Trauma and Orthopaedics Flashcards
What is Mallet finger?
Rupture of extensor tendon at DIPJ
What is gamekeepers thumb?
Hyperabduction of thumb - ruptures ulnar collateral ligament. Unstable
What is Karnavels signs (4) and what do they show (1)?
- Tenderness over flexor tendon
- Symmetrical swelling of finger
- Finger held in flexion
- Extreme pain on passive extension
Pyogenic flexor tenosynovitis
Flexor sheath infection
What is a clue towards lunate dislocation?
Median nerve parasthesia
What is Bartons/reverse Bartons #?
Intra-articular # involving only dorsal or volar portion of distal radius.
What is triangular fibrocartilage complex injury? (TFCC)
Distal end of ulnar, often thought to be simple sprain but doesn’t heal. Needs MRI
What is de Quervains Tenosynovitis?
Inflammation of sheath of abductor pollicis longus and extensor pollicis brevis. Pain/swelling lateral aspect of radial styloid
What is Finkelsteins test?
Clench thumn in fist and move ulnar-ward.
Positive test - de Quervains tenosynovitis
What is a Galeazzi # dislocation?
Middle/distal radius # and dislocation of distal radio-ulnar joint
What is a Monteggia # dislocation?
ulnar and dislocation of radial head
What can be damaged in both supracondylar #s and dislocated elbows? (2)
- Brachial artery
- Median/ulnar/radial artery
What is tennis elbow?
Lateral epicondylitis
Repetitive stress of extensors on lateral condyle
What is golfers elbow?
What can it lead to?
- Medial epicondylitis
Repetitive stress of flexors on medial condyle - Reduced grip strength secondary to ulnar neuritis
Describe the 3 grades of AC disruption
- Minimal
- Obvious subluxation but still some opposition
- Complete disruption
What part of the pelvis usually #s in hip dislocation?
Acetabulum
What nerve can be damaged in a hip dislocation and how do we test for it?
- Sciatic
- Dorseflexion foot and sensation below knee
In a # coccyx what should be done to check for further injury?
PR to check for rectal tear
What are Shentons Lines?
What does their disruption mean?
- Imaginary line from inferior border of superior pubic symphysis and along inferiomedial border of NOF
- NOF#
What are the Garden criteria? (4)
- # line not though both cortex
- # line through both cortex
- Mild displacement
- Displaced
What does NICE recommend as first line imaging for NOF# if can occur < 24 hours
MRI
What are the Ottawa knee rules? (4)
1 of the following:
1. Isolated patellar tenderness
2. Unable to flex to 90 degrees
3. Bony tenderness over fibula head
4. Unable to WB at time of injury and now
What are postero-lateral corner injuries?
Group of ligaments/tendons/muscles which when damaged can lead to a chronically unstable knee joint
What are anterior cruciate ligament injuries associated with? (2)
- ‘pop’
- medial collateral ligament or medial meniscus injury
What are the 3 grades of collateral ligament injury?
- Tenderness but no laxity
- laxity but definitive end point
- Major laxity and not end point - needs POP
What is a Maisonneuve #?
Transmitted forces from ankle injury leads to proximal fibula #
What is the test called for Achilles tendon rupture?
Simmonds/Thomas test
What is the managment of a Achilles tendon rupture?
Equinus cast
What are the Ottawa ankle rules?
- Unable to WB immediately after and now
- Tenderness of posterior medial or lateral malleolus
Describe the Weber ankle classification
A - below syndesmosis and stable
B - at the level, can be either
C - above the level of syndesmosis and unstable
What is Bohlers angle and what value should it be?
For assesssing calcaneal #s
35-40 degrees
How to we check for a Lisfranc injury?
Ensure medial side of second metatarsal aligns with medial side of medial cuneiform
What is Jones #?
Transverse # just distal to inter MT joint - prone for non-union
What is Perthes disease?
Aseptic necrosis of the upper femoral epiphysis
Who does Perthes disease affect most commonly? (2)
- M>F
- 3-10 years
What will an XR of Perthes disease show?
Increase bone density
Fragmentation/flattening of upper femoral epiphysis
What might an US show in a child with transient synovitis?
