Trauma and orthopaedics

Question 1

Rotator cuff tear:
- Function of rotator cuff muscles
- Definition + pathophysiology
- Risk factors
- Symptoms
- Investigations
- Management

Adhesive capsulitis:
- Definition
- Risk factors
- Symptoms
- Investigations
- Management

Shoulder impingement:
- Definition + pathophysiology
- Symptoms
- Risk factors
- Investigations
- Management
- Pathophysiology of calcific supraspinatous tendinopathy

Answer 1

Shoulder abduction:
0-15 - supraspin
15-90 - deltoid
90-150 - trapezius + serr ant

Rotator cuff tear:
- Function of rotator cuff muscles: supraspinatus abduction, infraspin + teres minor ext rotation, subscapularis int rot
- Definition + pathophysiology: complete or partial tear due to trauma or repeated microtrauma, chronic if >3 months
- Risk factors: repetitive overhead, smoking, alcohol, age, trauma
- Symptoms: painful abduction over 90 degrees, anterolateral pain, drop arm sign
- Investigations: xray, mri
- Management: heat, exercises, injection, if >3 weeks arthroscopic repair if young

Adhesive capsulitis:
- Definition: frozen shoulder where thickening glenohumeral capsule which becomes adherent to humerus. Freezing, frozen, thawed
- Risk factors: thyroid, breast cancer, diabetes, fem, trauma, inactivity, epilepsy
- Symptoms: stiff, pain esp passive, sleep affected, up to 18 months, external rotation mostly affected
- Investigations: mri
- Management: antiinflamm, physio, MAU to remove adhesions

Shoulder impingement:
- Definition + pathophysiology: narrowing of subacromial space via ca deposits etc means supraspinatus rubs on supraspinatus + inflammation
- Symptoms: painful arc 60-120 degrees abduction, dull ache, stiff, relieved by rest
- Risk factors: manual, active
- Investigations: mri
- Management: heat, analgesia nsaids, corticosteroid injections, physio, arthroscopic decompression if >6 months
- Pathophysiology of calcific supraspinatous tendinopathy: regional hypoxia causes ossification causing ca deposits which are resorbed by macrophages = inflammation

Question 2

Humerus fracture:
- Risk factors
- Symptoms
- Investigations
- Management
- Complications

Clavicle:
- Pathophysiology
- Symptoms
- Management
- Complications

Answer 2

Humerus fracture:
- Risk factors: female, early menopause, recurrent falls, prolonged steroid use
- Symptoms: pain, restricted movement. On examination swelling + bruising
- Investigations: NV examination, urgent bloods (coag screen, G&s), xray AP/lateral scapular/axillary
- Management: immobilisation then mobilisation 2-4 weeks, if open/neurovascular compromise or displaced then surgical fixation needed via ORIF or intermedullary nailing
- Complications: reduced ROM, AVN head, axillary/radial nerve damage, non/malunion, varus angulation

Clavicle:
- Pathophysiology: most are mid clavicular where medial segments moves up due to pull of SCM and lateral moves down due to weight of humerus and arm adducts due to pect major
- Symptoms: sudden onset pain, worse with movement, tender, deformity
- Management: conservative, ORIF
- Complications: pneumothorax, suprascapular nerve, subclavian artery

Question 3

Anterior shoulder dislocation:
- Symptoms
- Causes
- Complications
- Management

Posterior shoulder dislocation:
- Causes
- Symptoms
- Xray shows

Answer 3

Anterior shoulder dislocation:
- Symptoms: abducted/externally rotated, flattened deltoid, humeral head bulge, pain, reduced rom
- Causes: FOOSH or forced abducted /ext rot
- Complications: hill sachs (fracture head of humerus), bankart lesion (injury to glenoid labrum), axillary nerve damage (deltoid abduction, teres minor externally rotates), subclavian artery, recurrent (apprehension test +), rotator cuff tear
- Management: analgesia (gas / air), closed reduction via kocher, post reduction xrays + NV, sling 2 weeks, physio

