Trauma and Orthopaedics Flashcards
Outline the Salter-Harris Classification, who it’s used for and the rough classifications
A method used to grade fractures that occur in children and involve the growth plate
Type 1 – transverse fracture through the growth plate
Type 2 (most common) – fracture through the growth plate and the metaphysis
Type 3 – fracture through growth plate and epiphysis, sparing the metaphysis
Type IV – A fracture through all three elements of the bone, the growth plate, metaphysis, and epiphysis
Open fracture (any site including the hand) - answer the following:
- General pathology and mechanism of injury?
- Common presenting symptoms?
- Examination findings (signs)?
- Classification system used?
- Management?
- Complications?
General pathology and mechanism of injury:
- Fracture with break in the skin near the site of the broken bone
- Caused by a fragment of bone breaking through the skin at the moment of the injury
- Generally high energy trauma e.g. RTA or gunshot wound
- Need to ask about contamination
Common presenting symptoms:
- Pain
- Visible deformity
- Reduced use of limb/joint
Examination findings (signs):
- Open wound on exposure
- May have neurovascular compromise
Classification system:
- Gustilo-Anderson classification
Management:
- Early broad-spectrum antibiotics
- Surgical debridement within 24 hours (sooner if contaminated)
- Bone realignment and splinting (internal or external)
- Check tetanus vaccination status
Complications:
- Infection / sepsis
- Scarring
- Malunion
Outline the Gustilo-Anderson classification for open fractures
Suggest how it impacts management
Type 1: <1cm wound and clean
Type 2: 1-10cm wound and clean
Type 3A: >10cm wound and high-energy, but with adequate soft tissue coverage
Type 3B: >10cm wound and high-energy, but with inadequate soft tissue coverage
Type 3C: All injuries with vascular injury
Management:
3A managed by orthopaedics alone
3B requires plastics input
3C requires vascular input
Fractured neck of femur (intracapsular) - answer the following:
- General pathology and mechanism of injury?
- Risk factors?
- Common presenting symptoms?
- Examination findings (signs)?
- Classification system used?
- Differentials?
- Management?
- Complications?
- Expected outcomes?
General pathology and mechanism of injury:
- Fracture of the femoral neck proximal to the intertrochanteric line
- Low energy fall in the elderly
- High energy trauma in the young e.g. dashboard injury
Risk factors:
- Osteoporosis
- Any factors which increase falls risk e.g. poor eyesight, confusion
Common presenting symptoms:
- Pain
- Inability to weight bear
- Reduced ROM
Examination findings (signs):
- Shortened and externally rotated limb
- Reduced ROM
Classification system:
- Garden classification:
Differentials:
- Extracapsular neck of femur fracture
- Severe hip osteoarthritis
- Femoral shaft fractures
- Septic arthritis of the hip
Management:
Non-displaced (Grade 1 and 2) - urgent internal fixation with plates/screws
Displaced (Grade 3 and 4) - hemiarthroplasty
Also early mobilisation
Complications:
- Malunion
- DVT
- Avascular necrosis
- Hemiarthroplasty dislocation
Expected outcomes:
- High mortality rate (10% after 1 yr, 20% after 2 yrs)
Outline the classification used for intracapsular NOF fractures and how the results influence management
Grade 1 – incomplete and in-situ
Grade 2 – complete and in-situ
Grade 3 – incomplete and displaced
Grade 4 – complete and displaced
Grade 1 and 2 - blood supply likely to be intact, can use internal plates and screws
Grade 3 and 4 - blood supply unlikely to be intact, needs either a hemi-arthroplasty or THR
Fractured neck of femur (extracapsular) - answer the following:
- General pathology and mechanism of injury?
- Risk factors?
- Common presenting symptoms?
- Examination findings (signs)?
- Classification system?
- Differentials?
- Management?
- Complications?
- Expected outcomes?
General pathology and mechanism of injury:
- Occur between the greater and lesser trochanter, either on the intertrochanteric line or less than 5cm below it
- Low energy fall in the elderly
- High energy trauma in the young e.g. dashboard injury
- Twice as common as intracapsular fractures
Risk factors:
- Osteoporosis
- Any factors which increase falls risk e.g. poor eyesight, confusion
Common presenting symptoms:
- Pain
- Inability to weight bear
- Reduced ROM
Examination findings (signs):
- Shortened limb and less likely to be externally rotated
- Reduced ROM
Classification system:
- No classification system
Differentials:
- Intracapsular neck of femur fracture
- Severe hip osteoarthritis
- Femoral shaft fractures
- Septic arthritis of the hip
Management:
- Intertrochanteric fracture - Dynamic hip screw
- Subtrochanteric fracture - Intramedullary nail
Complications:
- Malunion
- DVT
- Fat emboli
Expected outcomes:
- Presence of a hip fracture increase mortality for the first year but after this period levels return back to near normal
Wrist fracture - answer the following:
- General pathology and mechanism of injury?