Effusion
Who tends to get SUFEs? (4)
- M:F = 3:1
- 10-16yrs
- Fat/hypogonadism
- Tall/skinny with rapid growth
How do patients with SUFE present?
Gradual limp
Often hx trauma
Legs maybe abducted and short/externally rotate
What type of XR is required for SUFE and what is the eponymous sign?
- Frogs leg
- Trethowans sign
Describe the Salter Harris classifcation
Which Salter Harris fractures are at most risk of premature growth plate fusion?
- I/II low risk
- III - moderate
- IV/V - high risk
What is the the order of the elbow ossification?
Capitellum
Radial head
Internal (med) epicondyle
Trochlea
Olecranon
External (lat) epicondyle
1yr - 11 yrs
What is Toddlers #
Minor trauma 1-4 years leading to a spiral undisplaced # of the distal tibia.
XR may be normal, if suspected POP and clinic review in 10 days
Which #s are suspicious of NAI? (4)
- Rib/spinal #s
- Long bone < 3years
- Epiphyseal seperation + metaphyseal ‘chip’ knees/wrist/ankles - shaking
- Multiple #s of different ages
What are the indications for immediate CTH in children? (8)
- ? NAI
- Seizure
- GCS <14 at presentation
- GCS <15 at 2 hours
- ? skull # / tense fontanelle
- Basal skull # signs
- Focal neurological deficit
- Bruising/swelling >5cm in <1years
What are the risk factors that may require observation in paeds head injurys? (5)
- LOC >5mins
- Amnesia > 5 mins
- Abnormal drowsiness
- 3 or more vomits
- Dangerous MOI
If a child has one risk factor following head injury what should be their management?
4 hours observation
If a child has more than one risk factor following head injury what should be done?
CTH < 1hour
What are the indications for CT neck over XR neck in kids? (7)
- GCS <15
- I+V
- Needs rapid definitive diagnosis i.e. theatre
- Polytrauma requiring other body parts CT
- Peripheral neuro signs
- Parasthesia upper/lower limbs
- XR normal but ongoing concerns
What is the primary modality for chest imaging in paediatric trauma?
XR
What 2 circumstances require CT chest in paeds trauma?
- Penetrating trauma
- Severe blunt trauma
What is the imaging recommended for high suspicion of spinal injury in children?
XR and MRI
(CT if unable to perform MRI)
What are 6 risk factors for needing CT abdomen in paeds trauma?
- Abdominal wall bruising
- Lap belt injury
- Abdominal tenderness
- Abdominal distension
- Persistent hypovolaemia
- PR or NG blood
What is the imaging of choice for paeds pelvic injuries?
CT
Pelvic XR as primary survey not recommended
What are the increased risk factors needing imagine in the Canadian c-spine rules? (3)
- Over 65years
- Dangerous MOI
- Parasthesia in the extremities
What constitutes a dangerous MOI in the Canadian C-spine rules? (5)
- Fall over 3 foot or 5 stairs
- Axial load to head
- High speed MVC (>100kmph)/rollover/ejection
- Motorised recreational vehicles
- Bicycle collision
What are the low risk factors in the Canadian C-Spine rules? (5)
- Simple rear end shunt
- Sitting position in ED
- Walking at any point
- Delayed onset neck pain
- Absence of midline tenderness
How many low risk factors do you need to avoid imaging in the Canadian C-spine rules?
1
What is the final step in the Canadian C-Spine rules?
Can they rotate their neck 45 degrees left to right
What are the indications for immediate CTH in adults? (7)
- GCS <13
- GCS <15 after 2 hours
- Open/suspected skull #
- Signs basal skill #
- Seizure
- Focal neurology
- More than 1 vomit
Within what period should patients on anticoagulation have a CTH according to NICE?
8 hours
If an adult patient has no indication for CTH immediately and is not on anticoagulation, what is the next question to be asked?
Any LOC or amnesia - if no then no imaging
If yes move onto risk factors
What are the risk factors used to determine whether a patient needs a CTH within 8 hours who have had a LOC or amnesia? (4)
- Over 65years
- Hx bleeding/clotting disorder
- Dangerous MOI
- > 30mins retrograde amnesia (events before injury)
What is Chance #? (2)
Spinal # through body + pedicle + posterior elements of vertabrae - 3 column
Usually thoracolumbar
How are Chance #s normally caused?