Posterior shoulder dislocation:
- Causes: electric shock, epilepsy seizure
- Symptoms: internally rotated, adducted
- Xray shows: lightbulb sign

Question 4

Suprachondylar fracture of humerus:
- Definition
- Risk factors
- Symptoms
- Investigations
- Management
- Complications (4)

Radial fracture:
- Causes
- Symptoms
- Investigations

Answer 4

Suprachondylar fracture of humerus:
- Definition: elbow injury
- Risk factors: 5-7 yrs, foosh
- Symptoms: pain, deformity, swelling, ecchymosis of ant cubital fossa
- Investigations: NV exam, xray AP + lateral shows displaced fat pad sign
- Management: closed reduction and percut k wire 3-4 weeks then above elbow cast. If unstable ORIF + percut pinning
- Complications (4): volkmanns ischaemic contracture, gunstock deformity/cubitus varus, median nerve, brachial artery

Radial fracture:
- Causes: foosh
- Symptoms: lateral forearm pain
- Investigations: xray shows fat pad displaced due to haemarthrosis

Question 5

Cubital tunnel syndrome:
- Definition
- Symptoms
- Signs
- Investigations
- Management

Answer 5

Ulnar nerve supplies:
- Arm: FCU + med 1/2 FDP
- Hand: adductor pollicis, medial 2 lumbricals, interossei, hypothenar muscles (opponens/abductor/flexor digiti minimi)

Cubital tunnel syndrome:
- Definition: compression of the ulnar nerve as it passes underneath the medial epichondyle
- Symptoms: tingling 2 medial digits
- Signs: wasting 1st dorsal website (adductor pollicis), froments + sign (when gripping piece of paper thumb can’t extend and adduct as adductor pollicis and interossei don’t work so flexor pollics longus works instead causing hyperflexion), ulnar claw hand (loss of lumbricals means hyperextension MCPJ and flexion IPJ, claw is better if higher up injury as FCU and 1/2 FDU also not working so less flexion of DIPJ)
- Investigations: NV exam, nerve conduction studies
- Management: rest, nsaids, steroid injections, decompression surgery

Question 6

Carpal tunnel syndrome:
- What’s within it
- Definition
- Symptoms
- Risk factors
- Investigations
- DD
- Management

Answer 6

Median nerve:
Hand: LOAF
Arm: all flexors (except FCU + 1/2 FDP), pronators

Carpal tunnel syndrome:
- What’s within it: 4 tendons FDS, 4 tendons FDP, median nerve, flexor pollicis longus
- Definition: compression of median nerve
- Symptoms: tingling of lateral 3 1/2 digits esp at night, relieved by shaking, thenar wasting, weakness of thumb abduction, palm sensation spared as palmar cutaneous branch of median nerve branches off and doesn’t enter tunnel, emergency if can’t do ADLs
- Risk factors: diabetes, obesity, female, pregnancy, thyroid, post menopause, wrist work, 40-50yrs
- Investigation: Nerve conduction studies, tinels test, phalens test
- DD: cervical spondylosis
- Management: splint, steroid injections 6 week trial conservative, diuretics, surgical release of flexor reticulum

Question 7

Dupuytren’s contracture:
- Definition + pathophysiology
- Symptoms
- Signs
- Risk factors
- Investigations
- Management
- Complications

Answer 7

Dupuytren’s contracture:
- Definition + pathophysiology: thickening and contraction of the palmar fascia due to fibroplastic hyperplasia leading thickening of a nodule which develops into a cord in the fascia and myofibroblasts contract pulling on MCJ/PIPJs leading to flexion deformity
- Signs: thickened skin, huestons test (pt can’t lay palm flat), reduced rom, modt common ring/little finger
- Risk factors: obesity, frozen shoulder, diabetes, smoking, alc, liver disease, hypercholesterolaemia, vibrating tools, thyroid
- Investigations: bloods (lfts, hba1c), USS
- Management: hand therapy, collagenase injections, surgical dermofasiectomy
- Complications: ulnar nerve damage, recurrence, scar,,

