Trauma and Orthopedics Flashcards
1
Q
What are the steps to a joint examination?
A
Introduce Ask Look Feel Move Special Tests
2
Q
When assessing the neurological functions of the limbs and trunk, what else do we need to assess?
A
Power
Co-ordination
Reflexes
Sensation
3
Q
What is the difference between primary and secondary bone healing?
A
Primary does not produce a callus, and is due to fracture fragments being reduced anatomically - there is no movement between the fracture surfaces.
4
Q
What are the 2 distinct but similtaneous processes occuring in secondary bone healing?
A
Intramembranous and endochondral ossification
5
Q
What are the 2 stages of secondary bone healing?
A
- Haematoma and inflammation
2. Callus formation - soft and hard
6
Q
What are Perkins rules?
A
Rules describing the length of time it takes for different fractures to unite
7
Q
How long, according to Perkins rules, do cancellous/metaphyseal bone fractures take to unite?
A
6 weeks
8
Q
How long, according to Perkins rules, do cortical/diaphyseal bone fractures take to unite?
A
12 weeks
9
Q
How long, according to Perkins rules, do tibial fractures take to unite?
A
24 weeks
10
Q
How long, according to Perkins rules, do fractures in children take to unite?
A
(Age of child + 1) weeks
Although should apply common sense in older children
11
Q
What is delayed union of a fracture?
A
A failure of union to occur in 1.5 times the normal time for fracture union
12
Q
What is non-union of a fracture?
A
A failure of union to occur in twice the normal time for fracture union
13
Q
What are the 2 types of non-union?
A
Hypertrophic and Atrophic
14
Q
Hypertrophic vs Atrophic non-union
A
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)
15
Q
What is a fracture?
A
A soft tissue injury with an associated broken bone
16
Q
Considering the definition of a fracture, what principle should be used when treating a pt with one?
A
Treat the soft tissues with care and the broken bone will heal well
17
Q
What are the 4 principles of modern fracture reduction and treatment?
A
- 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
18
Q
What is the cheapest and easiest way to reduce a fracture?
A
Casting
19
Q
What can we do to immobilise a fracture prior to definitive management?
A
Half casts, or back-slabbing
20
Q
What are the complications of casting?
A
Cast problems (loosening, pressure areas) Thromboembolic events Coverage of wounds Skin breakdown Compartment syndorme
21
Q
What injuries of the phalanges and metacarpals can occur?
A
Extra-articular - shaft fractures and base fractures
Dislocations - thumb MCPJ, PIP
Neck fracture (metacarpal)
22
Q
How do thumb injuries usually occur?
A
Direct blow, or forced opposition
23
Q
How do metacarpal injuries usually occur?
A
“punch” injury - Friday night, or boxers fracture
24
Q
How do distal phalanx injuries usually occur?
A
Crush injury
25
How do proximal and middle phalanx injuries usually occur?
Direct blow, or twisting
26
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.
27
What is the mechanism of a scaphoid fracture?
Fall onto outstretched hand (forced dorsiflexion)
28
What is the sign of effusion in a scaphoid fracture?
Anatomical snuffbox feels full
29
Where is tender in a scaphoid fracture? 2 sites
- Anatomical snuffbox (dorsal)
| - Tubercle of scaphoid (volar)
30
How do we investigate a ?scaphoid facture?
Scaphoid series radiograph films
31
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)
32
What are the complications of scaphoid fracture?
- Non union
- Avascular necrosis (esp. with proximal or displaced fractures)
- Degenerative change
33
After scaphoid, what is the next most commonly fractured carpal bone?
Hamate fracture
34
How are distal radius and ulna fractures usually obtained?
Fall on an outstretched hand
35
How common are distal radius or ulna fractures?
Very - makes up 1 in 6 of all fractures
36
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)
37
What can accompany #distal radius/ulna?
Scaphoid and ligamentous wrist injuries
38
What is a Colles fracture?
