/o loss of axonal continuity
temporary damage to the myelin sheath but leaves the nerve intact and is an impermanent condition
what is neurotmesis?
disruption of entire nerve fibre
surgery required
recovery usually not complete
What nerve injury is common after anterior shoulder dislocation/ fracture of surgical neck of humerus?
axillary n injury
-> weak abduction
numbness over deltoid skin area
what nerve injury is common after # of humeral shaft?
radial n
-> wrist drop
(weak wrist/ finger extensors)
weak supination
common nerve injury following elbow dislocation?
ulnar nerve injury
-> claw hand
common nerve injury following hip dislocation?
sciatic nerve
-> foot drop
common nerve injury following # of neck of fibula/ knee dislocation?
common peroneal n injury
-> foot drop
what is compartment syndrome?
osteofacial membranes separate limbs into separate compartments of muscles
oedema following # -> ↑ compartment pressure → ↓venous drainage → ↑ compartment pressure
If compartment pressure > capillary pressure → ischaemia
Muscle infarction -> rhabdomyolysis and ATN
fibrosis -> Volkman’s ischaemic contracture
presentation of compartment syndrome?
pain > clinical findings
pain on passive muscle stretching
warm, erythematous, swollen limb
↑ CRT and weak/absent peripheral pulses
mx of compartment syndrome?
elevate limb
remove all bandages / cast
fasciotomy
immediate complications of fracture?
neurovascular damage
visceral damage
early complications of fracture?
compartment syndrome
infection
fat embolism -> acute respiratory distress syndrome
late complications of fracture?
malunion
post-traumatic osteoarthritis
complex regional pain syndromes
avascular necrosis
growth disturbance
myositis ossificans (calcification of muscle)
causative factors of delayed/ non union?
ischaemia: poor blood supply/ avascular necrosis
infection
↑ interfragmentary strain
interposition of tissue between fragments
intercurrent disease e.g. malignancy or malnutrition
hypertrophic vs atrophic non-union of fracture?
hypertrophic: bone end is rounded, dense and sclerotic
atrophic: bone looks osteopenic
Mx of non-union of fracture?
optimise blood supply, infection, bone graft
optimise mechanics: ORIF
what is malunion of a #?
healed in an imperfect position
-> poor appearance +/- function
common sites of avascular necrosis following #?
femoral head, scaphoid, talus
consequence of avascular necrosis?
bone becomes soft and deformed ->
pain, stiffness and osteoarthritis
xray findings of avascular necrosis?
sclerosis and deformity
what is myositis ossificans?
formation of bone tissue inside muscle tissue after a traumatic injury to the area
-> restricted, painful movement
commonly affects elbow and quadriceps
can be excised surgically.
what is pellegrini-stieda disease?
ossification of the superior part of the medial collateral ligament of the knee following traumatic injury
Reflex Sympathetic Dystrophy aka?
Complex Regional Pain syndrome
what is complex regional pain syndrome?
disorder of a portion of the body, usually starting in a limb, which manifests as extreme pain, swelling, limited range of motion, and changes to the skin and bones.
usually abnormal blood flow, sweating and trophic changes.
no evidence of nerve injury
causes of complex regional pain syndrome?
injury: #s, carpal tunnel release, ops for dupuytrens
zoster, MI, idiopathic
presentation of complex regional pain syndrome?
occurs wks- months after injury
affects a neighbouring area to the traumatised area
lancing pain, hyperalgesia, allodynia (feeling pain from stimulus that doesnt normally cause pain)
vasomotor: hot/ sweaty or cold/ cyanosed
skin: swollen, atrophic, shiny
NM: weakness, hyperreflexia, dystonia, contractures
mx of complex regional pain syndrome?
usually self limiting
refer to pain team
medications for neuropathic pain: amitryptilline, gabapentin
sympathetic nerve blocks can be tried
what is Complex regional pain syndrome type II?
persistent pain following injury caused by nerve lesions
what classification system categorises growth plate injuries?
Salter Harris classification
what is the salter harris classification of growth plate injuries?
SALT Crush
- Straight across
- above
- lower
- through
- CRUSH
increasing risk of growth plate injury from 1 to 5
SH1: e.g. SUFE. normal growth with good reduction
SH4: union across growth plate may interfere with bone growth
SH5: crush -> growth plate injury -> growth arrest
common causes of hip fractures?
old: osteoporosis with minor trauma
young: major trauma
Risk factors of osteoporosis?
Age + SHATTERED
Steroids
Hyperthyroidism / hyperPTH
Alcohol and smoking
Thin (BMI <22)
Testosterone low
Early menopause
Renal/ Liver failure
Erosive/ inflammatory bone disease eg. Rheumatoid
Dietary Ca low/ malabsorption, diabetes
presentation of hip fracture O/E?
leg shortened and externally rotated
impt questions regarding hip fracture?
mechanism of injury
RFs for osteoporosis/ pathological #
premorbid mobility/ independence
comorbidities
MMSE
imaging of hip fracture?
ask for AP and lateral film
look at Shenton’s lines
intra/ extra capsular?
displaced or non displaced
osteopaenic?
dinner fork deformity of Colles fracture?
fracture of distal radius
with dorsal and proximal displacement of the distal fragment.
what is the blood supply to the femoral head?
Retinacular vessels from the medial and lateral circumflex femoral artery
intramedullary vessels
artery of ligamentum teres
where does the hip capsule attach to?
attaches proximally to the acetabular margin
and distally to the intertrochanteric line
types of hip fractures?
intracapsular: fractures occur at the level of the neck and the head of the femur, and are generally within the capsule
extracapsular:
intertrochanteric- # occurs between the NOF and lesser trochanter.
subtrochanteric- # occurs below the lesser trochanter
what is the Garden classification of intracapsular fractures?
predicts the development of AVN
stage 1. incomplete #, undisplaced
- complete #, undisplaced
- complete #, partially displaced
- complete #, completely displaced
surgical mx of extracapsular fracture?
ORIF
with dynamic hip screw
which allows controlled dynamic sliding of the femoral head component along the construct
surgical mx of intracapsular fractures types 1 and 2?
