Trauma & Orthopaedics Flashcards
Compartment Syndrome - presentation
Pain out of proportion of injury Pain on passive stretch Paraesthesia Pale/pallor High pressures Paralysis
Compartment Syndrome - management
Management:
Initial
• Notify trauma/ortho team - reg/consultant input needed
• Removed external dressings or bandages
• Elevate limb above heart
• Maintain good pressure control - avoid hypotension
Definitive
• Emergency fasciotomy - cut down & release fascia & relieve pressure
○ Explore, debride & remove any necrotic tissue
○ Wound left open but dressed
○ Plastics input for repair & potential grafts
Necrotising fasciitis - definition & aetiology/risk factors
rapidly progressing soft tissue infection which spreads along fascial planes
when involves penis/scrotum = Fournier’s gangrene
caused by polymicrobial infection or group a strep
trauma (open fractures), diabetes, immunocompromised, malignancy, IVDU, abscesses, age >60 - older age increases risk
Necrotising fasciitis - clinical features
Pain - precedes by 24-48hrs
Stages:
○ Stage I - Erythema, tenderness, swelling and warmth.
○ Stage II - Bullae formation, blistering and fluctuation of the skin.
○ Stage III - Haemorrhagic bullae, crepitus and tissue necrosis.
Fever, shock, AKI
Necrotising fasciitis - management
Imaging
Resuscitation
Surgical exploration & radical debridement +/- amputation
Board spec IV abx
Osteomyelitis - definition & pathogenesis
infection/inflammation of bone
causative organisms - staph aureus or pseudomonas aeruginosa (IVDU)
PATHOGENESIS
Haematogenous spread- refers to the spread via the blood
Non-haematogenous - breakdown or removal of the normal protective barriers
Osteomyelitis - clinical presentation
fever, pain, local inflammation
erythema
swelling
Osteomyelitis - risk factors
open fractures ortho ops inc prostetics IVDU diabetes - diabetic foot ulcers immunosuppressed PVD
osteomyelitis - investigations
Bloods • FBC - high WCC • CRP/ESR - high • U&Es - due to abx therapy • LFTs • HbA1c - DM = risk factor Imaging • X-rays; often won't show early changes, MRI; gold std used for dx
Osteomyelitis - management
Management:
• Medical; 6 week abx therapy
• Surgical; debridement of infected bone/tissu
Cauda Equina Syndrome - definition & classes
Compression of cauda equina (L2/L3)
Early - pain
Incomplete - + urinary difficulties
Retention – as above with painless retention
CES - causes
Lumbar disc herniation (L5/S1 and L4/L5 level most common) Metastasis/malignancy Lumbar cord stenosis Trauma NTD Infection (abscesses)
CES - Clinical Features
- Lower back pain
- Unilateral or bilateral leg pain
- Paraesthesia in lower limbs
- Weakness in lower limbs
- Incontinence - bladder/bowels
- Loss of sensation in perianal region
- Urinary retention
On examination CES will have LMN signs
CES - Investigations
Bedside • Observations • Urinalysis • Full neurological examination • PR exam Bloods • FBC & CRP
Imaging
• Bladder scan - if retention suspected
• X-rays - AP, lateral
• Emergency MRI - gold std to r/o or dx CES
CES - Management
• Surgical emergency - neurosurgical opinion & input is needed urgently
○ Lumbar decompression surgery
Red flags for back pain
Trauma Unexplained W/L Neurological sex Age>50 Fever IVDU Steroid use History of Ca
Hip Fractures - types & classification
above INTERtrochanteric line = INTRAcapsular
below INTERtrochanteric line = extracapsular (includes trochanteric & subtrochanteric lines)
Garden’s (for intracapsular fractures)
- Type I; incomplete & non-displaced - Type II; completed but non-displaced - Type III; partial displacement - Type IV; fully displaced
Risk factors for hip fracture
Trauma - low E in elderly, high E in younger patients Age Osteoporosis Sex Steroid Use Low BMI Smoking Excess alcohol intake Metastatic spread of cancer to bone
Clinical Features of Hip Fracture
• Pain over area
• Pain in groin or hip, may radiate to knee
• Unable to weight bear
• Leg shortened & externally rotated
○ only present if significant displacement
• Limited ROM
• Swelling
Investigations in A&E - Hip Fracture
Hip fracture is a radiological diagnosis but wider investigations & assessment should always take place into why the patient has fallen
Bedside • Observations • Urinalysis - r/o infection • Examination/A to E • ECG - r/o cardiac cause
Bloods • FBC - Hb (important for surgery), WCC (signs of infection), Fe • U&Es - dehydration, electrolyte abnormalities • CRP • Clotting - surgery • Group & Save x 2 • Bone profile • Vitamin D
Imaging
• CXR: required pre-operatively.
