Trauma and Orthopedics Flashcards
What are the steps to a joint examination?
Introduce Ask Look Feel Move Special Tests
When assessing the neurological functions of the limbs and trunk, what else do we need to assess?
Power
Co-ordination
Reflexes
Sensation
What is the difference between primary and secondary bone healing?
Primary does not produce a callus, and is due to fracture fragments being reduced anatomically - there is no movement between the fracture surfaces.
What are the 2 distinct but similtaneous processes occuring in secondary bone healing?
Intramembranous and endochondral ossification
What are the 2 stages of secondary bone healing?
- Haematoma and inflammation
2. Callus formation - soft and hard
What are Perkins rules?
Rules describing the length of time it takes for different fractures to unite
How long, according to Perkins rules, do cancellous/metaphyseal bone fractures take to unite?
6 weeks
How long, according to Perkins rules, do cortical/diaphyseal bone fractures take to unite?
12 weeks
How long, according to Perkins rules, do tibial fractures take to unite?
24 weeks
How long, according to Perkins rules, do fractures in children take to unite?
(Age of child + 1) weeks
Although should apply common sense in older children
What is delayed union of a fracture?
A failure of union to occur in 1.5 times the normal time for fracture union
What is non-union of a fracture?
A failure of union to occur in twice the normal time for fracture union
What are the 2 types of non-union?
Hypertrophic and Atrophic
Hypertrophic vs Atrophic non-union
H - non union due to excess mobility or strain at fracture site. Blood supply is good.
A - Due to poor blood supply (due to initial injury or surgical intervention)
What is a fracture?
A soft tissue injury with an associated broken bone
Considering the definition of a fracture, what principle should be used when treating a pt with one?
Treat the soft tissues with care and the broken bone will heal well
What are the 4 principles of modern fracture reduction and treatment?
- Reduce and fix fractures to restore anatomical relationships
- Stabilise with fixation or splinting as required
- Presvere the blood supply with the above gentle techniques
- Early and safe mobilization of the part and pt
What is the cheapest and easiest way to reduce a fracture?
Casting
What can we do to immobilise a fracture prior to definitive management?
Half casts, or back-slabbing
What are the complications of casting?
Cast problems (loosening, pressure areas) Thromboembolic events Coverage of wounds Skin breakdown Compartment syndorme
What injuries of the phalanges and metacarpals can occur?
Extra-articular - shaft fractures and base fractures
Dislocations - thumb MCPJ, PIP
Neck fracture (metacarpal)
How do thumb injuries usually occur?
Direct blow, or forced opposition
How do metacarpal injuries usually occur?
“punch” injury - Friday night, or boxers fracture
How do distal phalanx injuries usually occur?
Crush injury
How do proximal and middle phalanx injuries usually occur?
Direct blow, or twisting
PIP dislocation - What is the Edinburgh position, and why is it good?
MC joint immobilised in 90 degree flexion, and PIPJ in extension, and wrist at 30 degrees.
Ligaments are stretched to the max while immobile so the pt doesnt end up with a flexion deformity.
What is the mechanism of a scaphoid fracture?
Fall onto outstretched hand (forced dorsiflexion)
What is the sign of effusion in a scaphoid fracture?
Anatomical snuffbox feels full
Where is tender in a scaphoid fracture? 2 sites
- Anatomical snuffbox (dorsal)
- Tubercle of scaphoid (volar)
How do we investigate a ?scaphoid facture?
Scaphoid series radiograph films
How do we treat a scaphoid fracture?
Below elbow cast in neutral position for 8-12 weeks
If displaced >1mm or angulated -> Open reduction with internal fixation (ORIF)
What are the complications of scaphoid fracture?
- Non union
- Avascular necrosis (esp. with proximal or displaced fractures)
- Degenerative change
After scaphoid, what is the next most commonly fractured carpal bone?
Hamate fracture
How are distal radius and ulna fractures usually obtained?
Fall on an outstretched hand
How common are distal radius or ulna fractures?