ORIF with cancellous screws
surgical mx of intracapsular hip fractures types 3 and 4?
if <55:
ORIF with screws
(follow up in OPD and do arthroplasty if AVN develops)
if 55-75:
total hip replacement
if >75:
hemiarthroplasty
complications of hip fractures
AVN of femoral head in displaced #s
non/ malunion
infection
osteoarthritis
what deformity is common with colles fracture?
dinner fork deformity
what neurovascular injuries may occur with colles fracture?
median nerve and radial artery lie close
mx of colles fracture
examine for neurovascular injuries
if much displacement -> reduction
re-xray - satisfactory position?
if comminuted, intra-articular or re-displaces:
surgical fixation with external fixation, K wire or ORIF and plates
what are K wires?
aka Kirschner wire
sterilized, sharpened, smooth stainless steel pins.
different sizes and are used to hold bone fragments together (pin fixation) or to provide an anchor for skeletal traction.
complications of colles fracture?
median n injury
tendon rupture esp. EPL
carpal tunnel syndrome
mal/ non-union
complex regional pain syndrome
what is a smith’s fracture?
fall onto back of flexed wrist
fracture of distal radius w volar displacement and angulation of distal fragment
(garden spade deformity)
mx of smiths fracture?
reduction to restore anatomy
plaster of paris for 6 wks
what is a barton’s fracture?
an intra-articular fracture of the dorsal aspect of distal radius with dislocation of the radiocarpal joint.
ie. Colles + intra-articular involvement
what is reverse barton’s fracture?
volar aspect of radius # + dislocation of radio-carpal joint
fall onto outstretched hand
pain in anatomical snuffbox
pain on telescoping the thumb
scaphoid fracture
features of scaphoid fracture?
pain in anatomical snuffbox
pain on telescoping the thumb
mx of scaphoid fracture?
request scaphoid xray view
may tx even if xray normal if strong hx + exam
if initial xray -ve -> pt returns to # clinic after 10 days for re-xray
visible -> plaster for 6 wks
no visible # but clinically tender -> plaster for 2 wks
not visible and not clinically tender -> no plaster
complications of scaphoid fracture?
AVN of scaphoid as blood supply runs distal to proximal
-> pain, stiffness, OA of wrist
complication of monteggia fracture?
of proximal 3rd of ulna shaft
+ Anterior dislocation of radial head at capitulum
-> may cause palsy of deep branch of radial nerve -> weak finger extension but no sensory loss
mx of unstable forearm fractures in adults/ children?
adults: ORIF
Children: manipulation under anaesthesia + above elbow plaster
where should fractures of forearm be plastered?
should be plastered in most stable position
proximal #: supination
distal #: pronation
mid-shaft #: neutral
most common direction of shoulder dislocation?
antero-inferiorly (95%)
either due to direct trauma or falling on hand
posterior- caused by direct trauma or muscle contraction (in epileptics)
what is a Bankart lesion?
damage to anteroinferior glenoid labrum due to anterior shoulder dislocation
When this happens, a pocket at the front of the glenoid forms that allows the humeral head to dislocate into it.
what is a Hill-Sachs lesion?
cortical depression in the posterolateral part of the humeral head
after impaction against the glenoid rim during anterior dislocation
occurs in 35-40% of anterior dislocations
presentation of shoulder dislocation?
shoulder contour lost: appears square
bulge in infraclavicular fossa: humeral head
arm supported in opposite hand
severe pain
management of shoulder dislocation?
assess for neurovascular deficit. - axillary nerve
xray- AP and transcapular view
reduction under sedation e.g. propafol
rest arm in sling for 3-4 wks
physio
what neurovascular deficit to assess for in shoulder dislocation?
axillary nerve damage
- sensation over “chevron” area
before and after reduction
what methods of reduction are there for anterior shoulder dislocation?
Hippocratic: longitudinal traction w arm in 30 degree abduction and counter traction @ the axilla
Kocher’s: external rotation of adducted arm, anterior movement, internal rotation
complications of shoulder dislocation?
Recurrent dislocation
- 90% of pts. <20yrs with traumatic dislocation
Axillary N. injury
Types of recurrent shoulder instability?
TUBS: Traumatic Unilateral dislocations with a Bankart lesion often require Surgery
- Mostly young patients: 15-30yrs
- Surgery involves a Bankart repair
AMBRI: Atraumatic Multidirectional Bilateral shoulder dislocation is treated with Rehabilitation, but may require Inferior capsular shift
what test is used to identify presence of impingement of supraspinatus tendon?
Hawkins Test:
elevate the arm to 90 degrees of flexion then internally rotate the arm.
if painful-> positive
pathology of painful arc/ impingement syndrome?
entrapment of supraspinatus tendon and subacromial bursa between acromion and greater tuberosity of humerus
-> subacromial bursitis +/- supraspinatus tendonitis
presentation of subacromial bursitis +/- supraspinatus tendonitis?
painful arc: 60 -120
weakness and decreased ROM
+ve Hawkins test
Ix of subacromial bursitis +/- supraspinatus tendonitis?
Plain radiographs: may see bony spurs
US shoulder
MRI arthrogram
Mx of subacromial bursitis +/- supraspinatus tendonitis
conservative:
rest, physio
medical:
NSAIDs, subacromial bursa steroid +/- LA injection
surgical:
arthroscopic acromioplasty
differential of painful arc
impingement of supraspinatus tendon
supraspinatus tear/ partial tear
Acromioclavicular joint OA
subacromial bursitis
presentation of frozen shoulder?
(adhesive capsulitis)
progressively decreased active and passive ROM
↓ ext. rotation <30 degrees
↓ abduction <90 degrees
Shoulder pain, esp. @ night (can’t lie on affected side)
causes of adhesive capsulitis/ frozen shoulder?
unknown, may follow trauma in elderly
commonly assoc w DM
mx of adhesive capsulitis/ frozen shoulder?
conservative: rest, physio
medical:
NSAIDs, steroid injection
rotator cuff tear presentation?
partial tear: painful arc
complete tear:
shoulder tip pain
full range passive movement
inability to abduct arm
active abduction possible following passive abduction to 90
lowering the arm beneath 90-> sudden drop (drop arm sign)
mx of rotator cuff tear?
open or arthroscopic repair
presentation of supracondylar humeral fracture?
Common in children after FOOSH
Elbow very swollen and held semi-flexed.
Sharp edge of proximal humerus may injure brachial
artery which lies anterior to it.
classification of supracondylar fractures?
extension
commonest type
Distal fragment displaces posteriorly
Gartland further classification:
- non-displaced
- angulated w intact posterior cortex
- diplaced w no cortical contact
flexion
distal fragment displaces anteriorly
mx of supracondylar fracture of humerus
assess for neurovascular damage - esp brachial artery, median n
-> check radial pulse!
restore anatomy:
No displacement → flex the arm as fully as possible and apply a collar and cuff for 3wks – triceps acts as sling to stabilise fragments.