• Plain films: XR pelvis, AP and lateral of affected hip. Full length views of the femur may be obtained, particularly if metastatic disease in the bone is suspected.
• MRI/CT: if plain films are inconclusive, to rule out occult fracture. MRI is gold-standard, CTs are generally more readily available
Management of Hip Fracture
Dependent on type of fracture i.e. intracapsular vs extracapsular, displaced vs non-displaced
Initial
• Any resuscitation needed e.g. fluids
• Analgesia
• Medication review - anticoagulants
Surgical management
• Intracapsular fractures - assess risk of AVN
○ Minimally or non-displaced fractures –> hip screws
○ Displaced fractures –> THR or hemiarthroplasty (choice depends on patient’s performance status)
• Extracapsular fractures
○ Intertrochanteric (bet greater & lesser trochanters) –> DHS
○ Subtrochanteric (within 5cm below lesser trochanter) –> IM nail
Open fractures - definition, classification & management
Any fracture complicated by one or more wounds
Classified using Gustilo Anderson Classification
Management: Initially resuscitate & stabilise Photographs Cover/dress/clean superficially Realign & splint Board spectrum antibiotics Tetanus vaccination Surgical repair & debridement
Red Flag Causes of Back Pain & Hallmark Symptoms
Spinal fracture (e.g., major trauma)
Cauda equina (e.g., saddle anaesthesia, urinary retention, incontinence or bilateral neurological signs)
Spinal stenosis (e.g., intermittent neurogenic claudication)
Ankylosing spondylitis (e.g., age under 40, gradual onset, morning stiffness or night-time pain)
Spinal infection (e.g., fever or a history of IV drug use)
Metastatic Spinal Cord Compression - Definition
Metastasis in spine causing compression of spinal cord above the cauda equina -
RADIOLOGICAL EVIDENCE OF INDENTATION OF THECAL SAC 2O TO CANCER
MSSC - Clinical Features
• Back pain
○ Worse on straining or coughing
○ Progressive, severe, radicular, can precede neuro sx by weeks
• Motor symptoms - weakness, paralysis
• Sensory symptoms - pins & needles, loss of sensation
On examination MSSC will give UMN signs (hypertonia, hyperreflexia, positive Babinski)
MSSC - Common primary sites
Lung, breast, kidney, prostate and thyroid cancers
MSSC - investigations & management
Investigations & Diagnosis:
Urgent MRI needed
Management
• Activate MSSC pathway & notify co-ordinator
• High dose dexamethasone
• Analgesia
• Surgery - dependent on patient’s prognosis & perceived benefit
A 32 year old bouncer presents with pain in his right shoulder for 5 weeks. It is worse when he is lifting; sometimes catches when reaching for things. It is affecting his sleep.
On examination normal C spine, no visible deformity, no bony tenderness, painful abduction and internal rotation. Positive empty can test. What is the most likely diagnosis?
OPTIONS: Adhesive capsulitis, Referred pain from cervical spine, Shoulder Impingement, OA of the gleno-humeral joint
Shoulder Impingement
36 year old woman works in Asda. 12 month history of pain in right heel. Worse when walking, leading to increasing amount of time off work.