Very - makes up 1 in 6 of all fractures
When I say that distal radius/ulna #s are bimodal in incidence, what do I mean?
There are 2 peaks of incidence, one in childhood (6-10) and one in early old age (60-70)
What can accompany #distal radius/ulna?
Scaphoid and ligamentous wrist injuries
What is a Colles fracture?
The most common radial fracture - the wrist and hand (i.e. all structures distal to the #) are displaced posteriorly
What is seen on examination of a colles fracture?
Dinner fork deformity - on lateral view of affected wrist, the posterior displacement of distal structures causes a curve like a fork to be seen on the palmar surface
What is a Smith’s fracture?
of radius that is the opposite of a Colles. The wrist and hand (i.e. all structures distal to the #) are displaced anteriorly
Having made you learn what Colles, Barton’s and Smiths #s are, what is the safest way to describe a #?
By radiological/anatomical features
What is a Barton’s fracture?
Intra-articular distal radius # with associated dislocation of radio-carpal joint. Can be volar or dorsal.
What are the characteristics that we can describe in a #?
Site - which bone, where in that bone? Pattern Displacement Angulation Dislocated/In joint
What is important to remember when looking at a radiograph of a #?
Theres should be 2 views!! AP and lateral
What # patterns can there be?
Transverse Oblique Spiral Comminuted Multi-fragmented Segmental
How can radial/ulnar shaft fractures be caused?
Fall on outstretched hand
Direct blow to forearm
What often happens if the ulna or radius is fractured on its own?
The other bone is dislocated
What do we call a proximal ulnar fracture with proximal radial head dislocation?
Monteggia fracture
What do we call a distal radial fracture with distal radio-ulna joint dislocation?
Galaezzi fracture
How are the vast majority of R/U shaft fractures managed in adults?
Above elbow cast if undisplaced.
If displaced - open reduction and compression plate fixation
Closed reduction is impossible/insufficient.
Where can the humerous fracture in adults?
Shaft
Condyles
Olecranon
Radial head
How do humeral shaft #s usually occur?
Fall with torsion or direct blow
What would we suspect if a humeral shaft # occured after a low energy blow?
Osteoporosis
What nerve is at risk from a humeral shaft fracture? Why?
Radial nerve - it runs down the radial groove on the posteroir aspect of the humerus
What else should we get x-rays of with a humeral shaft #? Why?
Joint above and below i.e. shoulder and elbow
In case of intra-articular extension/floating elbow/shoulder
If the radial nerve is involved in a humeral shaft #, what signs do we get?
Wrist drop
Sensory loss to dorsal aspect of lateral 3.5 digits
(depending on site) ?weakened extension of arm
How are humeral shaft #s usually managed?
Conservatively
When would surgical intervention be indicated for a humeral shaft #?
Open fracture
Vascular injury
Floating shoulder/elbow
Intra-articular extension
What can a pt do if they fall onto their elbow?
Humeral condylar #
What is the mechanism for humeral condylar #s?
Olecranon driven into the humerus -> condyle splits into “T” or “Y” shape
What is the most common type of humeral condylar #?
Intercondylar - fracture line goes from articular surface to supracondylar region (T or Y shape)
There are 3 other types of humeral condylar #. What are they?
- Supracondylar
- Isolated medial or lateral condyle fracture
- Isolated capitellum #
What is the Colton classification?
Classification of olecranon fractures according to whether it is displaced.
What is a type one and a type two colton fracture?
1 - undisplaced
2 - displaced
How can a radial head # occur?
FOOSH with the forearm in pronation
Which system do we use for radial head # classification?
Mason classification
What complications can occur as a result of elbow fractures?
Joint stiffness
Osteoarthritis
Heterotopic ossification
Neurovascular injury
What is the terrible triad of the elbow?
Posterior elbow dislocation w/ radial head fracture + coronoid process fracture + lateral collateral ligament tear
By what mechanism does the clavicle #?
Fall, or direct blow to lateral shoulder
What % of all #s do clavicle #s make up?
