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Trauma and Orthopaedics Flashcards

1
Q

where does the achilles tendon insert distally?

where is the most likely site of achilles tendon rupture?

A

calcaneus

roughly 5cm proximal to its insertion

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2
Q

what action can a patient with achilles tendon rupture not do?

what is the test for achilles tendon rupture?

A

raise the heel from the floor when standing on that leg

Simmond’s/Thompson’s test - kneel on chair and squeeze the calf, lack of foot plantar flexion indicates tendon rupture

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3
Q

how do you manage achilles tendon rupture?

A

>50, diabetic, smoker, unfit - casting in equinus position with gradual (6-8 weeks) return to neutral. typically no weight baring for this whole time

young, fit, late presenting injury - percutaneous or open tendon repair

  • graded physio program, motivational interviewing
  • analgesia up the WHO pain ladder
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4
Q

what is the AO Weber classification of malleolar fractures?

how does this affect the management?

A

A - below the malleolus

B - at the level of the malleolus

C - above the malleolus

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5
Q

what is a maisonneuve’s fracture?

what is the management?

A

due to rotational force in the lower leg

  • # proximal 1/3rd of fibula
  • interosseuous membrane tear
  • # medial malleolus or deltoid legament tear

always surgical fixation - restore the ankle mortise and placement of 1/2 suprasyndesmotic screws at the proximal fibula

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6
Q

a displacement of one or more metatarsal bones from the tarsus is known as a …

A

Lisfranc fracture/dislocation

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7
Q

what is the management of a lisfranc fracture/dislocation?

A

needs surgical repair because of high risk of medial foot compartment syndrome

can be difficult to characterise the injury on plain film, MRI foot maybe necessary

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8
Q

what is a bunion?

A

a foot deformity in which hallux deviates laterally (valgus) at the metatarsophalangeal joint, typically presenting bilaterally

pressure of the MTP against the shoe causes soft tissue reaction and formaiton of a growth and induration which is disfiguring

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9
Q

what are the risk factors for halux valgus?

A
  • F>M
  • type of shoe wear
  • older age
  • hypermobile joints
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10
Q

what is the main complication of halux valgus?

A

OA of the affected joint

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11
Q

management options for halux valgus?

A
  • education
    • appropriate footwear (low-heel, flat, wide)
    • foot muscle stregthening exercises
    • bunion pads and plastic wedges (between big and 2nd toes)
  • correction of deformity requires surgery
    • aim to achieve toe alignment
    • relieve pain
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12
Q

what is morton’s neuroma?

diagnosis and treatment

A

compression of the foot for a long period of time (tight high heels) causes growth of a neuroma in the interdigital space

neuroma compresses the surrounding structures and leades to pain on the lateral aspect of one metatarsal and the medial aspect of the other

diagnosis: MRI or US
treatment: surgical excision

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13
Q

what is plantar fasciitis?

A

plantar fascia supports the arch of the foot

can affect obese/immobile or the highly active

damage due to microtrauma and erosions - not inflammatory

treatment: stretch achilles tendon, orthotics, shockwave therapy.
encourage activity in the inactive, and encourage patience in athletes

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14
Q

what is the course of the blood supply to the femoral head?

A
  • external iliac
  • femoral
  • profunda femoris
  • lateral and medial circumflex femoral
  • ascending retinacular

AND

  • internal iliac
  • obturator, lateral branch
  • small foveal artery in the ligamentum teres
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15
Q

is traumatic or elective hip arthroplasty more likely to be total hip replacement?

A

elective is more likely to he THR

traumatic is more likely to be a hemi, due to comorbidites

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16
Q

what is the garden classification of intercapsular neck of femur fractures?

A
  1. undisplaced, incomplete
  2. undisplaced, complete
  3. partial displacement, complete
  4. displaced, complete
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17
Q

what are all of these called?

how do these relate to management?