- Risk factors?
- Common presenting symptoms?
- Examination findings (signs)?
- Differentials?
- Management?
- Complications?
- Expected outcomes?
General pathology and mechanism of injury:
- Commonly refers to a distal radius fracture
- FOOSH is most common mechanism of injury
- High-energy trauma in young people e.g. fall from a ladder
- Low energy trauma in old people
Risk factors:
- Bimodal (extremes of young and old)
- Osteoporsis
Common presenting symptoms:
- Pain or tenderness
- Reduced ROM
Examination findings (signs):
- Bruising
- Swelling
- Joint deformity
Differentials:
- Scaphoid fracture - emergency
- Ligament damage / tendon rupture
Management:
- Stable and undisplaced = cast
- Stable and displaced = closed reduction then cast
- Unstable and displaced = closed reduction and K wire fixation or open reduction and plates
Complications:
- Post traumatic osteoarthritis
- Neurovascular complications e.g. medial nerve injury
- Malunion
- Compartment syndrome
Expected outcomes:
- 3 months to heal to return to all activities
- Full recovery can take up to 1 year
Ankle fracture - answer the following:
- General pathology and mechanism of injury?
- Risk factors?
- Common presenting symptoms?
- Examination findings (signs)?
- Classification system?
- Differentials?
- Management?
- Complications?
- Expected outcomes?
General pathology and mechanism of injury:
- Damage to either medial or lateral malleolus (tibia or fibula)
- Caused by a twisting mechanism
Risk factors:
- Bimodal distribution
- Obesity
- Smoking
- Alcohol consumption
Common presenting symptoms:
- Ankle pain
- Reduced ability to weight bear
Examination findings (signs):
- Swelling / redness
- Ankle deformity
- Reduced ROM
Classification system:
Danis-Weber (location of fibular fracture):
Differentials:
- Ankle sprain
- Subtalar dislocation
- Achilles tendon rupture
Management:
- Displaced fracture - reduce immediately and back slab
- Stable fracture (no talar shift) - immobilise with a cast/splint/boot below the knee for 6 weeks and x-ray after cast to check position
- Unstable fracture (talar shift) - fixation with a cast below the knee for 6 weeks
Complications:
- Malunion
- Post-traumatic arthritis
- Ankle stiffness
- DVT
- Neurovascular injury (if displaced)
- Infection (if open)
Expected outcomes:
- 90% mild/no ankle pain with minimal limitations and near full functional recovery at 1 year
Outline the classification used for ankle fractures, briefly describing each of the classifications and how it affects management
Danis-Weber classification
A - Below syndesmosis
B - At syndesmosis
C - Above syndesmosis (almost always need surgical fixation)
The more proximal the injury, the higher the likelihood of ankle instability
Therefore, Type C fractures almost always need surgical fixation
Tibial fracture - answer the following:
- General pathology and mechanism of injury?
- Common presenting symptoms?
- Examination findings (signs)?
- Differentials?
- Management?
- Complications?
- Expected outcomes?
General pathology and mechanism of injury:
- Either transverse/oblique or spiral fracture
- Transverse/oblique from direct blow, whereas spiral fracture from torsion/twisting
- Generally high energy trauma but can be low energy if elderly
Common presenting symptoms:
- Pain
- Inability to weight bear
Examination findings (signs):
- Deformity
- Swelling
- Bruising
- Look out specifically for compartment syndrome
Differentials:
- Soft tissue damage
- MSK injury e.g. muscle damage
- Nerve injury leading to pain
- DVT / underlying condition
Management:
- Reduction under analgesia and above knee backslab to control rotation
- Can consider non-surgical stabilisation with Sarmiento cast, but usually do surgery
- Generally requires surgery with intramedullary nail (or locking plates if quite proximal/distal)
Complications:
- Higher risk of compartment syndrome
- Anterior knee pain
- Malunion
- Malrotation
- Nerve injury
Expected outcomes:
- 4-6 months to heal completely
Osteoarthritis - answer the following:
- General pathology?
- Risk factors?
- Common presenting symptoms?
- Examination findings (signs)?
- Differentials?
- Management?