Question 8

Distal radial fractures:
- Definition
- Risk factors
- NV testing
- Investigations
- Colles fracture
- Smiths fracture
- Management
- Complications

Answer 8

Distal radial fractures:
- Definition: fracture through distal metaphysis of radius
- Risk factors: early menopause, female, prolonged steroids, recurrent falls/fractures, smoking, age
- NV testing: radial sensation 1st dorsal webspace + extension thumb, ulnar sensation 5th digit + adduct thumb, median sensation 2nd digit + abduct thumb
- Investigations: NV test, if fallen ecg/urine dip/cbg, bloods (fbc, u+es, lfts, bone profile (vit d, ca, alp), xray (radial height <11, radial inclination <22, volar tilt >11)
- Colles fracture: extra articular fracture (within 2cm) where distal segment displaces dorsally
- Smiths fracture: distal segment displaces vorally (palm)
- Management: A-E, closed reduction and then below elbow slab, physio. If displaced then ORIF or K wire
- Complications: malunion, OA, median nerve damage

Question 9

Scaphoid fracture:
- Causes:
- Symptoms:
- Investigations
- Management
- Complications

Answer 9

Scaphoid fracture:
- Causes: FOOSH
- Symptoms: tender over anatomical snuffbox, wrist pain
- Investigations: xray AP + lateral but in 2 weeks because seen better when bone resorption (if still inconclusive then mri)
- Management: if undisplaced immobilisation + thumb spica splint 6-8 weeks. If displaced then percutaenous variable pitched screw
- Complications: AVN of proximal part as retrograde supply from dorsal branch of radial artery, nonunion

Question 10

Osteoarthritis:
Of hands:
- Common places
- Symptoms
- Management

Of hips:
- Definition + pathophysiology
- Causes
- Risk factors
- Symptoms
- Signs
- Investigations
- Management
- Complications

Of knee:

Answer 10

Osteoarthritis:
Of hands:
- Common places: 1st carpometacarpal joint, DIPJs, PIPJs
- Symptoms: bouchards nodes, herbedens nodes
- Management: splint, hand exercises, nsaids, arthrodesis/arthroplasty surgery

Of hips:
- Definition + pathophysiology: a degenerative joint disease where there is activation of chrondrocytes in articular cartilage and inflammatory cells which break down cartilage and expose underlying bone which rubs on each other causing sclerosis. Reactive remodelling occurs causing formation of osteophytes and joint margins and bone cysts in the joint space
- Causes: primary unknown and secondary due to trauma, infection etc
- Risk factors: primary (age, female, ethnicity) and secondary (trauma, obesity, manual work, infection)
- Symptoms: dull ache worse with usage, stiff, swelling, crunching
- Signs: trendelenburg pos, fixed flexion deformity, reduced rom, crepitus
- Investigations: bloods (fbc, crp, esr), xray (loss of joint space, osteophytes, subarticular sclerosis, subchondral bone cysts)
- Management: advise weight loss/ exercise/smoking, antiinflammatories topical then oral + ppi, joint warming, walking aids, intra-articular steroids, surgery for THR
- Complications of THR: 15-20 years, infection risk, DVT, leg length discrepancy, fracture

Of knee:
- Signs - ‘knees giving way’, varus ‘bow legs’ deformity, decreased rom, quads wasting

Question 11

Posterior hip dislocation:
- Definition
- Symptoms + positions
- Causes
- Investigations
- Management
- Complications

Anterior hip dislocation:
- Symptoms
- Complications

Answer 11

Posterior hip dislocation:
- Definition: head of femur displaces of acetabulum
- Symptoms: shortened, adducted, internally rotated, pain, reduced rom
- Positions:
Internally rotated: medius and minimus pull on greater trochanter
Shorted: maximus, hip adductors pull femur head up
- Causes: dashboard injury, football
- Investigations: xray
- Management: A-E, NV exam, reduce under GA
- Complications: sciatic nerve palsy, AVN femoral head, OA