A
  1. sub-capital - garden class.
  2. transcervical - garden class.
  3. basi-cervical - DHS
  4. intertrochanteric - DHS
  5. reverse oblique/transtrochanteric - intramedullary hip screw
  6. subtrochanteric - intramedullary hip screw
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18
Q

what are the images needed for managing #NOF?

A

AP and lateral hip plain radiograph

may need a CT/MRI as 2-10% of #NOF can be missed on plan films

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19
Q

what are some strategies for preventing #NOF in primary practice?

A
  • exercise, balance training (Tai Chi) and keep fit classes
  • prevent sedation (medicines reconciliation)
  • prevent osteoporosis (bisphosphonates, vitamin D, exercise)
  • occupational therapy visit at home to check lighting and support on stairways and around doors
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20
Q

what is dangerous about a pubic ramus fracture?

A

can lead to laceration of the bladder, vagina or perineum

operative management should be considered

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21
Q

what are the early complications of arthroplasty?

A
  • local
    • dislocation
    • deep infection
    • fracture
    • neurovascular damage
    • limb-length discrepancy
  • general
    • VTE
    • sepsis
    • death
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22
Q

what are the indications for total hip replacement?

A

degenerative

  • OA
  • RhA

congenital

  • congenital dislocation of the hip

traumatic

  • intracapsular fracture neck of femur
  • avascular necrosis of the head of femur
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23
Q

you are considering whether an arthroplasty is loosening or infected.

plain radiographs are inconclusive.

what is the next step in investigation?

A

strontium or technetium bone scan to reveal level of bone activity

in suspected sepsis, US guided arthrocentesis is indicated

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24
Q

what are the major late complication/failures of arthroplasty?