On examination, mildly over-pronated feet. Tender over medial plantar fascia, pain with passive dorsiflexion of the ankle. Positive Windlass test. Most likely diagnosis?
Plantar fasciitis
What is plantar fasciitis associated with?
pronated foot type, Obesity Increased load (runners heel) Increased age (fat pad atrophy) Systemic causes – e.g. RA, Ank Spond
55 year oldlady, with T2DM.Gradual onset of severe pain and stiffness in her left shoulder.Cannot lie on the affected side, interfering with sleep.Works as a secretary, is struggling to drive.
On examination, shoulder joint generally tender throughout to palpation. Restriction of all shoulder movements, both active and passive. What is the likely diagnosis?
OPTIONS: OA of Glenohumeral joint, Rotator Cuff Injury, Subacromial Impingement
or Adhesive Capsulitis
Adhesive Capsulitis
There tends to be three phases:
Phase 1 - severe generalised pain associated with stiffness. Daily activities are limited (eg, putting on a jacket). It can last up to nine months.
Phase 2 - pain usually gradually subsides but the shoulder is stiff. Movement can become more limited. External rotation is usually very limited. This phase lasts between 4-12 months.
Phase 3 - the shoulder becomes less stiff. There is an increase in the range of movement. This phase usually lasts 1-3 years.
Symptoms can persist for 18 months to three years or more.However, over 90% of patients with spontaneous frozen shoulder have been shown to recover to normal levels of function and movement by two years without any treatment.
Treatment – Analgesia, Physiotherapy, corticosteroid injections, surgery
A 32/40 pregnant woman presents with increasing tingling, numbess and pain affecting her thumb, index and middle fingers of her right hand. What clinical examinations would be most appropriate?
Tinel‘s Sign - tapping lightly over the median nerve at the wrist causes a distal paraesthesia in the median nerve distribution.
What treatments for Carpal Tunnel has the highest success rate?
Surgical Release
The others are treatment options though!
Avoid overuse of the wrist
Analgesia/NSAIDS
Wrist splint
Steroid injection – helpful but recurrence within 12 months between 50-75%
Surgery – carpal tunnel release provides highest success rate (75%).
A 46 year old male presents with pain to his right (dominant) elbow for three weeks. It is most painful when trying to lift a full kettle or when carrying heavy shopping bags. When you examine him you are able to reproduce the pain by flexing (bend) the wrist and then pronating the forearm. Which of the following is the most likely diagnosis?
OPTIONS: Medial Epicondylitis (Golfer‘s Elbow), DeQuervains Tenosynovitis, Radial Head Subluxation (Pulled Elbow) OR Lateral Epicondylitis (Tennis Elbow)
Lateral Epicondylitis
(Tennis Elbow)
Test with Mill’s test
A 46 year old male presents with pain to his right (dominant) elbow for three weeks. It is most painful when trying to lift a full kettle or when carrying heavy shopping bags. When you examine him you are able to reproduce the pain by flexing (bend) the wrist and then pronating the forearm. Which of the following is the most likely diagnosis?
OPTIONS: Medial Epicondylitis (Golfer‘s Elbow), DeQuervains Tenosynovitis, Radial Head Subluxation (Pulled Elbow) OR Lateral Epicondylitis (Tennis Elbow)
Lateral Epicondylitis
Tennis Elbow
A 31 year old woman presents with severe pain in her right wrist which is affecting her ability to pick up and change the nappy of her 8 week old baby. You suspect a diagnosis of De Quervains Tenodynovitis after completing your history and examination. Diagnosis & treatments offers the highest chance of cure?
DeQuervain’s Tenosynovitis
Physiotherapy- usually too painful
Topical or oral NSAIDs - gels are usually not effective
***Steroid injection- cures 70% andoffenall that is needed
Thumbspica(not a wrist splint)
Surgical release in persistent cases