5-10%
Where do the majority of clavicle #s occur?
Middle 3rd (i.e. 2/3rds from sternum)
WRT displacement, how are clavicle #s assessed?
WRT the sternoclavicular joint
How are the majority of clavicle fracture treated?
Conservatively
How do most scapula #s occur?
Direct trauma, usually a RTA
What other injuries should be considered/ruled out when a scapula # is present?
- Rib #
- Pulmonary contusion
- Pneumo/haemothorax
- Ipsilateral clavicle #s
In the shoulder region, what can dislocate?
Sternoclavicular joint Acromioclavicular joint Glenohumeral joint (anterior or posterior)
Which shoulder dislocation is the most common?
Anteroir dislocation of glenohumeral joint - 95% of dislocations
Are sternoclavicular joint dislocations common?
Noop
Who is at risk of reoccuring shoulder dislocations?
Pts whos shoulder dislocates first at a young age
Why do shoulder dislocations reoccur?
Bankart lesions or capsular redundancy
When do single rib #s typically occur?
Direct injury such as a fall
Apart from trauma, when can lower ribs #?
With coughing
When do sternal #s typically occur?
Traaaaauma
What can happen with a high velocity RTA/crush injury to ribs and sternum?
“Stove-in” chest with flail segments (multiple rib #s)
How are rib #s treated?
- Single ribs - analgesia/symptomatic treatment
- Multiple (>3) - admit to observe overnight + analgesia
How is a sternal # treated?
Symptomatic treatment + observe for associated injuries
How are flail chest or extensive rib #s treated? Why?
High flow O2 and analgesia. CPAP or IPPV may be necessary. Adequate ventilation may be prevented, pt may present with severe respiratory distress
What are the serious complications that can occur fter rib or sternal #s?
- Cardiac tamponade
- Pneumothorax
How do fractures of the pelvis typically occur in pts >60?
Low energy - fall from standing height
How do fractures of the pelvis typically occur in pts <60?
High energy - RTA, falls at work, sport
Considering the force required to # a young pts pelvis, what are the outcomes like for these pts?
Morbidity and mortality can be as high as 20%.
Main cause of death in multiple trauma pts.
What system is used to classify pelvic #s?
Young and Burgess
What is true of an isolated pelvic #?
It is generally stable - the ring will not break
What is true of pelvic #s with 2 breaks in a ring?
Unstable as it is able to displace or open
What are the Young and Burgess classifications?
- AP compression
- Lateral compression
- Vertical shear
- Combined mechanical
How can we image the pelvis to assess the structures there?
AP x-ray pelvis
CT to assess posteroir structures
How do we treat a stable single ring #?
- Check for sacroiliac ligament injury (indicates if unstable)
- CT scan to confirm stability before mobilisation
- Bed rest, analgesia, early mobilisation
How do we treat an unstable multiple ring #s?
- Establish haemodynamic control as liable to massive haemorrhage + ABCDE
- CT to define the #
- External fixation to stabilise
- May require screw/plate fixation depending on location
Name some major complications of unstable pelvic #s.
- Haemorrhage
- Urogenital injury
- Thromboembolism
- Neuro injury
- Paralytic ileus
- OA
- Malunion -> difficult pregnancy
Apart from ring #s in the pelvis, what other #s can occur?
Acetabular #s
Sacral #s
What is the most common # in the elderly?
Neck of femur #s
What are the risk factors for NoF#s?
- Increasing age
- Decreasing bone mass/osteoporosis
- Increased risk of falls
- Lower body weight
How should NoF #s be described?
Anatomically - intra- or extra- capsular, subtrochanteric, displaced or undisplaced, relationship to the blood supply
What is an intracapsular NoF#?
occuring within the joint capsule, above the intertochanteric line
What is an extracapsular NoF#?
occuring outside the joint capsule, along or below the intertochanteric line
What kind of NoF#s are at risk of avascular necrosis?
Intracapsular displaced #s
Tell me about subtrochanteric #s
Occur below the level of the lesser trochanter.