Displacement → MUA + fixation with K-wires +
collar and cuff with arm flexed for 3wks.
complications of supracondylar fracture of humerus?
neurovasc injury:
brachial artery, radial nerve, median nerve
compartment syndrome
gunstock deformity:
cubitus varus deformity
complications of femoral and tibial fractures
hypovolaemic shock
neurovascular:
sciatic nerve, superficial femoral artery (check pulses)
compartment syndrome
resp complications: fat embolism, ARDS, pneumonia
mx of open femoral / tibial #?
take to theatre urgently for debridement, washout and stabilisation
abx and anti-tuberculous mx
what ligaments are strained during an inversion injury of the ankle?
Anterior talofibular and calcaneofibular
if severe, posterior talofibular ligament also involved
what are the Ottowa Ankle rules?
xray ankle if pain in malleolar zone +
Bone tenderness at posterior edge or tip of lateral OR medial malleolus
OR
Inability to bear weight both immediately after injury AND in ED.
What is the weber classification of ankle fracture?
relation of fibula # to joint line
A: below joint line
B: at joint line
C: above joint line
Weber’s B and C represent possible injury to the syndesmotic ligaments between tibia and fibula -> instability
mx of displaced weber B/C ankle fracture?
closed reduction and POP if anatomical reduction achieved
ORIF if closed reduction fails
mx of weber A/ non displaced Weber B/C ankle fracture?
below knee POP
qns to ask about knee injury?
mechanism
swelling:
immediate -> haemarthrosis? from #/ torn cruciate
overnight -> effusion
pain/ tenderness
locking: menisceal tear -> mechanical obstruction
giving way: instability following ligament/ meniscus injury
causes of knee haemarthrosis?
primary: spontaneous
- coagulopathy: warfarin, haemophilia
secondary: trauma
80% ACL injury
10% patella dislocation
10% meniscal injury (outer third where it is vascularised)
osteophyte #
what is the unhappy triad of O’Donoghue?
ACL
MCL
Medial Meniscus
mx of acutely injured knee
Full examination of acutely swollen knee after injury is difficult.
Take x-ray to ensure no #s
- Fluid level indicates a lipohaemarthrosis and indicates either a # or torn cruciate.
If no # → RICE (rest, ice, compression, elevation) + later re-examination for pathology
If meniscal or cruciate injury suspected → MRI
Arthroscopy:
direct vision of inside of knee joint by arthroscope
mensical tears can be trimmed or repaired
mx of ruptured ACL
conservative:
rest, physio to strengthen quads and hamstrings
not enough stability for many sports
surgical:
gold std is autograft repair
- can use semitendinosus +/- gracilis or patella tendon
tendon threaded through heads of tibia and femur and held using screws
definition of osteoarthritis?
Degenerative joint disorder in which there is progressive loss of hyaline cartilage and new bone formation at the joint surface and its margin.
risk factors of osteoarthritis
age
obesity
joint abnormality
symptoms of osteoarthritis?
pain: worse on movement/ @ end of day, background rest/ night pain
stiffness: especially after rest, lasts ~30 min
deformity
decreased ROM
signs of osteoarthritis?
Heberdons (distal) and Bouchards nodes
Fixed flexion deformity
Thumb CMC squaring
why do osteophytes form in osteoarthritis?
Proliferation and ossification of cartilage in unstressed areas
Xray changes of Osteoarthritis?
loss of joint space
osteophytes
Subchondral cysts
subchondral sclerosis
deformity
mx of osteoarthritis?
MDT: GP, physio, OT, orthopod
Conservative:
weight loss, exercise
physio- muscle strengthening
OT: walking aids, supportive footwear
Medical:
NSAIDS, paracetamol
Local anaesthetic/ steroid injections
Surgical:
Arthroscopic washout (knees)
realignment osteotomy (e.g. medial knee OA)
Arthroplasty: replacement/ excision
Arthrodesis: last resort for pain mx
what is Osteochondritis?
Idiopathic condition in which bony centres of children/adolescents become temporarily softened due to osteonecrosis.
Pressure → deformation
Bone hardens in new, deformed position
what is Osgood-schlatter’s disease?
apophysitis of the tibial tubercle + inflammation of the patellar ligament at the tibial tuberosity
most common 10-14 yo, M>F 3:1
features of osgood-schlatter disease?
pain over the tibial tuberosity
swelling over tibial tubercle
assoc w physical activity, esp w quads contraction
mx of osgood - schlatter disease
rest
NSAIDs
physio- stretching exercises
what is osteochondritis dissecans?
when piece of bone and overlying cartilage dissects off into joint space
commonly knee, also elbow, hip, ankle
in young adult/ adolescent
features of osteochondritis dissecans?
pain, swelling of affected joint
catches and locks during movement
decreased ROM
xray findings of osteochondritis dissecans?
usually medial femoral condyle
loose bodies
lucent crater
mx of osteochondritis dissecans?
rest
+/- splinting
surgical tx if severe
causes of avascular necrosis?
fracture, dislocation
sickle cell anaemia, thalassaemia
SLE
Gauchers
Drugs: Steroids, NSAIDs
what is Developmental dysplasia of the hip?
congenital hip deformity in which the femoral head is or can be completely/ partially displaced
risk factors of developmental dysplasia of the hip?
female
family history
breach presentation
oligohydramnios
presentation of developmental hip dysplasia?
during screening (Barlows and Ortolanis)
asymmetric skin folds
limp/ abnormal gait
ix of developmental hip dysplasia?
USS of hips
Mx of developmental hip dysplasia?
Pavlik harness
or
Reduction: (if baby > 6mo)
Closed/ Open
commonest cause of acute hip pain in children
of 2-12 yrs
sudden onset hip pain/ limp
often following or with viral infection
not systemically unwell
dx?
Transient Synovitis
ix of transient synovitis?
-ve blood cultures
ESR/ CRP normal or slightly raised
Xray normal
US hip may demonstrate fluid
may need joint aspiration and culture
Mx of transient synovitis?
rest and analgesia
settles over 2-3 days
what is Perthes’ Disease?
disruption of blood supply to hip -> avascular necrosis of femoral head
childhood condition: 4-10 yrs old
M>F 5:1
Presentation of Perthes disease?
insidious onset
limp
hip pain (usually worsened by activity)
10-20% bilateral
Ix of Perthes’ Disease?