A
  • dislocation (mostly THR)
    • weakness of the muscles that are divided during surgery leads to increased risk of posterior hip dislocation
  • prosthetic loosening
    • chronic pain, increased risk of fracture
    • worst with metal on metal
  • periprosthetic fractures
    • presents after relatively minor trauma to the joint
  • infection
    • catastrophe
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25
what is the mechanism of injury for ACL tear?
twisting injury to the knee with foot fixed on the ground
26
what is the management of ACL tear?
* rest the knee for 3 weeks with adequate pain relief * if young, perform ACL reconstruction after this time otherwise.. rest, physio and exercise gradually, pain control
27
what is the main complication of leaving an ACL unrepaired (i.e. chronic ACL insufficiency)?
OA of that joint
28
what is the mechanism of injury in a PCL tear?
car crash as the knee hits the dashboard and is driven backwards
29
explain 'knee locking' as a sign following trauma?
indicates damage to the meniscus displaced meniscal segment becomes trapped between the femoral and tibial condyles
30
what is the management of meniscal tear?
PRICER - protect, rest, ice, compression, elevation, rehabilitate orthopaedic surgeons will assess: * partial or total mesicectomy (not really done anymore) * implantation of biodegradable scaffold * meniscal repair (favoured)
31
sum up the difference in management between PCL and ACL tear
PCL is much stronger so tears much less frequently than AClL also, reconstruction is much more difficult and outcomes are less predictable management is often conservative
32
what is the management of a medial collateral ligament tear?
medial - treated conservatively PRICER firm support is needed during rehab using splints and braces
33
what is the management of a lateral collateral ligament tear?
lateral collateral tear will be a more high energy injury than a medial, so there is likely to be damage to other structures such as: * ACL/PCL * common peroneal nerve look for signs of this damage and surgery is more likely to be required
34
what are the signs of IT band pain syndrome? what is the pathology?
irritation and pain produced when the IT band slides over the lateral tibial tuberosity during knee flexion lateral pain on knee flexion and palpation of the lateral tibial tuberosity
35
what is patellofemoral pain syndrome? who gets it? what is the main priciple of treatment? what is the clinical sign for diagnosis?
PFPS - overuse injury of the lower limb also associated with previous patella dislocation/subluxation, trauma, muscle imbalance or malalignment medial retropatellar tenderness on compression young atheles with recent increase in exercise reigme Rx - rest initially, then graded return to exercise program with quadraceps muscle stregthening diagnosis - Clarke's sign = retropatellar pain on patellar crompression with tensed quadraceps
36
do hip or knee replacements last longer?
knee 90% last 15 years
37
define a knee replacement
can be total or partial (unicompartmental) involves resection of the articular surfaces of the knee and replacement with metal or polyethylene components
38
what are the indications for knee replacement?
* (mostly) osteoarthritis * debilitating pain, gets pt up at night, interferes with ADLs, stops social function * rheumatoid arthritis * post-traumatic (haemarthrosis) arthritis
39
what are the phases of adhesive capsulitis?
1. painful phase (up to 1 yr) - pain on acitve and passive movement, reduced ROM (esp ABduction and external rotation) 2. frozen phase (6-12 months) - pain settles but shoulder is still stiff 3. thawing phase (1-3 years) - no pain, shoulder slowly regains movement
40
what are the association of adhesive capsulitis?
* cervical spondylosis * diabetes * thyroid disease always check glucose, HbA1c and TFTs
41
what is the role of steroids in adhesive capsulitis?
can be given intra-articularly for the painful phase no use of systemic steroids, not used in clinical practice
42
what are the surgical management options for adhesive capsulitis?
* manipulation under anaesthesia * arthroscopic arthrolysis
43
what is the test for biceps tendonopathy?
**Speed's** test - elbow extended, sholder flexed to 60deg shoulder flexion against resistance and palpation of biceps tendon ilicits pain
44
what are the origin sites for the long and short head of the biceps tendon?
long - supraglenoid tubercle short - coracoid process of scapula
45
how do you test for biceps tendon rupture?
bruising and pain in the upper arm Popeye sign - flexion of the elbow shows a swelling in the distal portion of the arm caused by the muscle belly of biceps brachii contracting against no resistance Ludington's test - both hands behind the patients head, clinician behind the patient, observing for asymmetry and painful swelling
46
what is the movement **most sensitive** for proximal biceps tendon rupture?
forearm supination NB not elbow flexion, as the other flexor muscles of the arm contribute more to this
47
mostly what is the management of biceps tendon rupture? what factors would affect the decision?
PRICER and slow rehab - surgery not usually indicated young, fit, active and healthy patient maybe considered for surgical repair
48
what point along the clavicle is most likely to fracture?
middle 1/3rd, with the proximal segment pulled superiorly by action of SCM contraction