Often occur through an area of pathological bone (metastatic) in older pts.
What medical problems must be considered in pts with NoF #s?
Stroke, MI, hypotension, alcoholism, infection, electrolyte imbalance, etc etc - causes of a fall that arent purely mechanical
What is the common appearance of a hip fracture? Why?
Leg shortened and externally rotated if the fracture is displaced
What will be found O/E of a hip #?
Straight leg raise and hip movements globally painful
Leg short and externally rotated
WRT SHx, what is important to know with a hip #?
- Pre-injury mobility baseline
- Home circumstances
What must we assess with a NoF #?
Neurovascular state
How should we image a NoF #?
AP and lateral plain radiograph - good for displaced #s.
If unable to visualise # on xray, Gold standard = MRI
Generally speaking, what is the treatement for hip #s?
Surgical stabilisation
How are intracapsular NoF undisplaced impacted #s in the elderly treated?
Mobilise early w/ analgesia
Operate only if displaces later
How are intracapsular NoF undisplaced #s treated?
Internal fixation - dynamic hip screw (DHS) or cannulated screws
How are intracapsular NoF displaced #s treated?
Hemiarthroplasty
When are total hip replacements used?
If symptomatic pre-existing arthritis or those with few co-morbidities
How are extracapsular NoF #s treated?
DHS
Intramedullary hip screw if 4-part #
How are subtrochanteric #s treated?
Intramedullary nail or fixed angle plating
After NoF #s, what is the 90 day mortality rate in the elderly?
20%
Aside from mortality, what are the possible complications of NoF #s/surgery?
- AVN of femoral head
- Dislocation of arthroplasty
- Loss of fixation
- Non-union
- Lower limb thromboembolic disease
How are femoral shaft #s described?
Anatomically e.g. oblique mid-shaft femoral #
When the femoral shaft is #ed, what else should we look for?
Associated injuries - polytrauma is common (head, chest, abdo, ipsilateral NoF)
When a pt comes into A&E with a femoral shaft #, what should ya do?
ABCDE assessment haemorrhage assessment and compensation**
Why do an A to E with a femoral shaft #?
Large blood loss is common (up to 1.5 L/ 4U), but can be hidden by haemodynamic compensation in young pts
How do we compensate for potential blood loss in a femoral shaft #?
Give 2000ml of crystalloid via 1 of 2 large bore cannula
Before imaging a femoral shaft #, what should we do in A&E?
Splint it! Helps control pain and haemorrhage
What are the potential complications of femoral shaft #s/surgery? It’s a big ol’ list.
- Compartment syndrome
- Fat embolus
- Infection
- Non-union
- Thromboembolic disease
- Neuro injury
- Malunion
- Pressure sores/bronchpneumonia/UTI if treated conservatively
What is an “open” fracture?
When there is direct communication between the # and the external environment
What are the most common places for open #s to occur?
Tibial Phalangeal Forearm Ankle Metacarpal
What should all pt with open fractures get?
Abx cover and an up to date tetanus vaccination
With an open #, which teams should potentially be involved?
T&O
Plastics
Vascular surgeons
Define OA.
Condition characterised by progressive loss of articular cartilage and remodelling of underlying bone
What is responsible for remodelling and cartilage degradation in OA?
Chondrocytes and inflammatory cells in the surrounding tissues
Which joints are most commonly affected in OA?
Small joints of hands/feet
Hips
Knees
What is the pattern of pain and stiffness with OA?
Worse with use, relieved by rest
If you suspect OA in the hands, what else should you rule out?
De Quervain’s tenosynovitis
RA
Gout
If you suspect OA in the hip, what else should you rule out?
Trochantic bursitis
Radiculopathy
Spinal stenosis
Iliotibial band syndrome
If you suspect OA in the knee, what else should you rule out?
Referred hip pain
Meniscal tear
Ligament tear
Chondromalacia patellae
What radiological features can you see on an xray of a pt with OA?
Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis
What conservative management can we give for OA?