Sciatic nerve is L4-S3. Supplies posterior thigh muscles and splits into tibial nerve which supplies post muscles leg and common fibular which supplies anterior muscles

Anterior hip dislocation:
- Symptoms: externally rotated, abducted
- Complications: femoral nerve palsy

Question 12

Intracapsular femur fracture:
- Definition
- Classification
- Symptoms
- Investigations
- Management
- Complications

Intertrochanteric Fracture:
- Management

Extracapsular fracture:
- Management

Answer 12

Intracapsular femur fracture:
- Definition: fracture of the proximal femur up to 5cm below lesser trochanter
- Classification: Garden classification
- Symptoms: externally rotated / shortened / abducted, pain, reduced rom, swelling, bruising, can’t weight bear
Shortened: adductors pull distal femur up
Externally rotated: Lateral hip rotators (piriformis, gemelli etc)
Abducted: medius + minimus pull + abductors pull distal femur
- Investigations: NV exam, A-E, bloods (fbc, u+es, coag, G&s, CK), xray AP/lateral, nottingham hip fracture (30 day mortality rate)
- Management: analgesia, if garden 1/2 then cannulated screws, if unactive hemiarthroplasty, if active THR, LMWH for surgery
- Complications: AVN of femoral head due to disruption of medial circumflex artery, GA SE (dental injury, anaphylaxis, VTE/PE, bed sores, pneumonia), THR SE (leg discrepancy, pain, infection, nerve injury)

Intertrochanteric Fracture:
- Management: Dynamic hip screw

Extracapsular fracture:
- Management: if subtrochanteric then intramedullary nail

Question 13

Tears in the knee:
Meniscal tears:
- Cause
- Symptoms
- Investigations
- Management

Collateral ligament tears:
- Cause
- Symptoms
- Management

Anterior cruiciate:
- Cause
- Signs
- Management

Posterior cruciate:
- Cause
- Signs

Unhappy triad

Answer 13

Tears in the knee:
Meniscal tears:
- Cause: weight bearing twisting injury (medial more prone)
- Symptoms: sudden pain WORSE WHEN STRAIGHTENING KNEE, swelling, instability, knee locked in flexion
- Investigations: apleys test pos, mri
- Management: RICE

Collateral ligament tears:
- Cause: contact sport injury on side knee (MCL more common but LCL more instability)
- Symptoms - pop, swell, pain, increased laxity
- Management: RICE, splint, opioids, physio

Anterior cruiciate: (weaker than pcl)
- Cause: non contact twisting
- Signs: pop, lachmans test, ant drawer test, sudden knee swelling, instability
- Management: operative reconstruction

Posterior cruciate:
- Cause: force on bent knee (dashboard), hyperflexion
- Signs: drawers test, post sag sign

Unhappy triad: ACL, medial meniscus, medial collateral r

Question 14

Femoral shaft fracture:
- Causes
- Symptoms
- Investigations
- Management
- Complications

Answer 14

Femoral shaft fracture:
- Causes: high energy trauma, fragility, pathological
- Symptoms: pain, weight bearing, deformity, swelling
proximal femur abducts: due to pull of med/min
distal femur adducts: due to pull adductors
flexed: pull of iliopsoas on greater trochanter
- Investigations: NV, A-E, bloods (fbc, coag, g&s), bone profile if suspect pathological, xray AP + lateral
- Management: analgesia, reduce, if displaced intramed screws, immobilisation
- Complications: hypovolaemic shock (highly vascularised), femoral nerve inj, malunion, fat embolism

Question 15

Septic arthritis of knee:
- Definition
- Causes
- Risk factors
- Symptoms
- Investigations
- Management
- Complications