49
what are the complications of a clavicle # that you should always consider?
neurovascular (subclavian artery and brachial plexus) pneumothorax
50
what active movement will bring pain to a patient with a dislocated AC joint?
ADduction of the arm across the body
51
what are the two main options for managing AC joint dislocations?
* rest in broad arm sling (minor injury with minimal displacement) * open reduction and rotator cuff/ligament repair
52
what is one of the most important nerves to test in a AC joint dislocation?
axillary nerve supplying sensation to the regemental patch (pre- and post-reduction)
53
who gets proximal humerus fracture?
elderly osteoporotics, injury = FOOSH
54
what is the management of a mid-humeral shaft fracture
rarely surgical - treat with brace and 'collar and cuff' sling gives satisfactory reduction immobilize 8-12 weeks
55
what is the complication of a mid-humeral shaft fracture?
damage to the radial nerve as it passes around the spiral groove of the humerus sings - wrist drop and loss of digit extension
56
what are the shoulder lesions associated with AC dislocation?
**Bankhart** - avulsion injury of the anterior inferior glenoid labrum **Hill-Sachs** - impaction fracture of the posterior lateral humeral head, seen on lateral shoulder plain film with medial arm rotation
57
what is the referral criteria for impingement syndrome?
if pain has lasted \>6 months refractory to physiotherapy, subacromial bursa injection of steroids and local anaesthetic, and NSAIDs
58
at what level(s) is disc herniation most likely to occur?
98% occurs between L4-S1
59
what are some common causes of sciatica/sciatic nerve pain?
disc herniation pregnancy spinal stenosis cauda equina syndrome
60
what is the diagnostic investigation for spinal stenosis?
MRI back
61
wrist # dorsal angulation of the distal radial segment...
Colle's # less dangerous from a neurovascular perspective
62
wrist #... volar displacement and angulation of the distal radial fragment
Smith's fracture more dangerous to the neurovascular structures and the distal fragment tends to migrate
63
allergy to which commonly used drug is associated with allergy to sulfasalazine?
aspirin
64
what are the causes of a +ve tendelenburg sign?
**muscle** * wasting 2ary to surgery * wasting 2ary to degenerative arthritis **nerve (superior gluteal)** * damage 2ary THR * damage 2ary developmental dysplasia of the hip * GBS * old polio
65
what are the extra-articular features of rheumatoid arthritis?
**eyes** * keratoconjunctivitis sicca, scleritis (painful), episcleritis **nodules** * skin, lung, pleura, pericardium, CNS, lymph nodes **lungs** * restrictive LD (20%), obstructive LD (bronchiolitis - 55%), pleurisy/pleural effusion (5%), cavitating lesion **heart** * pericardial effusion, pericarditis, restrictive cardiomyopathy **systemic** * ACD, osteomalacia/osteoporosis, AL amyloidosis, splenomegaly (+/- Felty's syndrome)
66
what are the causes of dupytren's contracture?
* A - AIDS * B - '*bent penis'* = peyronie's disease * C - cirrhotic liver disease * D - diabetes mellitus * E - epilepsy esp. phenytoin * F - familial (autosomal dominant) * F - fibromatoses
67
which muscles of the hand are innervated by the median nerve?
* first and second **L**umbricals * **O**pponens pollicis * **A**Bductor pollicis brevis * **F**lexor pollicis brevis
68
how do you isolate median, ulnar and radial nerve motor function in a UL/hand exam?
**ulnar** - finger ADduction (hold piece of paper together between fingers) **median** - thumb ABduction (lift thumb to ceiling with hand on table, palm facing upwards) **radial** - MCPJ extension
69
what are the causes of carpel tunnel syndrome?
**anatomy** * solid - deformity 2ary to # * soft - acromegaly, ganglion, obestiy **fluid** * pregnancy, menopause, hypothyroidism **inflammation** * RhA and gout **diabetes** * excess collagen proliferation within the endoneurium
70
at what level does the **adult** cord terminate?
L1-2
71
what are the features of anterior spinal artery syndrome (Beck's syndrome)?
1. **pain** (at the level of the lesion) 2. complete **motor paralysis** below the level of the lesion 3. partial **sensory deficit** below the level of the lesion * loss of pain and temperature sensation * intact proprioception, vibration and two-point descrimination 4. **autonomic dysfunction** - orthostatic hypotension; * depending on level of lesion - loss of urinary and anal sphincters, sexular dysfunction
72
what is the difference between cona medullaris and cauda equina syndrome?
CM - involvement of the end of the cord (lesion at L1-2 level) so mixed UMN and LMN signs and autonomic dysfunction CE - only LMN signs with autonomic dysfunction
73
explain urinary retention and faecal incontinence in CE/CM syndromes?
**loss of tone** in both cases anal sphincter - no tone = loss of continence bladder atony = no expressive force to pass urine through the autonomous internal sphincter, retention and baldder distension, overflow incontinence
74
what are the common causative organisms for prosthetic joint infection?
*staph aureus* then coagulase negative staphylococcus - *S. epidermidis, S. haemolyticus*
75
what is the diagnostic criteria for compartment syndrome?
intracompartmental pressure measurement \>20 mmHg is consistent with CS \>40 mmHg is diagnostic

Finals (10 decks)

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