Trauma ortho 2 Flashcards
Hip fractures
X-ray - what would you see [2]
Disruption of Shenton’s line
Intracapsular or extracapsular
Hip fractures Mx
Immediate management [6]
ABCDE Analgesia: IV morphine Fluid resus Imaging DVT prophylaxis Prepare for theatre
Hip fractures Mx
Why would a conservative approach be rare? [2]
Who would this be applicable to? [1]
What is involved in prep for theatre? [6]
Why? Takes weeks to heal, leaves patient bedridden for extended periods of time
Those unfit for surgery
Prep for theatre:
- FBC
- Clotting, crossmatch 2 units
- U&E
- CXR
- ECG
- Gain consent
Hip fractures Mx
Surgical management
Intracapsular vs extracapsular
Intracapsular - REPLACE
Extracapsular - FIX
Hip fractures Mx
Surgical management of intracapsular # [3]
Disrupted blood supply so risk of AVN
Hemiarthroplasty
OR THR
Types of extracapsular fractures [2]
Trochanteric
Subtrochanteric
Mx of intracapsular hip fractures: Undisplaced [2]
- internal fixation or
- hemiarthroplasty if unfit.
Mx of intracapsular hip fractures: displaced [2]
- young and fit: reduction and internal fixation
- old and reduced mobility: hemiarthroplasty or THR
Mx of extra capsular hip fractures
Post-operative management of hip fractures in general [3]
Dynamic hip screw
SAME DAY MOBILISATION, anti-coagulation, good nutrition
Displaced intracapsular hip fracture: THR between hemiarthroplasty
THR: >70 with no co-morbidities
Hemiarthroplasty: >70 with major co-morbidities or immobile
Mx of extra capsular fractures
Dynamic hip screw
When would you use an intramedullary device for extra capsular fracture? [3]
Reverse oblique
Transverse
Subtrochanteric
Hip OA
RF [3]
Mx
- post-avascular necrosis of the hip
- paediatric hip disease
- BUT NOT increased BMI (unlike knee OA)
Mx: THR
Hip OA symptoms [4]
Poorly localized groin, thigh or buttock pain
Referred pain to knee
Worse on weight bearing
Stiffness on hip flexion eg tying shoelaces
Hip OA signs [3]
Antalgic gait Positive Trendelenburg sign Reduced ROM (esp internal rotation)
Types of THR for Hip OA [2]
Conventional (replacement of femoral head and neck)
Simple resurfacing of femoral head (young with preserved femoral neck)
Early complications of THR [6]
VTE Dislocation Deep infection Pathological fracture Nerve palsy Limb length discrepancy
Causes of hip replacement failure [4]
Prostethic loosening*
Dislocation
Periprosthetic fracture
Infection
Hip pain in adults differentials [8]
Osteoarthritis Inflammatory arthritis Referred lumbar spine pain Greater trochanteric pain syndrome Meralgia parenthetic Avascular necrosis Pubic symphysis dysfunction Transient idiopathic osteoporosis
Greater trochanteric pain syndrome AKA Cause Ep Symptoms
AKA Trochanteric bursitis
Due to repeated movement of the fibroelastic iliotibial band
Ep: women, 50-70 years
Pain and tenderness over the lateral side of thigh
Avascular necrosis definition
Causes [4]
Investigation [3]
Def: death of bone tissue secondary to loss of blood supply Causes: - long term steroid use - chemotherapy - alcohol excess - trauma Ix: - x-ray normal initially - crescent sign means collapse of articular surface - MRI*
Pubic symphysis dysfunction:
Causes
Symptom [2]
Sign
Common in pregnancy due to ligament laxity
Pain over the pubic symphysis with radiation to the groins and the medial aspects of the thighs.
