Trauma and Orthopaedics Flashcards
where does the achilles tendon insert distally?
where is the most likely site of achilles tendon rupture?
calcaneus
roughly 5cm proximal to its insertion
what action can a patient with achilles tendon rupture not do?
what is the test for achilles tendon rupture?
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
how do you manage achilles tendon rupture?
>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
what is the AO Weber classification of malleolar fractures?
how does this affect the management?
A - below the malleolus
B - at the level of the malleolus
C - above the malleolus
what is a maisonneuve’s fracture?
what is the management?
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
a displacement of one or more metatarsal bones from the tarsus is known as a …
Lisfranc fracture/dislocation
what is the management of a lisfranc fracture/dislocation?
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
what is a bunion?
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
what are the risk factors for halux valgus?
- F>M
- type of shoe wear
- older age
- hypermobile joints
what is the main complication of halux valgus?
OA of the affected joint
management options for halux valgus?
- 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
what is morton’s neuroma?
diagnosis and treatment
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
what is plantar fasciitis?
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
what is the course of the blood supply to the femoral head?
- 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
is traumatic or elective hip arthroplasty more likely to be total hip replacement?
elective is more likely to he THR
traumatic is more likely to be a hemi, due to comorbidites
what is the garden classification of intercapsular neck of femur fractures?
- undisplaced, incomplete
- undisplaced, complete
- partial displacement, complete
- displaced, complete
what are all of these called?
how do these relate to management?
- sub-capital - garden class.
- transcervical - garden class.
- basi-cervical - DHS
- intertrochanteric - DHS
- reverse oblique/transtrochanteric - intramedullary hip screw
- subtrochanteric - intramedullary hip screw
what are the images needed for managing #NOF?
AP and lateral hip plain radiograph
may need a CT/MRI as 2-10% of #NOF can be missed on plan films
what are some strategies for preventing #NOF in primary practice?
- 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
what is dangerous about a pubic ramus fracture?
can lead to laceration of the bladder, vagina or perineum
operative management should be considered
what are the early complications of arthroplasty?
-
local
- dislocation
- deep infection
- fracture
- neurovascular damage
- limb-length discrepancy
-
general
- VTE
- sepsis
- death
what are the indications for total hip replacement?
degenerative
- OA
- RhA
congenital
- congenital dislocation of the hip
traumatic
- intracapsular fracture neck of femur
- avascular necrosis of the head of femur
you are considering whether an arthroplasty is loosening or infected.
plain radiographs are inconclusive.
what is the next step in investigation?
strontium or technetium bone scan to reveal level of bone activity
in suspected sepsis, US guided arthrocentesis is indicated
what are the major late complication/failures of arthroplasty?
-
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
what is the mechanism of injury for ACL tear?
twisting injury to the knee with foot fixed on the ground
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
what is the main complication of leaving an ACL unrepaired (i.e. chronic ACL insufficiency)?
OA of that joint
what is the mechanism of injury in a PCL tear?
car crash as the knee hits the dashboard and is driven backwards
explain ‘knee locking’ as a sign following trauma?
indicates damage to the meniscus
displaced meniscal segment becomes trapped between the femoral and tibial condyles
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)
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
what is the management of a medial collateral ligament tear?
medial - treated conservatively
PRICER
firm support is needed during rehab using splints and braces
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
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
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
do hip or knee replacements last longer?
knee
90% last 15 years
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
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
what are the phases of adhesive capsulitis?
- painful phase (up to 1 yr) - pain on acitve and passive movement, reduced ROM (esp ABduction and external rotation)
- frozen phase (6-12 months) - pain settles but shoulder is still stiff
- thawing phase (1-3 years) - no pain, shoulder slowly regains movement
what are the association of adhesive capsulitis?
- cervical spondylosis
- diabetes
- thyroid disease
always check glucose, HbA1c and TFTs
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
what are the surgical management options for adhesive capsulitis?
- manipulation under anaesthesia
- arthroscopic arthrolysis
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
what are the origin sites for the long and short head of the biceps tendon?
long - supraglenoid tubercle
short - coracoid process of scapula
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
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
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
what point along the clavicle is most likely to fracture?
middle 1/3rd, with the proximal segment pulled superiorly by action of SCM contraction
what are the complications of a clavicle # that you should always consider?
neurovascular (subclavian artery and brachial plexus)
pneumothorax
what active movement will bring pain to a patient with a dislocated AC joint?
ADduction of the arm across the body
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
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)
who gets proximal humerus fracture?
elderly osteoporotics, injury = FOOSH
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
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
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
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
at what level(s) is disc herniation most likely to occur?
98% occurs between L4-S1
what are some common causes of sciatica/sciatic nerve pain?
disc herniation
pregnancy
spinal stenosis
cauda equina syndrome
what is the diagnostic investigation for spinal stenosis?
MRI back
wrist #
dorsal angulation of the distal radial segment…
Colle’s #
less dangerous from a neurovascular perspective
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
allergy to which commonly used drug is associated with allergy to sulfasalazine?
aspirin
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
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)
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
which muscles of the hand are innervated by the median nerve?
- first and second Lumbricals
- Opponens pollicis
- ABductor pollicis brevis
- Flexor pollicis brevis
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
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
at what level does the adult cord terminate?
L1-2
what are the features of anterior spinal artery syndrome (Beck’s syndrome)?
- pain (at the level of the lesion)
- complete motor paralysis below the level of the lesion
- partial sensory deficit below the level of the lesion
- loss of pain and temperature sensation
- intact proprioception, vibration and two-point descrimination
-
autonomic dysfunction - orthostatic hypotension;
- depending on level of lesion - loss of urinary and anal sphincters, sexular dysfunction
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
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
what are the common causative organisms for prosthetic joint infection?
staph aureus
then coagulase negative staphylococcus
- S. epidermidis, S. haemolyticus
what is the diagnostic criteria for compartment syndrome?
intracompartmental pressure measurement
>20 mmHg is consistent with CS
>40 mmHg is diagnostic