The most common radial fracture - the wrist and hand (i.e. all structures distal to the #) are displaced posteriorly
39
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
40
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
41
Having made you learn what Colles, Barton's and Smiths #s are, what is the safest way to describe a #?
By radiological/anatomical features
42
What is a Barton's fracture?
Intra-articular distal radius # with associated dislocation of radio-carpal joint. Can be volar or dorsal.
43
What are the characteristics that we can describe in a #?
```
Site - which bone, where in that bone?
Pattern
Displacement
Angulation
Dislocated/In joint
```
44
What is important to remember when looking at a radiograph of a #?
Theres should be 2 views!! AP and lateral
45
What # patterns can there be?
```
Transverse
Oblique
Spiral
Comminuted
Multi-fragmented
Segmental
```
46
How can radial/ulnar shaft fractures be caused?
Fall on outstretched hand
| Direct blow to forearm
47
What often happens if the ulna or radius is fractured on its own?
The other bone is dislocated
48
What do we call a proximal ulnar fracture with proximal radial head dislocation?
Monteggia fracture
49
What do we call a distal radial fracture with distal radio-ulna joint dislocation?
Galaezzi fracture
50
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.
51
Where can the humerous fracture in adults?
Shaft
Condyles
Olecranon
Radial head
52
How do humeral shaft #s usually occur?
Fall with torsion or direct blow
53
What would we suspect if a humeral shaft # occured after a low energy blow?
Osteoporosis
54
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
55
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
56
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
57
How are humeral shaft #s usually managed?
Conservatively
58
When would surgical intervention be indicated for a humeral shaft #?
Open fracture
Vascular injury
Floating shoulder/elbow
Intra-articular extension
59
What can a pt do if they fall onto their elbow?
Humeral condylar #
60
What is the mechanism for humeral condylar #s?
Olecranon driven into the humerus -> condyle splits into "T" or "Y" shape
61
What is the most common type of humeral condylar #?
Intercondylar - fracture line goes from articular surface to supracondylar region (T or Y shape)
62
There are 3 other types of humeral condylar #. What are they?
- Supracondylar
- Isolated medial or lateral condyle fracture
- Isolated capitellum #
63
What is the Colton classification?
Classification of olecranon fractures according to whether it is displaced.
64
What is a type one and a type two colton fracture?
1 - undisplaced
| 2 - displaced
65
How can a radial head # occur?
FOOSH with the forearm in pronation
66
Which system do we use for radial head # classification?
Mason classification
67
What complications can occur as a result of elbow fractures?
Joint stiffness
Osteoarthritis
Heterotopic ossification
Neurovascular injury
68
What is the terrible triad of the elbow?
Posterior elbow dislocation w/ radial head fracture + coronoid process fracture + lateral collateral ligament tear
69
By what mechanism does the clavicle #?
Fall, or direct blow to lateral shoulder
70
What % of all #s do clavicle #s make up?
5-10%
71
Where do the majority of clavicle #s occur?
Middle 3rd (i.e. 2/3rds from sternum)
72
WRT displacement, how are clavicle #s assessed?
WRT the sternoclavicular joint
73
How are the majority of clavicle fracture treated?
Conservatively
74
How do most scapula #s occur?
Direct trauma, usually a RTA
75
What other injuries should be considered/ruled out when a scapula # is present?
- Rib #
- Pulmonary contusion
- Pneumo/haemothorax
- Ipsilateral clavicle #s
76
In the shoulder region, what can dislocate?
```
Sternoclavicular joint
Acromioclavicular joint
Glenohumeral joint (anterior or posterior)
```
77
Which shoulder dislocation is the most common?
Anteroir dislocation of glenohumeral joint - 95% of dislocations
78
Are sternoclavicular joint dislocations common?
Noop
79
Who is at risk of reoccuring shoulder dislocations?