Xray of hip:
may be normal initially
Increased density of femoral head
- > fragmented and irregular femoral head
- > flattening and sclerosis
Xray shows the different stages of the disease: necrosis, fragmentation, reossification, healed
typical examination findings in Perthes’ disease?
limited abduction and internal rotation
management of perthes’ disease?
if detected early and <50% femoral head affected:
bed rest, traction
more severe, >50% femoral head affected:
maintain hip in abduction w plaster
femoral or pelvic osteotomy (cutting of bone to allow realignment)
what is a slipped capital femoral epiphysis? (or SUFE)
postero-inferior displacement of femoral head epiphysis
after fracture through growth plate
usually 10-15 yrs
fat and sexually underdeveloped
or
tall and thin
presentation of slipped upper femoral epiphysis?
acute or chronic, or acute on chronic
acute: groin pain, shortened, externally rotated leg + painful movements
pain may be in knee/ thigh due to pain being referred along obturator nerve distribution
chronic: gradual, progressive onset of thigh or knee pain with a painful limp.
20% bilateral
ix of SUFE?
x ray hips: ice cream cone sign
MRI may be indicated if xray normal
Mx of slipped upper femoral epiphysis
Acute:
orthopaedic emergency -> seek ortho consultant review
patient should be non weight bearing.
surgery: open reduction and pinning
Chronic:
in situ pinning
Complications of SUFE?
Avascular necrosis of femoral head
Contralateral hip SUFE
Chondrolysis: breakdown of articular cartilage
Residual proximal femoral deformity & limb length discrepancy
most common organisms of acute osteomyelitis?
staph aureus
e coli, pseudomonas, strep also common
salmonella (sickle cell)
risk factors for acute osteomyelitis
trauma
vascular disease
Sickle cell disease
immunosuppression e.g. DM
Children - rich blood supply to growth plate, usually affects metaphysis
features of acute osteomyelitis?
pain, tenderness, erythema, warmth, decreased ROM
effusion in neighbouring joints
signs of systemic infection
Ix of acute osteomyelitis?
+ve blood cultures in 60%
high WCC, raised ESR/CRP
xray: changes take 10-14d,
haziness + decreased bone density
sub-periosteal reaction
sequesterum and involucrum
MRI: sensitive and specific
Mx of acute osteomyelitis?
Antibiotics for 4-6 wks:
IV at first. Vanc + cefotaxime until MCS known
drain abscess and remove sequestra
analgesia
most common organism in septic arthritis?
staphylococcus aureus
ix for septic arthritis?
joint aspiration for MCS
Blood cultures, high WCC, high CRP/ESR
Xray of joint
mx of septic arthritis?
IV abx: vanc + cefotaxime
usually IV 2 weeks, then oral 4 weeks
consider joint washout under GA / arthroscopy to drain effusion
splint joint
physiotherapy after infection resolved
complications of septic arthritis
osteomyelitis
arthritis
ankylosis: fusion
mx of painful bony met?
radiotherapy
which type of bone mets are sclerotic instead of lytic/ radiolucent?
prostate
anatomy of brachial plexus: what muscles do the roots of the brachial plexus leave the vertebral column between?
scalenus anterior and medius
what is the brachial plexus?
C5-T1
Roots -> Trunks -> Divisions -> cords -> Terminal nerves
divisions occur under the clavicle, medial to coracoid process
plexus has intimate relationship with subclavian and brachial arteries.
(median n formed anterior to brachial artery)
what terminal nerves originate from the posterior cord, (formed from the 3 posterior divisions of the 3 trunks)?
Radial n
axillary n
what terminal nerve is formed from the lateral and medial cord?
median n
what terminal nerve is formed from the median cord only?
ulnar nerve
what terminal nerve is formed from the lateral cord only?
musculocutaneous nerve
What is Erb’s Palsy?
C5-6 affected
waiter tip position:
arm is internally rotated, adducted, extended, pronated and wrist flexed
(abductors and external rotators paralysed)
loss of sensation in C5/6 dermatomes
what is Klumpke’s paraysis?
C8-T1
paralysis of small hand muscles -> claw hand
Claw because of hyperextension of MCP and flexion of PIP joints -> due to paralysis of median 2 lumbricals
loss of sensation in C8/T1 dermatomes
How does a low lesion of a radial nerve palsy present?
ie. # around elbow or forearm (head of radius#)
posterior interosseus nerve affected
loss of extension of CMC joints (finger drop) and wrist
no sensory loss
(as sensation provided by superficial radial nerve)
what is the presentation of radial nerve palsy due to a high lesion?
ie. # of shaft of humerus
wrist drop
+ weakness of supination
Loss of sensation in posterior forearm, dorsal aspect of radial 3 1⁄2 digits
presentation of radial nerve injury due to very high lesion?
ie. axilla e.g. crutches, sat night palsy
triceps affected -> loss of extension of arm
wrist drop -> loss of extension of wrist and fingers
weakness of supination
Loss of sensation in lateral arm, posterior forearm, and dorsal aspect of radial 3 1⁄2 digits,
what are the common sites of entrapment of ulnar nerve?
elbow: cubital tunnel
wrist: Guyon’s canal
presentation of ulnar nerve injury?
claw hand -> intrinsic hand muscle paralysis
ulnar paradox: lesion at elbow has less clawing as FDP is paralysed, decreasing flexion of 4th and 5th digits
weakness of finger ad/abduction (interossei)
sensory loss over medial 1.5 fingers
what tests can you do for ulnar nerve function?
hold sheet of paper between fingers -> weak palmar interossei
Froment’s sign: flexion of thumb IPJ when trying to hold onto paper held between thumb and finger
-> indicates weak adductor pollicis
where are the common sites of injury for median nerve?
most commonly carpal tunnel syndrome
injury above antecubital fossa/ at wrist in midline (wrist laceration)
pronator syndrome: entrapment between 2 heads of pronator teres
anterior interosseous syndrome: compression of the anterior interosseous branch by the deep head of pronator teres
presentation of median nerve injury when injury occurs at wrist?
ie. wrist laceration
Weakness in flexion of radial half of digits and thumb, loss of abduction and opposition of thumb
Presence of an ape hand deformity when the hand is at rest may be likely, due to an hyperextension of index finger and thumb, and an adducted thumb
Presence of a benediction sign when attempting to form a fist, due to weakness in flexion of radial half of digits
Sensory deficit: Loss of sensation in lateral 3 1⁄2 digits including their nail beds, and the thenar area
presentation of median nerve injury when injury occurs above the antecubital fossa?
e.g. during supracondylar humeral #
motor deficit of most forearm muscles.
ie. weakness of pronation, flexion of wrist/ fingers/ thumb
ape hand deformity
hand of benediction when trying to form a fist
Sensory deficit: Loss of sensation in lateral 3 1⁄2 digits including their nail beds, and the thenar area
What does the Carpal tunnel contain?