Answer 15

Septic arthritis of knee:
- Definition: infection of synovial fluid of joint
- Causes: haematological spread or direct via staph aures or haem influ or neisseria gon and then abscesses form
- Risk factors: immunocomp, trauma, previous, recent surgery, injections
- Symptoms: red hot swollen painful, fever, tachycardia, limited rom, can’t weight bear
- Investigations: joint aspiration and send for MC+S, bloods (fbc, crp, esr, blood culture), xray
- Management: IV abx 2 weeks usually fluclox then 4 weeks, splint, drain/washout
- Complications: OA, dislocation, osteomyelitis

For knee swellings if <6 hours assume haemarthrosis due to ACL rupture and if >6hrs reactive synovitis

Question 16

Ankle fractures:
- Cause
- Classification
- Symptoms
- Investigations
- Management
- Complications

Answer 16

Ankle fractures:
- Cause: twisting injury
- Classification: syndesmosis is fibrous structure connecting the tibia and fibula (ant inf talofibular, post inf talofibular, intraosseous). Dennis weber classific bases level of fibular fracture in relation to the tibiofibular syndesmosis for lateral malleolus fractures.
A: below
B: passes through it
C: above it so is torn
If the tibiofibular space is >5mm then is unstable
- Symptoms: weight bear, swell, deformity, tender
- Investigations: AP, mortoise xray
Do xray if pain on either malleolus, inability to walk
- Management: elevate. A or B w/o talar shift = controlled ankle motion boot weight bear asap B w talar shift or C = ORIF
- Complications: OA, DVT, non union, regional pain syndrome

Forced inversion - damages ant talofibular lig
Forced eversion - deltoid
Ankle sprain can cause fracture of 5th metatarsal as pressure on fibularis brevis which attaches to proximal 5th metatarsal so can pull off and cause avulsion fracture

Question 17

Tibial shaft fracture:
- Symptoms
- Causes
- Investigations
- Management
- Complications

Answer 17

Tibial shaft fracture:
- Symptoms: lower leg pain, weight bear, deformity, swelling, bruising
- Causes: direct blow, twisting
- Investigations: NV, bloods (fbc, u+es, clotting, g&s), full length AP/lat xray
- Management: analgesia, intramed nail, above knee slab
- Complications: compartment syndrome, limb ischaemia, mal union, takes longest time for reunion - 4-6 months

Question 18

Achilles tendon rupture:
- Definition
- Risk factors
- Symptoms
- Investigations
- Management

Answer 18

Achilles tendon rupture:
- Definition: decreased blood supply 6cm above calcaneous insertion point so increased tear risk
- Risk factors: training, footwear, quinolone abx, steroids, statins, hypercholest (tendon xanthomata)
- Symptoms: can’t planterflex, swell, bruise, pop, weight bear, can’t plantarflex
- Investigations: simmonds triad (resting ankle dorsiflexion when knees bent, palp gap above heel, lack plantarflexion when calf squeezed is thompsons +), uss
- Management: equinus cast if ends close 8 weeks, if not repair

Question 19

Toe deformities:
Hallux valgus:
- Definition
- Risk factors
- Management

Hallux rigidus:
- Definition
- Management

Answer 19

Toe deformities:
Hallux valgus:
- Definition: bunion, lateral deviation of hallux and medial deviation of 1st metatarsal (should be <15 degrees)
- Risk factors: footwear, female, ehlers danlos, RA
- Management: footwear, physio, osteotomy

Hallux rigidus:
- Definition: OA of 1st MTPJ
- Management: soles, injections, analgesia, arthropathy/arthrodesis (fusion of 1st MTPJ)

Talipes equinovarus (club foot) = inverted + plantarflexed foot in newborns

Question 20

Lumbar puncture:
- Level
- Layers

Answer 20

• L3/4
• Skin, subcut tissue, supraspinous, interspinal, lib flavum, epidural space, dura mater, arachnoid mater, subarachnoid space

Question 21

Radiculopathy vs myleopathy
Back pain red flags
Quadriplegia vs paraplegia
Common mets from

Answer 21

• irritation of a spinal nerve root causing neurological loss vs injury to the sc due to compression
• trauma, fever, iv drug use, steroid use, cancer history, incontinence, retention, bilateral saddle parasthesia
• cervical cord transection hence loss all limbs vs dorsolumbar spine so loss of lower limbs
• thyroid, lung, breast, renal