Pts whos shoulder dislocates first at a young age
80
Why do shoulder dislocations reoccur?
Bankart lesions or capsular redundancy
81
When do single rib #s typically occur?
Direct injury such as a fall
82
Apart from trauma, when can lower ribs #?
With coughing
83
When do sternal #s typically occur?
Traaaaauma
84
What can happen with a high velocity RTA/crush injury to ribs and sternum?
"Stove-in" chest with flail segments (multiple rib #s)
85
How are rib #s treated?
- Single ribs - analgesia/symptomatic treatment
| - Multiple (>3) - admit to observe overnight + analgesia
86
How is a sternal # treated?
Symptomatic treatment + observe for associated injuries
87
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
88
What are the serious complications that can occur fter rib or sternal #s?
- Cardiac tamponade
| - Pneumothorax
89
How do fractures of the pelvis typically occur in pts >60?
Low energy - fall from standing height
90
How do fractures of the pelvis typically occur in pts <60?
High energy - RTA, falls at work, sport
91
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.
92
What system is used to classify pelvic #s?
Young and Burgess
93
What is true of an isolated pelvic #?
It is generally stable - the ring will not break
94
What is true of pelvic #s with 2 breaks in a ring?
Unstable as it is able to displace or open
95
What are the Young and Burgess classifications?
- AP compression
- Lateral compression
- Vertical shear
- Combined mechanical
96
How can we image the pelvis to assess the structures there?
AP x-ray pelvis
| CT to assess posteroir structures
97
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
98
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
99
Name some major complications of unstable pelvic #s.
- Haemorrhage
- Urogenital injury
- Thromboembolism
- Neuro injury
- Paralytic ileus
- OA
- Malunion -> difficult pregnancy
100
Apart from ring #s in the pelvis, what other #s can occur?
Acetabular #s
| Sacral #s
101
What is the most common # in the elderly?
Neck of femur #s
102
What are the risk factors for NoF#s?
- Increasing age
- Decreasing bone mass/osteoporosis
- Increased risk of falls
- Lower body weight
103
How should NoF #s be described?
Anatomically - intra- or extra- capsular, subtrochanteric, displaced or undisplaced, relationship to the blood supply
104
What is an intracapsular NoF#?
occuring within the joint capsule, above the intertochanteric line
105
What is an extracapsular NoF#?
occuring outside the joint capsule, along or below the intertochanteric line
106
What kind of NoF#s are at risk of avascular necrosis?
Intracapsular displaced #s
107
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.
108
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
109
What is the common appearance of a hip fracture? Why?
Leg shortened and externally rotated if the fracture is displaced
110
What will be found O/E of a hip #?
Straight leg raise and hip movements globally painful
| Leg short and externally rotated
111
WRT SHx, what is important to know with a hip #?
- Pre-injury mobility baseline
| - Home circumstances
112
What must we assess with a NoF #?
Neurovascular state
113
How should we image a NoF #?
AP and lateral plain radiograph - good for displaced #s.
| If unable to visualise # on xray, Gold standard = MRI
114
Generally speaking, what is the treatement for hip #s?
Surgical stabilisation
115
How are intracapsular NoF undisplaced impacted #s in the elderly treated?
Mobilise early w/ analgesia
| Operate only if displaces later
116
How are intracapsular NoF undisplaced #s treated?
Internal fixation - dynamic hip screw (DHS) or cannulated screws
117
How are intracapsular NoF displaced #s treated?
Hemiarthroplasty
118
When are total hip replacements used?
If symptomatic pre-existing arthritis or those with few co-morbidities
119
How are extracapsular NoF #s treated?
DHS
| Intramedullary hip screw if 4-part #
120
How are subtrochanteric #s treated?
Intramedullary nail or fixed angle plating
121
After NoF #s, what is the 90 day mortality rate in the elderly?
20%
122
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
123
How are femoral shaft #s described?