Median Nerve
4 tendons of Flexor Digitorum Superficialis
4 tendons of Flexor Digitorum Profundus
Tendon of Flexor Pollicis Longus
what is the carpal tunnel formed by?
flexor retinaculum and carpal bones
why is sensation of the thenar area spared in carpal tunnel syndrome?
palmar branch of median n travels superficial to the flexor retinaculum
causes / risk factors of carpal tunnel syndrome
primary/ idiopathic
secondary to:
water- pregnancy, hypothyroidism
radial #
inflammation- RA, gout
soft tissue swelling- lipomas, acromegaly, amyloidosis
Toxic- DM, alcohol
symptoms of carpal tunnel syndrome?
tingling / pain in thumb, index and middle fingers
pain worse at night / after repetitive actions
relieved by shaking/ flaking
signs of carpal tunnel syndrome?
decreased sensation over lateral 3.5 fingers
decreased 2 point touch discrimination (early sign of irreversible damage)
wasting of thenar eminence (late sign of irreversible damage)
Phalen’s (flexing) and Tinel’s (tapping) +ve
Ix of carpal tunnel syndrome
Nerve conduction studies
?US wrist
Non-surgical mx of carpal tunnel syndrome?
mx of underlying case
wrist splints: use at night to keep wrist in neutral position
local steroid injections
surgical mx of carpal tunnel syndrome?
carpal tunnel decompression by division of flexor retinaculum
complications of surgical treatment of carpal tunnel syndrome?
scar formation
scar tenderness
nerve injury: motor branch to thenar muscles, palmar cutaneous branch of the median n
failure to relieve symptoms
what is the anterior interosseous syndrome?
compression of the anterior interosseous branch of median n by deep head of pronator teres
muscle weakness only:
of pronator quadratus, FPL, radial half of FDP
What is dupuytren’s contracture?
progressive, painless fibrotic thickening of palmar fascia
what is dupuytren’s contracture associated with?
idiopathic
male
middle age/ elderly
HIV
FHx
Alcholic liver disease
epilepsy meds
DM
smoking
mx of Dupuytren’s contracture?
conservative: physio/ exercises
collagenase injection
fasciectomy - z-shaped scars to prevent contracture
usually recurs
what is trigger finger?
tendon nodule which catches on proximal side of tendon sheet
-> triggering on forced extension
essentially tendon sheath too narrow for flexor tendon
usually at A1 pulley
-> fixed flexion deformity
mx of trigger finger
steroid injection
or
surgery: US-guided, using a piece of dissecting thread to transect A1 pulley without incision
what is a ganglion?
smooth, multilocular cystic swellings
filled with thick, jelly-like synovial fluid
arises from the synovial lining of joints and tendons.
may be in communication with joint capsules/ tendons
presentation of ganglion?
most common cause of lump in hand
90% located on dorsum of wrist
subdermal, fixed to deeper structures
may cause pain or nerve pressure symptoms
Mx of ganglions
50% disappear spontaneously
aspiration +/- steroid and hyaluronidase injection
surgical excision
what is meralgia paraesthetica?
tingling, numbness and burning pain in the outer part of your thigh
No motor deficit
what nerve is compressed in meralgia paraesthetica?
entrapment of lateral cutaneous nerve of thigh
(betwen ASIS and inguinal ligament)
increased risk w obesity: compression by belts, underwear
relieved by sitting down
can be damaged in laparoscopic hernia repair
what is chondromalacia patellae?
cartilage on the undersurface of the patella(kneecap) deteriorates and softens
predominantly young athletic individuals
patellar aching after prolonged sitting or climbing stairs
pain on patellofemoral compression: Clarke’s test
what is a Baker’s cyst?
Popliteal swelling arising between the medial head of gastrocnemius and semimembranosus muscle
flow of synovial fluid from the knee joint to the gastrocnemio-semimembranosus bursa, resulting in its expansion
rupture of baker’s cyst can present w?
acute calf pain and swelling
difference between hammer/ claw/ mallet toe?
what is hallux valgus
Great toe deviates laterally @ MTP joint
bunion
increased weight bearing @ 2nd metatarsal head
-> pain, hammer toe
Mx of bunions?
conservative: bunion pads, plastic wedge between great and second toes
surgical: metatarsal osteotomy
what is morton’s neuroma?
may feel as if you are standing on a pebble in your shoe or on a fold in your sock.
thickening of the tissue around one of the nerves leading to your toes
sharp, burning pain in the ball of your foot.
mx: neuroma excision
risk factors for development dysplasia of the hip?
Female gender
Breech presentation
Family history
Firstborn
Oligohydramnios
femoral n injury presentation?
loss/ weakness of
motor: Knee extension, thigh flexion
sensory: Anterior and medial aspect of the thigh and lower leg
obturator n injury presentation?
loss/ weakness of
motor: Thigh adduction
sensory: medial thigh
(mechanism: anterior hip dislocation)
Lateral cutaneous nerve of the thigh injury
presentation?
loss/ weakness of
motor: none
sensory: Lateral and posterior surfaces of the thigh
Mechanism: Compression of the nerve near the ASIS → meralgia paraesthetica, a condition characterised by pain, tingling and numbness in the distribution of the lateral cutaneous nerve
tibial nerve injury presentation?
loss/ weakness of
motor: Foot plantarflexion and inversion
sensory: sole of foot
mechanism: Not commonly injured as deep and well protected.
Popliteral lacerations, posterior knee dislocation
common peroneal nerve injury
presentation?
loss/ weakness of
motor: Foot dorsiflexion and eversion
Extensor hallucis longus
sensory: Dorsum of the foot and the lower lateral part of the leg
mechanism: Injury often occurs at the neck of the fibula
Tightly applied lower limb plaster cast
Injury causes foot drop
superior gluteal nerve injury presentation?
loss/ weakness of
motor: Hip abduction
sensory: none
Injury results in a positive Trendelenburg sign
mechanism: Misplaced intramuscular injection
Hip surgery
Pelvic fracture
Posterior hip dislocation
inferior gluteal nerve injury presentation?
loss/ weakness of
motor: Hip extension and lateral rotation (gluteus maximus)
sensory: none
mechanism: Generally injured in association with the sciatic nerve
Injury results in difficulty rising from seated position. Can’t jump, can’t climb stairs
two main fractures that lead to compartment syndrome?
supracondylar fractures and tibial shaft injuries.
symptoms and signs of compartment syndrome
Pain, especially on movement (even passive)
Parasthesiae
Pallor may be present
Arterial pulsation may still be felt as the necrosis occurs as a result of microvascular compromise
Paralysis of the muscle group may occur
swelling of limb
diagnosis of compartment syndrome?
measurement of intracompartmental pressures. Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic.
mx of compartment syndrome?
prompt and extensive fasciotomy
Myoglobinuria may occur following fasciotomy and result in renal failure -> require aggressive IV fluids
Where muscle groups are frankly necrotic at fasciotomy -> consider debridement and amputation
also give analgesia
what is a Bennett’s fracture?