Hyperflexion
Classically lap seat belt
3 column injury
What does a Chance # look like on XR?
2 spinous processed excessively apart
How is a tear drop # caused?
Severe flexion and compressive forces i.e diving
What is a tear drop # ?
anteroinferior lip of vertebrae
What other structures are damaged in a tear drop #? (3)
1, Posterior ligamentous injury/rupture
2. Can lead to subluxation and retropulsion and cord damage
3. Anterior cord syndrome common
What mechanism causes odontoid peg #s? (2)
Either hyperextension or hyperflexion
In which 2 types of injury are odontoid peg #s typically seen?
- Low energy falls in elderly
- High impact in young
What are the 3 types of odontoid peg #?
1 - tip of odontoid process avulsed
2 - base of process # secondary to extensive extension
3 - # though body of C2
Which odontoid #s are not stable?
II
What mechanism causes most spinal #s?
Flexion/rotation
What is a clay shovellers #
Avulsion C6/7 from spinous process
What mechanism causes a Hangmans #
Hyperextension through C2 pedicles
What is a Hangmans #?
though both pedicles of C2
What does a Hangmans # normally show on XR?
C2 moves forward over C3
What is a Jeffersons #?
Burst # of Atlas
Anterior and posterior arches of C1
What can Jeffersons # lead to? (4)
Vascular damage leading to:
1. Horners syndrome (proptosis/miosis/anhidrosis)
2. Ataxia
3. Lateral medullary sydrome
Commonly no neurology
In which group is SCIWORA more common?
Children (around 30%)
Describe the 3 columns in the 3 column spinal theory
Anterior column - anterior longitudinal ligmaent, anterior 1/2 of vertebral body
Middle column - posterior ligament, posterior half of vertebral body
Posterior column - everything posterior to vertebral ligament - neural arch, facet joints etc.
Which column is the most important for the spines stability?
Middle
Posterior also unstable
How much prevertebral swelling should you see above C4?
< 1/3 adjacent vertebral body or <7mm
How much prevertebral swelling should you see C4 or below?
No larger than the width of one whole vertebral body or <22 mm
Give 3 clinical features of an orbital blow out #
If inferior rectus involved
- Unable to look up
- Diplopia
What can happen as a consquence of an orbital blow out
#?
- Inferior rectus can become trapped leading to ischaemia and diplopia
What sign maybe on facial XR to suggest orbital blow out #?
Tear drop sign
What is a sign that a nasal # has lead to nasoethmoidal #?
CSF in rhinorrhoea
What can occur following a zygomatic arch #?
Temporalis muscle can become trapped leading to trismus
What can ZMC #s lead to?
Infra-orbital nerve damage
- Lower eyelid
- lateral nose
- upper lip
What does damage to infra-orbital nerve lead to and what can cause it?
Numb cheek and upper lip
ZMC #s
What are the risk factors than mandate a CTH in patients who have had a LOC/amnesia? (4)
- Over 65 year
- Any bleeding or clotting disorder
- Dangerous MOI
- More than 30 mins retrograde amnesia (before event)
Within 8 hours
What nerve causes meralgia paresthesia?
Lateral cutaneous nerve
What nerve is involved in tarsal tunnel syndrome?
Tibial nerve
Where does the compression occur in tarsal tunnels syndrome?
As the tibial nerve passes through tarsal tunnel (flexor retinaculum provides roof) - posterior to medial malleolus
What are the symptoms of tarsal tunnel syndrome?
Pain radiating from ankle to foot/toes
Describe the 3 neck zones in terms of trauma?
- Region bounded by the clavicles/sternum and up to cricoid cartilage
- Between cricoid cartilage and angle of mandible
- Superior to the angle of the mandible
What ages do you expect the ossification centres to have fused by?
Capitellum - 1 yr
Radial head - 3 years
Internal condyle - 5 years
Trochlea - 7 years
Olecranon - 9 years
Lateral epidondyle - 11 years
What are the 4 compartments of the lower limb?
- Lateral
- Anterior
- Deep posterior
- Superficial posterior
What is Trethowans sign?
What percentage of SUFEs are bilateral?
20%
Above what spinal level would you see neurogenic shock in the context of cord injury?
T6