General pathology:
- Imbalance of the wearing down of cartilage and the repair of the cartilage by chondrocytes leading to cartilage destruction and imperfect cartilage regeneration
- General wear and tear over time
Risk factors:
- Obesity
- Age
- Previous trauma
- Overuse of joint / occupation
- Family history
Common presenting symptoms:
- Stiffness (worse at end of day)
- Pain (can be referred to adjacent joint!)
- Reduced range of movement
Examination findings (signs):
- Crepitus
- Reduced range of movement
- Effusions around the joint
- Bony enlargement of the joint
Differentials:
- Rheumatoid arthritis
- Fracture / ligament damage
- Septic joint
- Osteoarthritis of adjacent joint (not where complaint of pain is from)
Management:
Holistic approach!
- Weight loss if obese
- Physiotherapy / occupational therapy
- Analgesia (oral NSAIDs if knee OA, if any other joint then topical NSAIDs with Paracetamol as an adjunct if needed)
- Intra-articular corticosteroid joint injections
- Joint replacement / surgery
Fat Embolism - answer the following:
- Common cause and pathophysiology?
- Potential syndrome resulting from this including the triad of signs?
- What can be done to reduce risk of syndrome?
Common cause and pathophysiology:
- Fracture of long bones e.g. femur, causes release of fat into the circulation which can then become lodged in distal vessels and cause blood flow obstruction
Potential syndrome resulting from this and the triad of signs:
Fat embolism syndrome
1. Respiratory distress
2. Cerebral involvement
3. Petechial rash
What can be done to reduce risk of syndrome:
- Operate early to fix the fracture
State the management for the different types of hip fracture:
Intracapsular fracture (undisplaced)
Intracapsular fracture (displaced)
Extracapsular fracture (intertrochanteric)
Extracapsular fracture (subtrochanteric)
Describe the indications of use for hemiarthroplasty vs total hip replacement
Intracapsular fracture (undisplaced)
- Form of internal fixation to hold femoral head in place during healing (don’t need to replace femoral head)
Intracapsular fracture (displaced)
- Replacement of femoral head as high risk of avascular necrosis
Extracapsular fracture (intertrochanteric)
- Dynamic hip screw which both applies compression and ensures alignment during healing
Extracapsular fracture (subtrochanteric)
- Intramedullary nail
Hemiarthroplasty is performed if patient is not fully mobile or has significant co-morbidities. If the patient is fully mobile and fit for surgery, then a total hip replacement is generally used
Acute Compartment Syndrome - answer the following:
- Pathophysiology and common causes?
- Presentation?
- Management?
Pathophysiology and common causes:
- Where pressure within a fascial compartment is abnormally elevated which reduces blood flow to tissues within the compartment
- Commonly caused by fractures or crush injuries
Presentation:
5 Ps
- Pain (disproportionate to injury)
- Pale
- Paraesthesia
- Pressure (high)
- Paralysis (late and worrying sign)
Plus pulseless but does not help discriminate from acute limb ischaemia
Management:
- Emergency fasciotomy
Osteomyelitis - answer the following:
- Pathophysiology?
- Risk factors?
- Presentation?
- Investigations?
- Management?
Pathophysiology:
- Bacterial or fungal infection of the bone and bone marrow, which can be acute or chronic
- Can be from haematogenous spread in the blood or from direct contamination
Risk factors:
- Orthopaedic surgery
- Open fracture
- Peripheral arterial disease
- Diabetes
- Immunosuppressed
- IV drug use
Presentation:
- Severe pain / tenderness
- Fever
- Swelling
- Redness / erythema
- May be unable to weight bear
Investigations:
- Definitive diagnosis = MRI
- Gold standard = bone biopsy during debridement
- Plain x-ray (can’t exclude a diagnosis, but might see some changes on x-ray indicating osteomyelitis)
- Blood cultures
Management:
- Long-term antibiotics e.g. 6 weeks of Flucloxacillin
- May need surgical debridement of infection bone/tissue, if progressive or patient clinically unwell
List some complications of osteomyelitis
- Chronic osteomyelitis
- Osteonecrosis
- Sepsis
- Associated septic arthritis or soft tissue infections
- Recurrence of infection
- Children may develop growth disturbances
Outline common organisms causing osteomyelitis
S. aureus (most common)
Haemophilus influenzae
Streptococci
Pseudomonas aeruginosa
Salmonella
Cauda equina syndrome - answer the following:
- Pathophysiology?
- Causes?
- Red flag symptoms?
- Management?