A waddling gait may be seen
Transient idiopathic osteoporosis
Ep
Clinical features [4]
Third trimester Groin pain Associated with limited ROM at hip NWB Elevated ESR
Femoral shaft fracture
Management [4]
- stabilisation in ED with traction AND
- Thomas splint
- followed by locked intramedullary nail introduced proximally with a guide wire
- to allow early immobilisation
What must you always assess for in femoral shaft fractures? [2]
Sciatic nerve injury
Femoral artery injury, blood loss
Posterior hip dislocation
Most common mechanism of injury
Presentation [2]
Complications [3]
Ax: front seat passenger when knee strikes dashboard
Sy/Si:
- femoral head palpable in buttock
- leg is flexed, INTERNALLY rotated, adducted and shortened
Complications:
- sciatic nerve injury
- Equinus deformity
- AVN
Posterior hip dislocation
Investigation [2]
Mx [2]
Ix:
- AP and lateral XR
- MRI to assess for sciatic nerve injury
Mx:
- closed reduction under GA within 4h reduces risk of AVN
- followed by traction for 3w to promote joint capsule healing
Scaphoid fracture
Ax
Symptoms [3]
Investigations [2]
Ax: FOOSH
Sy/Si:
- tenderness over anatomical snuff box and scaphoid tubercle
- pain on axial compression of the thumb
- pain on ulnar deviation of a pronated wrist or supination against resistance
Ix:
- scaphoid series of XR
- MRI or repeat XR in 2w if -ve but highly suspicious of #
Scaphoid fracture mx [2]
Complication
Mx:
- immobilisation in neutral cast (or Futura splint) or
- percutaneous cannulated screw fixation
Cx: avascular necrosis (proximal pole relies on interosseous supply from distal part)
Ankle ligament strain
Classification [3]
Symptoms [3]
Inversion injury to anterior tibiofibular part of lateral ligament
Eversion injury: medial deltoid ligament
Syndesmosis injury
Symptoms:
- stifness
- tenderness over lateral ligament
- pain on inversion
Management of simple sprains
POLICE
Protection from further injury Optimal Loading Ice Compression Elevation + analgesia Aim: allow WB ASAP
What is a severe sprain?
How do we manage severe sprains?
Safety net [3]
Ligament completely ruptured, NWB Below knee immobilization for 10d Advise to return if: - any NV compromise - pain hindering WB after 24h - Not fully WB by 4d
ANKLE FRACTURES
Management of minimally displaced or stable fractures [3]
Management of high velocity or proximal injuries
Management of elderly patients
Weight bear
Immobilisation
the Controlled Ankle Motion boot does both these things
Surgical repair: compression plate
Elderly: conservative mx as thin bone doesn’t hold metalwork well
Neck of talus fracture
Mechanism
Mx
Ax: forced dorsiflexion
Mx: ORIF if displaced
Calcaneous fracture
Mechanism
Presentation [3]
Mx
Ax: serious manual worker fall e.g. ladder or scaffolding
Sy/Si:
- often bilateral
- swelling, bruising, inability to weight bear
- look for associated spinal injury*
Mx: immobilisation or surgery (cx higher with surgery)
Stress/March fracture
Ep
Ax
Mx
Ep: soldiers
Ax: excessive walking causes shaft # of 2nd or 3rd metatarsal
Sy/Si: pain and excessive walking
Ix: XR may be normal or show subtle periosteal changes
Mx: rest and analgesia +/- plaster cast
Lisfranc fracture
Ax
Which bones are involved
Ax: polytrauma or awkwardly stepping off kerb
Px:
- fracture dislocation of a tarsometatarsal joint causes
- dislocation of the second metatarsal joint (Lisfranc joint)
Lisfranc fracture
Presentation [2]
Mx [2]
Sy/Si:
- pain, tenderness and swelling
- causes COMPARTMENT SYNDROME OF MEDIAL FOOT
Mx:
- ORIF (precise anatomic reduction
- with screw fixation across second metatarsal joint (Lisfranc joint))
Ankle fractures
Ottawa Rules
Uses [2]
Can help to clinically ddx between likely sprain and likely fracture
Can guide indication for imaging in ED
Ankle fractures
Classification [4]
Medial malleolar
Lateral malleolar
Bimalleolar
Trimalleolar (third is the posterior part of tibia)
Ankle fractures
Weber AO system refers to level of fibular #
Describe what a Weber A # is and their likely management [2]
Transverse fractures
below the syndesmosis [1] generally stable fractures (can often be managed non- operatively) [1]
Ankle fractures
Weber AO system
Describe what a Weber B # is and their likely management [3]
at the level of the syndesmosis [1], extending proximally – spiral or short oblique fracture pattern [1]; may be stable or unstable fractures (more likely to require surgical fixation) [1]
Ankle fractures
Weber AO system
Describe what a Weber C # is and their likely management [3]
fracture above the tibial plafond [1], likely to involve a syndesmotic injury [1]; unstable fractures (should always be considered for surgical fixation) [1]
Ankle fractures
General mx approach [4]
Assess
Reduce
Immobilise in backslab
Plan definitive mx
Ankle fractures
Conservative management is best for which group of patients [2]
Stable, undisplaced fractures [1] with minimal disruption to articular surface [1]
Ankle fractures
Conservative management for displaced fractures - descrbe [3]
Manipulation under anaesthesia
Moulded casting to hold in place
Requires close follow up - X-ray at week 1 then week 2 as re-displacement is common
Ankle fractures
Surgical management indications [2]
Unstable # with taller shift or displacement and fragmentation of articular surface
Where conservative has failed