Question 22

Prolapsed invertebral disc:
- Functions of disc
- Definition + pathophysiology
- Symptoms
- Causes
- Investigations
- Management
- Sciatica definition

Answer 22

• Functions of disc: shock absorbers and flexibility of spine
• Definition + pathophysiology: when nucleus pulposus bulges posterolaterally which then pressures on transitioning nerves. Disc degen/bulging –> disc prolapse –> disc extrusion –> disc herniation
• Symptoms: back pain acute worse when sitting, leg pain, tingling/numbness, weak
• Causes: age, lifting heavy object
• Investigations: NV exam, positive leg raise. Then if >6weeks mri
• Management: nsaids, physio, exercise, Light work then heavy after 3 months
• Sciatica: irritation to nerves contributing to this nerve L4-S3

Question 23

Cauda equina:
- Definition
- Causes
- Symptoms
- Signs
- Investigations
- Management

Answer 23

• Definition: compression of caudal equina (bundle nerves from roots L1-S5) which supplies lower limb including anal sphincters and psns to the bladder - most common at l4/5, l5/s1
• Causes: herniation, trauma, infection (abscess, discitis staph aures), tumour, ankylosing spondylitis causing inflammation, iatrogenic where haematoma due to spinal injection
• Symptoms: bilateral saddle parasthesia, urinary retention, faecal incontinence, erectile dysfunction, lower limb weakness, lower back pain, bilateral sciatica
• Signs: decreased anal tone
• Investigations: NV exam, post void bladder scan, emergency lumbar sacral spine MRI
• Management: emergency lumbar decompression surgery. If >6 hours can get complete permanent sphincter and lower limb dysfunction

Discitis: infection of invert disc space (aures) - needs 6 weeks abx and echo for endocarditis

Question 24

Canal stenosis:
- Definition + pathophysiology
- Causes
- Symptoms
- Investigations
- Management

Cervical spondylosis:
- Definition

Answer 24

Canal stenosis:
- Definition + pathophysiology: natural deterioration of invertebrate disc narrows vertebral foramen causing compression of sc/exiting nerves. Compression of nerves decreases venous drainage and hence decreased arterial which causes pain/parasthesia of legs
- Causes: arthritis osteophytes, disc herniation, spinal fractures
- Symptoms: claudication eased leaning forward/rest, spine tenderness, stiff, reduced movement
- Investigations: NV, lasegue, xray, MRI
- Management: analgesia, physio, nsaids, steroid injections. If >3 months then pain clinical or decompressive laminectomy

• Definition: age degen/OA of spine putting pressure on nerves (disc bulging, osteophytes, ligamentum flavum hypertrophy, facet joint OA). Can cause myelopathy (myelopathy can also be caused from fracture, dislocation, herniated disc) or radiculopathy.
  Needs nsaids, physio, cervical collar, epidural steroid injections, facet joint injections

Question 25

Spondylolisthesis:
- Definition

Cervical spinal fractures:
- Jefferson
- Hangmans
- Odontoid peg fracture
- Symptoms
- Investigations
- Management
- Osteoporotic

• Spondylodiscitis

Answer 25

• pars interarticularis and facet joint maintains vertebral position but this can displacement e.g. L4 forward displacement onto L5 - scotty dog sign
• Jefferson: c1 atlas fracture from diving where ant and post arches fractured (unlikely to get damage at c1 though as vert foramen large)
• Hangermans: c2 axis when hyperextension neck and fracture through pars articularis
• Odontoid: need PEG AP xray
• Symptoms: neck pain, sensory/motor deficits
• Invest: CT adult, mri child
• Manage: ATLs c spine immobilisation, operative
• Osteoporotic: xray
• infection of spine via body nutrient artery