Pt education
Physiotherapy - strengthen and exercise
Ice/heat packs
Joint supports
What medical management can we give for OA?
Simple analgesia and topical NSAIDs
Depending on the site affected and the failure of conservative and medical management, what surgical intervention can we offer for OA?
Arthroplasty, athroscopy, or osteotomy
What is septic arthritis?
Infection of a joint
What organisms commonly cause septic arthritis? Who are they most common in?
Staph aureus (adults)
Strep spp.
N. gonorrhoea (young, sexually active)
Salmonella (sickle cell disease)
If not treated in a timely fashion, what can septic arthritis lead to?
Articular cartilage damage -> OA
What are the main risk factors for septic arthritis?
Age over 80 Pre-existing joint disease DM/immunosuppression Chronic renal failure Hip/knee prosthesis IV drug use
What is the most common presentation for septic arthritis?
Single swollen joint, causing severe pain
60% will be pyrexic
What will you find O/E of a septic arthritic joint?
Red, swollen, warm, pain on movement (active and passive), unabe to weight bear.
How should we investigate ?septic arthritis?
- Routine bloods, including FBC, CRP, ESR, urate, and blood cultures.
- Joint aspiration
How is joint fluid analysed in ?septic arthritis?
Gram stain
Leucocyte count
Polarising microscopy
Fluid culture
Do we use imaging for septic arthritis?
Yes - plain radiograph
Further imaging isn’t used regularly
How do we manage septic arthritis?
Manage as per results of investigations.
Fluid resus, empirical abx asap initially IV, continue for ~4-6 weeks.
Surgical irrigation and drainage (“washout”)
Aside from OA, what can be another complication of septic arthritis?
Osteomyelitis
What is compartment syndrome?
Critical pressure increase within a confined compartmental space
What does compartment syndrome cause in the affected limb?
Decline in perfusion pressure -> ischaemia and necrosis if not treated quickly.
If untreated -> limb loss, multi-organ failure, and death.
When does compartment syndrome usually occur?
Post #, trauma, iatrogenic vascular injury, tight cast/splint, DVT, or post-reperfusion syndrome swelling
In the first stage of compartment syndrome, how does it make itself worse?
Fluid in the compartment increases the pressure, causing venous congestion, which further increases the pressure
What are the Heberdens nodes?
Hard or bony swellings that can develop in the distal interphalangeal joints due to OA
What are the clinical features of compartment syndrome?
- Pain disproportionate to the injury
- Worsening pain with passive movement
- Parasthesia
- Generalised muscular tenderness
How do we manage compartment syndrome?
- Keep limb at neutral level
- High flow oxygen
- IV crystalloids
- Remove constricting dressings
- Analgesia and anti-emetics
Definitive treatment with emergency open fasciotomy
What, apart from death and limb loss, can be complications of compartment syndrome?
Rhabdomyolysis
Reperfusion syndrome
What is adhesive capsulitis? What is it also known as?
Glenohumeral joint capsule becomes contracted and adherent to the humeral head.
Frozen shoulder
What clinical features occur in adhesive capsulitis?
Shoulder pain - deep and constant, often disturbs sleep.
Reduced range of movement.
Generalised tenderness.
External rotation and flexion mostly affected.
What causes adhesive capsulitis?
Primary is idiopathic
Secondary due to shoulder pathology and co-morbidities
What shoulder conditions can cause adhesive capsulitis?
Rotator cuff tendinopathy
Subacromial impingement
Biceps tendinopathy
Prev. surgery/trauma
What co-morbidities can cause adhesive capsulitis?
Diabetes mellitus
Inflammatory conditions
What are the 3 stages of adhesive capsulitis?
Initial painful stage
Freezing stage
Thawing stage
Can imaging help us with diagnosis of adhesive capsulitis?
Noop.
Generally not as a rule. MRI can show joint capsule thickening, but can also rule out other pathology.
How do we manage adhesive capsulitis?
It is usually self limiting, but has high incidence of recurrence.