Intra-articular fracture of the first carpometacarpal joint
Impact on flexed metacarpal, caused by fist fights
X-ray: triangular fragment at ulnar base of metacarpal
what is Pott’s fracture?
Bimalleolar ankle fracture
due to forced eversion
deltoid ligament affected
Red flags for lower back pain?
age < 20 years or > 50 years
history of previous malignancy
night pain
history of trauma
systemically unwell e.g. weight loss, fever
Dx of spinal stenosis?
MRI spine
Usually gradual onset
Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as ‘aching’, ‘crawling’.
Relieved by sitting down, leaning forwards and crouching down
Clinical examination is often normal
Spinal Stenosis
Typically a young man who presents with lower back pain and stiffness
Stiffness is usually worse in morning and improves with activity
Peripheral arthritis (25%, more common if female)
ankylosing spondylitis
Pain on walking, relieved by rest
Absent or weak foot pulses and other signs of limb ischaemia
Past history may include smoking and other vascular diseases
peripheral arterial disease
Features of
initially intermittent tingling in the 4th and 5th finger
may be worse when the elbow is resting on a firm surface or flexed for extended periods
later numbness in the 4th and 5th finger with associated weakness
cubital tunnel syndrome
- compression of the ulnar nerve
Swelling over the posterior aspect of the elbow. There may be associated pain, warmth and erythema. It typically affects middle-aged male patients.
olecranon bursitis
Features of
pain and tenderness localised to the lateral epicondyle
pain worse on resisted wrist extension with the elbow extended or supination of the forearm with the elbow extended
episodes typically last between 6 months and 2 years. Patients tend to have acute pain for 6-12 weeks
tennis elbow
lateral epicondylitis
Features
pain and tenderness localised to the medial epicondyle
pain is aggravated by wrist flexion and pronation
symptoms may be accompanied by numbness / tingling in the 4th and 5th finger due to ulnar nerve involvement
medial epicondylitis
Golfer’s elbow
hip dislocation results in what appearance of leg?
A shortened, internally rotated leg
neck of femur fractures result in what appearance of the leg?
shortened, externally rotated leg.
most common type of hip dislocation?
Posterior dislocation: Accounts for 90% of hip dislocations. The affected leg is shortened, adducted, and internally rotated.
Anterior dislocation: The affected leg is usually abducted and externally rotated. No leg shortening.
Central dislocation
management of hip dislocation
ABCDE approach.
Analgesia
reduction under GA within 4h to reduce the risk of avascular necrosis.
Long-term management: Physiotherapy to strengthen the surrounding muscles.
complications of hip dislocation?
Sciatic or femoral nerve injury
Avascular necrosis
Osteoarthritis: more common in older patients.
Recurrent dislocation: due to damage of supporting ligaments
complications of hip replacement?
wound and joint infection
thromboembolism: NICE recommend patients receive low-molecular weight heparin for 4 weeks following a hip replacement
dislocation
Advice to minimise hip dislocation following hip replacement?
avoiding flexing the hip > 90 degrees
avoid low chairs
do not cross your legs
sleep on your back for the first 6 weeks
post op recovery mx of pts with hip replacement?
physiotherapy and a course of home-exercises
walking sticks or crutches are usually used for up to 6 weeks after hip or knee replacement surgery
most common type of hip replacement?
cemented hip replacement.
A metal femoral component is cemented into the femoral shaft. This is accompanied by a cemented acetabular polyethylene cup
what movements are affected in frozen shoulder (adhesive capsulitis)?
external rotation is affected more than internal rotation or abduction
both active and passive movement are affected
risk factors of aspiration pneumonia?
Poor dental hygiene
Swallowing difficulties
(incompetent swallowing mechanism, ie. neurological disease or injury such as stroke, multiple sclerosis and intoxication.)
Prolonged hospitalization or surgical procedures
(ie. intubation)
Impaired consciousness
Impaired mucociliary clearance
mx of clubfoot?
(inverted, plantarflexed foot)
Ponseti method: manipulation and progressive casting which starts soon after birth. The deformity is usually corrected after 6-10 weeks. An Achilles tenotomy is required in around 85% of cases but this can usually be done under local anaesthetic
night-time braces should be applied until the child is aged 4 years. The relapse rate is 15%
what are the clinical signs of a fracture?
pain
swelling
crepitus
deformity
adjacent structural injury: nerves, vessels, ligament, tendons
Describing a # radiograph?
location: which bone, which part of bone?
pieces: simple/ multifragmentary?
pattern:
transverse/ oblique/ spiral
displaced/ undisplaced?
translated (lateral) / angulated (rotation)?
valgus vs varus
valgus: away from midline
varus: towards midline
management of shoulder dislocation?
prompt reduction is mainstay
neurovascular status must be checked pre and post reduction
X-rays pre and post reuction
recurrent anterior shoulder dislocation assoc w?
Bankart lesion
causes of posterior dislocation of shoulder?
rare, caused by seizure or electrocution
lightbulb sign
Posterior shoulder dislocation
- will also see trough line through head of humerus
For all ortho examinations, how to complete your exam?
- Examine joint above and below
- Assess neurovascular integrity
- Imaging of joint
Features of Chondromalacia patellae?
Teenage girls, following an injury to knee e.g. Dislocation patella
Typical history of pain on going downstairs or at rest
Tenderness, quadriceps wasting
Causes of carpal tunnel?
idiopathic
pregnancy
oedema e.g. heart failure
lunate fracture
rheumatoid arthritis
mx of proximal humerus fracture?
Impacted fractures of the surgical neck -> a collar and cuff for 3 weeks followed by physiotherapy
More significant displaced fractures may require open reduction and fixation or use of an intramedullary device.
Distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation
Fall onto extended and pronated wrist
Bartons fracture
Often picked up on newborn examination
Barlow’s test, Ortolani’s test are positive
Unequal skin folds/leg length
Development dysplasia of the hip
Typical age group = 2-10 years
Acute hip pain associated with viral infection
Commonest cause of hip pain in children
Transient synovitis (irritable hip)
hip pain: develops progressively over a few weeks
limp
stiffness and reduced range of hip movement
x-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening
Perthes disease
avascular necrosis of the femoral head
ages 4-8
Perthes disease is 5 times more common in boys. Around 10% of cases are bilateral
knee or distal thigh pain is common
loss of internal rotation of the leg in flexion
Typical age group = 10-15 years
More common in obese children and boys
May present acutely following trauma or more commonly with chronic, persistent symptoms
Slipped upper femoral epiphysis
Displacement of the femoral head epiphysis postero-inferiorly
Acute hip pain associated with systemic upset e.g. pyrexia. Inability/severe limitation of affected joint
Septic arthritis
Perthes disease - both femoral epiphyses show extensive destruction, the acetabula are deformed
Slipped upper femoral epiphysis - left side
most common cause of heel pain in adults?
Plantar fasciitis
The pain is usually worse around the medial calcaneal tuberosity.
Mx of plantar fasciitis?
rest the feet where possible
wear shoes with good arch support and cushioned heels
insoles and heel pads may be helpful
Failed conservative management of plantar fasciitis should lead to a referral to orthopaedics
+ Physiotherapy
what is De Quervains tenosynovitis?
the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed
pain on the radial side of the wrist
tenderness over the radial styloid process
abduction of the thumb against resistance is painful
Finkelstein’s test: with the thumb is flexed across the palm of the hand, pain is reproduced by movement of the wrist into flexion and ulnar deviation
Mx of De Quervains tenosynovitis?
analgesia
steroid injection
immobilisation with a thumb splint (spica) may be effective
surgical treatment is sometimes required
mx of Intracapsular fracture, displaced?
if pt Independently mobile, does not use more than a stick -> Total hip replacement
if pt Not independently mobile -> Hemiarthroplasty, cemented implants preferred
mx of Trochanteric fracture?
sliding hip screw
mx of Subtrochanteric fracture?
Intramedullary nail
classic sign of hip fracture?
shortened and externally rotated leg
pain
Fracture through the physis and metaphysis
Salter Harris type II
Salter Harris classification?
I: Fracture through the physis only (x-ray often normal)
II: Fracture through the physis and metaphysis
III: Fracture through the physis and epiphyisis to include the joint
IV: Fracture involving the physis, metaphysis and epiphysis
V: Crush injury involving the physis (x-ray may resemble type I, and appear normal)
Types III, IV and V will usually require surgery. Type V injuries are often associated with disruption to growth.
instructions about weight bearing after hip fracture surgery?
patient able to fully weight bear, unrestricted, immediately following surgery.
1st line pain relief for back pain?
NSAIDs + PPI
A 28-year-old professional footballer is admitted to the emergency department. During a tackle he is twisted with his knee flexed. He hears a loud crack and his knee rapidly becomes swollen.
ACL rupture
mx: intense physio or surgery
Rotational sporting injuries
Delayed knee swelling
Joint locking (Patient may develop skills to ‘unlock’ the knee
Recurrent episodes of pain and effusions are common, often following minor trauma
Menisceal tear
Teenage girls, following an injury to knee e.g. Dislocation patella
Typical history of pain on going downstairs or at rest
Tenderness, quadriceps wasting
Chondromalacia patellae
signs of meralgia parasthetica?
Symptoms may be reproduced by deep palpation just below the ASIS (pelvic compression) and also by extension of the hip.
There is altered sensation over the upper lateral aspect of the thigh.
There is no motor weakness.
mx of meralgia parasthetica?
Injection of the nerve with local anaesthetic will abolish the pain. Using ultrasound is effective both for diagnosis and guiding injection therapy in meralgia paraesthetica
Nerve conduction studies may be useful.
Anatomical neck fractures of humeral head which are displaced by >1cm carry a risk of?
avascular necrosis
severe shoulder or arm pain followed by weakness and numbness
following recent viral illness
winging of scapula common
Parsonage - Turner syndrome
autoimmune inflammation of unknown cause of the brachial plexus
two main fractures causing compartment syndrome?
supracondylar fractures and tibial shaft injuries.
diagnosis of compartment syndrome?
measurement of intracompartmental pressure measurements. Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic.
Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of fingers or toes.) They are a sign of osteoarthritis, and are caused by formation of calcific spurs of the articular cartilage.
Bouchards nodes
Typically develop in middle age, beginning either with a chronic swelling of the affected joints or the sudden painful onset of redness, numbness, and loss of manual dexterity. This initial inflammation and pain eventually subsides, and the patient is left with a permanent bony outgrowth that often skews the fingertip sideways.
affects DIP
heberdens nodes
mx of displaced intracapsular fracture if pt is v young and fit?
if <70
internal fixation and hip screw
mx of Undisplaced intracapsular fracture?
internal fixation
if major illness or not fit for surgery: hemiarthroplasty
features of Ewings Sarcoma?
Location by femoral diaphysis is commonest site
Histologically it is a small round tumour
Blood borne metastasis is common and chemotherapy is often combined with surgery
risk factors for psoas abscess?
immunosupression such as HIV, cancer and diabetes
IVDU
previous surgery
TB
sign of psoas irritation?
when the position of comfort is the patient lying on their back with slightly flexed knees.
Inability to weight bear or pain when moving the hip is usually evident.
Gold standard Ix of Psoas abscess?
MRI
most common organisms of psoas abscess?
staph aureus
streptococcus
Which of the following neurovascular structures is most likely to be compromised in scaphoid fracture?
dorsal carpal branch of the radial artery
-> avascular necrosis
signs of scaphoid fracture?
Point of maximal tenderness over the anatomical snuffbox
Wrist joint effusion: Hyper acute injuries (<4hrs old), and delayed presentations (>4days old) may not present with joint effusions.
Pain elicited by telescoping of the thumb (pain on longitudinal compression)
Tenderness of the scaphoid tubercle (on the volar aspect of the wrist)
Pain on ulnar deviation of the wrist
Ottawa ankle rules for Xrays?
x-rays are only necessary if there is pain in the malleolar zone and:
- Inability to weight bear for 4 steps
- Tenderness over the distal tibia
- Bone tenderness over the distal fibula
Weber classification of ankle fractures?