Pathophysiology:
- Results from compression of the cauda equina (after the spinal cord terminates at L2/L3)
- Normally, nerve roots of the cauda equina supply:
1. Sensation to the perineum, bladder and rectum
2. Motor innervation to the lower limbs (past the knee) and the urethral/anal sphincters
3. Parasympathetics to the bladder and rectum
Causes:
- Herniated disc
- Cancer tumours (metastasis)
- Spondylolisthesis
- Abscess
- Spinal trauma
Red flag symptoms:
- Bilateral sciatica
- Perianal numbness
- Urinary retention or incontinence
- Faecal incontinence
- Loss of bladder or bowel sensation
- Erectile dysfunction
Management:
- Emergency MRI to confirm or exclude
- Emergency surgical decompression
Explain how Cauda equina syndrome is different from Metastatic spinal cord compression (MSCC) and how they present differently
Cauda equina syndrome is compression of the nerve roots at the cauda equina (for many different reasons)
Whereas Metastatic spinal cord compression is compression before the end of the spinal cord and the start of the cauda equina from a metastasis tumour of cancer
Presentation:
- Metastatic spinal cord compression has back pain that’s worse on coughing or straining
- MSCC tends to present with upper motor neurone symptoms, whereas cauda equina tends to present with lower motor neurone symptoms
Spinal stenosis - answer the following:
- Pathophysiology and 3 types?
- Causes?
- Presentation?
- Investigations?
- Management?
Pathophysiology:
- Refers to narrowing of the spinal canal leading to compression of the spinal cord at either the cervical or the lumbar level (lumbar is more common)
3 types:
1. Central stenosis
2. Lateral stenosis
3. Foramina stenosis
Causes:
- Congenital spinal stenosis
- Herniated disc
- Degenerative changes
- Thickening of ligamentum flavum or PLL
- Spondylolithesis
- Tumour
- Abscess
Presentation:
- Gradual onset
If central stenosis - then key presenting feature: intermittent neurogenic claudication:
- Lower back pain which improves on flexion of back but worsens on extension
- Buttock and leg pain
- Leg weakness (difficultly walking)
If lateral or foramina stenosis - sciatic is more commonly the presenting feature
Investigations:
- MRI
- May need investigations to exclude peripheral arterial disease
Management:
- Exercise / weight loss
- Physiotherapy
- Analgesia
- Decompression surgery if above does not work
Explain how you can differentiate between spinal stenosis and peripheral arterial disease?
Spinal stenosis:
- More likely to struggle with back pain
- Ankle-brachial pressure index is more likely to be normal
Peripheral arterial disease:
- Back pain is much less likely to be an issue
- Ankle-brachial pressure index is likely to be abnormal
Meralgia Paraesthetica - answer the following:
- Pathophysiology?
- Causes?
- Presentation?
- Investigations?
- Management?
Pathophysiology:
- Impingement of the lateral femoral cutaneous nerve leading to purely sensory symptoms in the nerve territory
Causes:
- Tight clothing
- Tool belts
- Obesity
- Pregnancy
Presentation:
- Patients can present with either abnormal sensations (dysaesthsia) or absent sensations (paraesthesia) of the lateral thigh on the affected nerve side
- Sensations can include: burning, tingling, cold sensation or numbness
Investigations:
- Generally diagnosis made on clinical picture
- May need to rule out more sinister causes with imaging
Management:
Varies based on suspected cause
Conservative:
- Exercise / weight loss
- Physiotherapy
- Rest
Medical:
- Analgesia
- NSAIDs
- Local steroid or analgesia injections
Surgery:
- Decompression surgery
- Transection or resection of nerve
Trochanteric bursitis - answer the following:
- Pathophysiology?
- Causes?
- Presentation?
- Which hip movements are restricted?
- Management?
- Recovery time?
Pathophysiology:
- Inflammation of the bursa over the greater trochanter of the femur, leading to thickening of the synovial membrane and increased fluid production
Causes:
- Repetitive use
- Trauma
- Infection (would be septic bursitis)
- Inflammatory conditions e.g. RA
Presentation:
- Gradual onset pain over the outer hip, can radiate down outer thigh
- Pain described as burning or aching
- Pain worse on exercise / on standing after sitting for a long time / on sitting cross legged / can’t lie on affected side
Which hip movements are restricted?
1. Trendelenburg test
2. Resisted abduction
3. Resisted internal rotation
4. Resisted external rotation
Management:
- Rest
- Analgesia
- Ice
- Physiotherapy
- Steroid injections
- If suspect infection, would need antibiotics
Recovery:
- Around 6-9 months to recover fully