Educate and reassure
Physiotherapy
Analgesia - start with paracetamol/NSAIDS. Injection/oral corticosteroids if no improvement.
Can we operate on adhesive capsulitis?
Yeah, why else would it be in this deck of flashcards? It’s rarely done though.
Why would we use surgery to help with adhesive capsulitis?
No improvement with conservative management over 3 months/ significant affect on QoL
How can we use surgery to help with adhesive capsulitis?
Joint manipulation under GA to remove adhesions, or release joint capsule
What is subacromial impingement syndrome?
Inflammation and irritation of rotator cuff tendons as they pass through the subacromial space
What does subacromial impingement syndrome cause?
Pain, weakness, and reduced range of movement
What conditions can cause SAIS?
Rotator cuff tendonitis
Subacromial bursitis
Calcific tendonitis
Who is SAIS most common in?
Pts under 25, active individuals, and manual workers
What is the most common symptom of SAIS?
Progressive pain in anterior superior shoulder
What is Hawkin’s test?
Test for SAIS in the shoulder - flex shoulder to 90 degrees, and elbow also. Examiner stabilises the humerus and passively internally rotates arm.
What is the sign of a positive Hawkins test?
Pain in the anterolateral aspect of shoulder
How is imaging useful in SAIS?
Confirming a clinical diagnosis by MRI
How is SAIS managed mainly?
Conservatively
What is the conservative management for SAID?
Analgesia (usually NSAIDS)
Physio
Trialed corticosteroid injections if required
When do we consider surgery for SAIS?
6 months with no response to conservative management
What complications can SAIS cause?
Rotator cuff degeneration/tear
Adhesive capsulitis
Complex regional pain syndrome
What is the resolution rate for SAIS?
60-90% with early diagnosis and management
How will OA present typically?
Dull ache around hip, that can extend or refer to the knee.
Worse with activity, better with rest.
O/E of a pt with hip OA, what do we see on inspection?
Muscle wasting (quads and gluts). Leg length discrepancy or fixed flexion deformity. Antalgic/Trendelenberg gait
O/E of a pt with hip OA, what do we see on movement?
Crepitus on passive movement
Reduced range of movement
What are the symptoms of carpal tunnel syndrome?
Pain, numbness, and parasthesia in lateral 3.5 digits
Who usually gets carpal tunnel syndrome?
Women
People aged 45-60
Main risk factors for carpal tunnel syndrome?
Female Increasing age Pregnancy Obesity Previous wrist injury
MEDIAN TRAP?
Myoxoedma (O)Edema Diabetes Idiopathic Acromegaly Neoplasm
Trauma
Rheumatoid arthritis
Amyloidosis
Pregnancy
In carpal tunnel syndrome, why can the palm be spared from symptoms?
Te palmar cutaneous branch of median nerve branches off proximal to flexor retinaculum, so does not pass through the carpal tunnel.
What story might a carpal tunnel pt tell about the pain?
Worse at night but the symptoms go away if they hang their arm over the edge of the bed, or by shaking the arm
How do we test for carpal tunnel syndrome?
Tinel’s test
Phalen’s test
What is Tinel’s test?
Percuss over median nerve to try and reproduce symptoms
What is Phalen’s test?
Hold wrist in full flexion for one minute.
Differentials for carpal tunnel syndrome?
Cervical radiculopathy involving C6
Pronator teres syndrome
Flexor carpi radialis tenosynovitis
How do we manage carpal tunnel syndrome?
Wrist splint at night
Trial injected corticosteroids
Release surgery in severely limiting cases
What is De Quervain’s tenosynovitis?
Inflammation of the tendons within the first extensor compartment of the wrist, resulting in wrist pain and swelling.
Which tendons are involved in De Quervain’s tenosynovitis?
Extensor policis brevis
Abductor pollicis longus
Risk facors for De Quervain’s tenosynovitis?
Age 30-50
Female
Pregnancy
Hobbies/occupations involving repetative wrist movement
Which antiobiotic can predispose a person to achilles tendonitis?
Ciprofloxacin