Anatomically e.g. oblique mid-shaft femoral #
124
When the femoral shaft is #ed, what else should we look for?
Associated injuries - polytrauma is common (head, chest, abdo, ipsilateral NoF)
125
When a pt comes into A&E with a femoral shaft #, what should ya do?
ABCDE assessment ****haemorrhage assessment and compensation******
126
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
127
How do we compensate for potential blood loss in a femoral shaft #?
Give 2000ml of crystalloid via 1 of 2 large bore cannula
128
Before imaging a femoral shaft #, what should we do in A&E?
Splint it! Helps control pain and haemorrhage
129
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
130
What is an "open" fracture?
When there is direct communication between the # and the external environment
131
What are the most common places for open #s to occur?
```
Tibial
Phalangeal
Forearm
Ankle
Metacarpal
```
132
What should all pt with open fractures get?
Abx cover and an up to date tetanus vaccination
133
With an open #, which teams should potentially be involved?
T&O
Plastics
Vascular surgeons
134
Define OA.
Condition characterised by progressive loss of articular cartilage and remodelling of underlying bone
135
What is responsible for remodelling and cartilage degradation in OA?
Chondrocytes and inflammatory cells in the surrounding tissues
136
Which joints are most commonly affected in OA?
Small joints of hands/feet
Hips
Knees
137
What is the pattern of pain and stiffness with OA?
Worse with use, relieved by rest
138
If you suspect OA in the hands, what else should you rule out?
De Quervain's tenosynovitis
RA
Gout
139
If you suspect OA in the hip, what else should you rule out?
Trochantic bursitis
Radiculopathy
Spinal stenosis
Iliotibial band syndrome
140
If you suspect OA in the knee, what else should you rule out?
Referred hip pain
Meniscal tear
Ligament tear
Chondromalacia patellae
141
What radiological features can you see on an xray of a pt with OA?
Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis
142
What conservative management can we give for OA?
Pt education
Physiotherapy - strengthen and exercise
Ice/heat packs
Joint supports
143
What medical management can we give for OA?
Simple analgesia and topical NSAIDs
144
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
145
What is septic arthritis?
Infection of a joint
146
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)
147
If not treated in a timely fashion, what can septic arthritis lead to?
Articular cartilage damage -> OA
148
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
```
149
What is the most common presentation for septic arthritis?
Single swollen joint, causing severe pain
60% will be pyrexic
150
What will you find O/E of a septic arthritic joint?
Red, swollen, warm, pain on movement (active and passive), unabe to weight bear.
151
How should we investigate ?septic arthritis?
- Routine bloods, including FBC, CRP, ESR, urate, and blood cultures.
- Joint aspiration
152
How is joint fluid analysed in ?septic arthritis?
Gram stain
Leucocyte count
Polarising microscopy
Fluid culture
153
Do we use imaging for septic arthritis?
Yes - plain radiograph
Further imaging isn't used regularly
154
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")
155
Aside from OA, what can be another complication of septic arthritis?
Osteomyelitis
156
What is compartment syndrome?
Critical pressure increase within a confined compartmental space
157
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.
158
When does compartment syndrome usually occur?
Post #, trauma, iatrogenic vascular injury, tight cast/splint, DVT, or post-reperfusion syndrome swelling
159
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
160
What are the Heberdens nodes?
Hard or bony swellings that can develop in the distal interphalangeal joints due to OA
161
What are the clinical features of compartment syndrome?
- Pain disproportionate to the injury
- Worsening pain with passive movement
- Parasthesia
- Generalised muscular tenderness
162
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
163
What, apart from death and limb loss, can be complications of compartment syndrome?
Rhabdomyolysis
| Reperfusion syndrome
164
What is adhesive capsulitis? What is it also known as?
Glenohumeral joint capsule becomes contracted and adherent to the humeral head.
Frozen shoulder
165
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.
166
What causes adhesive capsulitis?
