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 developmental hip dysplasia?
Pavlik harness
or
Reduction: (if baby > 6mo)
Closed/ Open
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
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 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
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
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
surgical mx of carpal tunnel syndrome?
carpal tunnel decompression by division of flexor retinaculum
What is dupuytren’s contracture?
progressive, painless fibrotic thickening of palmar fascia
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
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
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
difference between hammer/ claw/ mallet toe?
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
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
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
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
recurrent anterior shoulder dislocation assoc w?
Bankart lesion
lightbulb sign
Posterior shoulder dislocation
- will also see trough line through head of humerus
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
Perthes disease - both femoral epiphyses show extensive destruction, the acetabula are deformed
Slipped upper femoral epiphysis - left side
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
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.
mx of displaced intracapsular fracture if pt is v young and fit?
if <70
internal fixation and hip screw
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
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.
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.
Calcaneal spur
occur at the origin of the plantar fascia and usually represent the result of longstanding traction in patients with plantar fasciitis.
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.