Question 26

Open fractures:
- Definition
- Classification
- Management
- Complications

Answer 26

Open fractures:
- Definition: direct communication between fracture site and external environment
- Classification: gustillo anderson - 1. small clean wound <1cm. 2. clean wound 1-10cm. 3. a. >10cm. b. inadeq soft tissue coverage. c. arterial injury
- Management:
1. A- E
2. Analgesia, antiemetics
3. NV exam
4. splint
5. sterile dressing
6. tetanus prophylaxis - toxoid, human antiserum if not immunised (tetanus blocks NT release from spinal inhibitory neurones)
7. coamoxiclav/ clarithromycin
8. gentamicin or metronidazole 72 hours before surgery
9. wound debridement + irrigation, external fixation
10. wound cover/skin grafting, gentamicin/vancomycin
- Complications: compartment syndrome, infection, malunion

Question 27

Compartment syndrome:
- Leg compartments
- Pathophysiology
- Causes
- Symptoms
- Investigations
- Management

Answer 27

Compartment syndrome:
- Leg compartments: ant (deep interosseous art), post/lat, super, deep
- Pathophysiology: bleeding or inflammation increases pressure in osteofacial compartments which compresses veins so engorgement and decreases arterial supply so muscle ischaemia, necrosis and rhabdomyolysis.
This infarcted muscle can regenerate and fibrose causing volmanns isch contracture
- Causes: trauma, tight casting, infection, crush injury
- Symptoms: severe pain worse stretching, parasthesia, 5ps
- Investigations: clinical diagnosis, intracompartment pressure, monitor creatine kinase for rhabdo
- Management: remove casts, flat, emergency fasciectomy

Question 28

Fracture:
- Symptoms
- Healing stages
- Management
- Complications
- Causes non union
- Salter harris classification

Answer 28

Fracture:
- Symptoms: pain, swell, bruising, deformity, reduced rom, weight bear
- Healing stages: 1. haematoma 2. inflammation + angiogenesis 3. fibrocartilaginous soft callus formation 4. consolidation 5. remodelling
- Management: undisplaced then split. if displaced reduce - MAU, mech traction, Orif, external fixation if infected/open
- Complications: damage nerves/blood, haemorrhage, compartment s, fat embolism, malunion, arthritis, regional pain syndrome, decreased function
- Causes non union: excessive movement, poor blood supply, infection, abnormal bone
- salter harris:
1. through physis, often can’t see on xray
2. through physis and metaphysis
3. through physis and epiphysis
4. involves physis, metaphysis, epiphysis
5. crush injury involving physis

Question 29

Osteomyelitis:
- Definition + pathophysiology
- Causes
- Risk factors
- Symptoms
- Investigations
- Management
- Complications

Answer 29

Osteomyelitis:
- Definition: infection of bone
- Causes: heamat spread or direct via aures, strep, h influenza, p aeruginosa if drug, salmonella if sickle cell
- Risk factors: Diabetes, immunosuppressive, alc, iv drugs
- Symptoms: pain worse night, pyrexia, tender, swelling
- Investigations: fbc/crp/blood cultures, xray (osteopenia/periosteal thickening/ cortical bone loss/ endosteal scalloping visible 7-10 days post), mri gold standard
- Management: long term iv abx 4 weeks normally fluclox, surgery
- Complications: sepsis, premature physical closure, recurrence

Question 30

De quervain’s tenosynovitis:
- Definition
- Symptoms
- Mx

Answer 30

• definition: inflammation of sheath containing APL + EPB
• symptoms: radial wrist pain, tender over radial styloid process, abduction thumb against resistance painful, finkelsteins test +
• Mx: analgesia, steroid injection, thumb splint, surgery

Question 31

Osteochondritis dissecans
- definition
- symptoms
- signs
- ix
- mx

Answer 31

Osteochondritis dissecans
- definition: issues with joint cartilage, free bodes and mechanical dysfunction esp in knee
- symptoms: pain, swelling worse with exercise, knee locking
- signs: joint effusion, tender when palpating
- ix xray (loose bodies or subchrondral crescent sign), mri
- mx: degenerative changes if untreated