Primary is idiopathic
| Secondary due to shoulder pathology and co-morbidities
167
What shoulder conditions can cause adhesive capsulitis?
Rotator cuff tendinopathy
Subacromial impingement
Biceps tendinopathy
Prev. surgery/trauma
168
What co-morbidities can cause adhesive capsulitis?
Diabetes mellitus
| Inflammatory conditions
169
What are the 3 stages of adhesive capsulitis?
Initial painful stage
Freezing stage
Thawing stage
170
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.
171
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.
172
Can we operate on adhesive capsulitis?
Yeah, why else would it be in this deck of flashcards? It's rarely done though.
173
Why would we use surgery to help with adhesive capsulitis?
No improvement with conservative management over 3 months/ significant affect on QoL
174
How can we use surgery to help with adhesive capsulitis?
Joint manipulation under GA to remove adhesions, or release joint capsule
175
What is subacromial impingement syndrome?
Inflammation and irritation of rotator cuff tendons as they pass through the subacromial space
176
What does subacromial impingement syndrome cause?
Pain, weakness, and reduced range of movement
177
What conditions can cause SAIS?
Rotator cuff tendonitis
Subacromial bursitis
Calcific tendonitis
178
Who is SAIS most common in?
Pts under 25, active individuals, and manual workers
179
What is the most common symptom of SAIS?
Progressive pain in anterior superior shoulder
180
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.
181
What is the sign of a positive Hawkins test?
Pain in the anterolateral aspect of shoulder
182
How is imaging useful in SAIS?
Confirming a clinical diagnosis by MRI
183
How is SAIS managed mainly?
Conservatively
184
What is the conservative management for SAID?
Analgesia (usually NSAIDS)
Physio
Trialed corticosteroid injections if required
185
When do we consider surgery for SAIS?
6 months with no response to conservative management
186
What complications can SAIS cause?
Rotator cuff degeneration/tear
Adhesive capsulitis
Complex regional pain syndrome
187
What is the resolution rate for SAIS?
60-90% with early diagnosis and management
188
How will OA present typically?
Dull ache around hip, that can extend or refer to the knee.
Worse with activity, better with rest.
189
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
```
190
O/E of a pt with hip OA, what do we see on movement?
Crepitus on passive movement
| Reduced range of movement
191
What are the symptoms of carpal tunnel syndrome?
Pain, numbness, and parasthesia in lateral 3.5 digits
192
Who usually gets carpal tunnel syndrome?
Women
| People aged 45-60
193
Main risk factors for carpal tunnel syndrome?
```
Female
Increasing age
Pregnancy
Obesity
Previous wrist injury
```
194
MEDIAN TRAP?
```
Myoxoedma
(O)Edema
Diabetes
Idiopathic
Acromegaly
Neoplasm
```
Trauma
Rheumatoid arthritis
Amyloidosis
Pregnancy
195
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.
196
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
197
How do we test for carpal tunnel syndrome?
Tinel's test
| Phalen's test
198
What is Tinel's test?
Percuss over median nerve to try and reproduce symptoms
199
What is Phalen's test?
Hold wrist in full flexion for one minute.
200
Differentials for carpal tunnel syndrome?
Cervical radiculopathy involving C6
Pronator teres syndrome
Flexor carpi radialis tenosynovitis
201
How do we manage carpal tunnel syndrome?
Wrist splint at night
Trial injected corticosteroids
Release surgery in severely limiting cases
202
What is De Quervain's tenosynovitis?
Inflammation of the tendons within the first extensor compartment of the wrist, resulting in wrist pain and swelling.
203
Which tendons are involved in De Quervain's tenosynovitis?
Extensor policis brevis
| Abductor pollicis longus
204
Risk facors for De Quervain's tenosynovitis?
Age 30-50
Female
Pregnancy
Hobbies/occupations involving repetative wrist movement
205
Which antiobiotic can predispose a person to achilles tendonitis?
Ciprofloxacin