Type A is below the syndesmosis
Type B fractures start at the level of the tibial plafond and may extend proximally to involve the syndesmosis
Type C is above the syndesmosis which may itself be damaged
Which of the following is the most appropriate method of analgesia for a NOF fracture?
1st line: iliofascial nerve block
Local anaesthetic injected into this potential space affects the femoral, obturator and lateral femoral cutaneous nerves.
what is the ulnar paradox?
ulnar nerve also innervates the ulnar half of the FDP. If the ulnar nerve lesion occurs more proximally (closer to the elbow), the FDP muscle may also be denervated.
-> flexion of the IP joints is weakened, which reduces the claw-like appearance of the hand(Instead, the fourth and fifth fingers are simply paralyzed in their fully extended position.)
This is called the “ulnar paradox” because one would normally expect a more proximal and thus debilitating injury to result in a more deformed appearance.
May be acute or chronic
lower back Pain worse in the morning and on standing
On examination there may be pain over the facets.
The pain is typically worse on extension of the back
Facet joint pain
more common in the thumb, middle, or ring finger
initially stiffness and snapping when extending a flexed digit
a nodule may be felt at the base of the affected finger
Trigger finger
caused by a disparity between the size of the tendon and pulleys through which they pass
-> tendons become stuck and cannot pass through smoothly
Associations of trigger finger?
women > men
rheumatoid arthritis
diabetes mellitus
Mx of trigger finger?
steroid injection is successful in the majority of patients. A finger splint may be applied afterwards
surgery should be reserved for patients who have not responded to steroid injections
most common reason total hip replacements need to be revised?
Aseptic loosening
(then pain, dislocation, infection)
appearance of the leg in posterior hip dislocation?
Accounts for 90% of hip dislocations. The affected leg is shortened, adducted, and internally rotated.
Knavel’s signs of flexor tendon sheath infection?
fixed flexion, fusiform swelling, tenderness and pain on passive extension
surgical emergency and requires prompt recognition and treatment
mx: medical w abx and elevation, most pts require surgical debridement
On examination she has swelling of the entire digits that stops at the distal palmer crease and holds the finger in strict flexion. There is pain on palpation and passive extension of the digit.
Infective flexor tenosynovitis
Kienbock’s disease
increased density of the lunate, which also has an abnormal shape due to partial collapse. These are relatively advanced features of avascular necrosis (AVN), also known as Kienbock’s disease when it occurs in the lunate.
Neuropathic joint
destruction of the ankle joint, fragmentation of the talus, deformity of the ankle and hind foot, increased sclerosis of the affected bones, and some periarticular debris.
e.g. Charcot marie tooth, diabetic neuropathy
Rheumatoid arthritis – hands
Here we see extensive fusion (ankylosis) at both wrists – all of the carpal bones have fused. The patient has had previous joint replacements at the right 2nd, 3rd and 4th MCP joints, while on the left you can see erosions at the MCP joints, with ulnar subluxation.
Osteoarthritis – hip
This case of severe osteoarthritis of the right hip is a nice example of joint space loss, marked sclerosis on both sides of the joint and very large subchondral cysts – but there is no osteophytosis.
features of fat embolus?
Triad of symptoms:
Respiratory:
Early persistent tachycardia
Tachypnoea, dyspnoea, hypoxia usually 72 hours following injury
Pyrexia
Neurological:
Confusion and agitation
Retinal haemorrhages and intra-arterial fat globules on fundoscopy
Petechial rash (tends to occur after the first 2 symptoms):
Red/ brown impalpable petechial rash (usually only in 25-50%)
Subconjunctival and oral haemorrhage/ petechiae
Osgood-Schlatter Disease
well-corticated bone fragments in front of the tibial tuberosity
in the patellar tendon and are due to an inflammatory process called Osgood-Schlatter disease at the junction between the tendon and bone,
rheumatoid arthritis
There is symmetric erosion of the metacarpal heads in this patient with severe ulnar subluxation of the MCP joints due to rheumatoid arthritis. Note also the abnormal appearance of the fifth fingers due to Boutonniere deformities – the proximal interphalangeal joints are flexed while the DIP joints are extended.
simmonds test +ve?
Achilles tendon rupture
performed by asking the patient to lie prone with their feet over the edge of the bed. The examiner should look for an abnormal angle of declination. They should also feel for a gap in the tendon and gently squeeze the calf muscles if there is an acute rupture of the Achilles tendon the injured foot will stay in the neutral position when the calf is squeezed.
Calcaneal spur
occur at the origin of the plantar fascia and usually represent the result of longstanding traction in patients with plantar fasciitis.
features of L3 nerve root compression?
Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
features of L4 nerve root compression?
Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
features of L5 nerve root compression?
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
features of S1 nerve root compression?
Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test
Developmental dysplasia of hips
The acetabula in this patient are shallow, and are slanting superiorly. The right femoral head is not completely covered by the acetabulum, indicating dysplasia, while the left is even more severe and has resulted in dislocation of the femoral head.
Dupeytren’s contracture. The fixed flexion deformity of the fifth finger in this patient is due to palmar fibromatosis, better known as Dupeytren’s contracture.
initial imaging modality of choice for suspected Achilles tendon rupture?
US ankle
what condition is assoc w frozen shoulder?
diabetes mellitus: up to 20% of diabetics may have an episode of frozen shoulder
In children what is the most common site where osteomyelitis occurs in a long bone?
metaphysis
as it is a highly vascular area.
In adults it tends to be the epiphysis.
what abx may cause tendon rupture?
ciprofloxacin
Mx of grade I to II acromioclavicular joint injury?
conservative: rest joint w sling
Mx of Grade IV, V, VI AC joint injury?
surgical intervention
monitoring of SLE disease activity?
ESR high during active disease
C3/4 low during active disease
anti-dsDNA titres
Management of patients at risk of corticosteroid-induced osteoporosis
age <65, T score > 0?
reassure
Management of patients at risk of corticosteroid-induced osteoporosis
age <65, T score between 0 and -1.5
Repeat bone density scan in 1-3 years
Management of patients at risk of corticosteroid-induced osteoporosis
age <65, T score < -1.5?
Offer bone protection
Management of patients at risk of corticosteroid-induced osteoporosis
if age >65, previous fragility fracture?
offer bone protection
mx of ank spond after oral NSAIDs have failed to improve symptoms?
anti-TNFa
e.g. etanercept
allopurinol has a significant interaction w?
azathioprine.
both inhibitors of xanthine oxidase, causing bone marrow suppression.
