Trauma & Orthopaedics Flashcards
Risk factors for primary OA?
obesity, advancing age, female gender, and manual labour occupations
Differentials for OA in the hands?
De Quervain’s tenosynovitis, rheumatoid arthritis, and gout
Differentials for OA in the hip?
trochanteric bursitis, radiculopathy, spinal stenosis, or iliotibial band syndrome
Differentials for OA in the knee?
meniscal or ligament tears, or chondromalacia patellae
General differentials for OA?
inflammatory arthropathies (e.g. rheumatoid arthritis), crystal arthropathies (e.g. gout or CPPD), septic arthritis, fractures, bursitis, or malignancy (primary or metastatic)
Classic radiological features of OA?
Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis
Outline management of OA
Conservative:
weight loss, strengthening exercises, local heat packs, joint support, physio
Medical:
simple analgesics and NSAIDs
intra-articular steroid injections (can cause steroid flare)
Surgical:
mainstay of management is with arthroplasty, however other options include osteotomy and arthrodesis (joint fusion)
What is the most important adage to remember for the surgical management in traumatic orthopaedic complaints?
‘Reduce – Hold – Rehabilitate’
In the context of high-energy injuries, this is precluded by resuscitation following ATLS principles
Reduction involves restoring the anatomical alignment of a fracture or dislocation of the deformed limb.
Reduction allows for what 4 things to occur?
- Tamponade of bleeding at the fracture site
- Reduction in the traction on the surrounding soft tissues, in turn reducing swelling
- Reduction in the traction on the traversing nerves, therefore reducing the risk of neuropraxia
- Reduction of pressures on traversing blood vessels, restoring any affected blood supply
Fracture reduction is typically performed closed in ED. However, some fractures need to be reduced open intraoperatively
What are the clinical requirements for fracture reduction?
Analgesia
- where regional or local blockade is sufficient and easily provided (e.g. phalangeal/metacarpal/distal radius fractures), this is the method of choice
short period of conscious sedation often in anaesthetic room
3 staff members - one to perform the reduction manoeuvre and one to provide counter-traction, with a third person needed to apply the plaster.
What is meant by ‘hold’ in fracture management?
generic term used to describe immobilising a fracture
consider whether traction needed - e.g. where the muscular pull across the fracture site is strong and the fracture is inherently unstable
most common ways to immobilise a fracture are via simple splints or plaster casts
When applying a plaster cast, the most important principles to remember are what?
For the first 2-weeks, plasters are not circumferential: (not always the case in children)
- They must have an area which is only covered by the overlying dressing, to allow the fracture to swell; if not the cast will become tight (and painful) overnight, and if left the patient is at risk of compartment syndrome
If there is axial instability ( the fracture is able to rotate along its long axis), e.g. combined tibia-fibula metaphyseal fractures or combined radius-ulna metaphyseal fractures, the plaster should cross both the joint above and below:
- usually termed ‘above knee’ or ‘above elbow’ plasters, respectively, preventing the limb to rotate on its long axis
What is important to consider when initiating fracture immobilisation?
Can the patient weight bear?
Do they need thromboprophylaxis?
If the patient is immobilised in a cast and is non-weight bearing, it is common to provide thromboprophylaxis
Have you provided advice about the symptoms of compartment syndrome?
What is the most important investigation when investigating an acute monoarthritis?
joint aspiration
The aspirate can be sent for white cell count and MCS, as well as light microscopy (for crystals)
aspiration of prosthetic joints should be done in theatre due to infection risk
What will synovial fluid appear like in a non- inflammatory arthritis, inflammatory arthritis and septic arthritis?
non- inflammatory arthritis - clear/straw coloured
inflammatory arthritis - clear/cloudy yellow
septic arthritis - turbid
What will the WCC look like in a non- inflammatory arthritis, inflammatory arthritis and septic arthritis?
non- inflammatory arthritis - moderate <2000
inflammatory arthritis - high >2000
septic arthritis - very high >50,000
What is septic arthritis?
infection of a joint most commonly caused by S. aureus
It is important that it is identified and treated quickly as it can cause irreversible articular cartilage damage or overwhelming sepsis and mortality
What are Spondyloarthropathies?
group of conditions comprising of Psoriatic Arthritis, Ankylosing Spondylitis, Reactive Arthritis, and Enteropathic arthropathy
seronegative conditions (RF negative)
associated with HLA-B27
all can present with “axial arthritis” (those affecting the spinal and SI joints)
What is haemarthrosis?
Bleeding into a joint cavity
most commonly due to trauma although can also be caused by bleeding disorders and anti-coagulation
may also be a concurrent ligamentous or meniscal injury that has specifically caused the bleeding (e.g. ACL containing a genicular artery)
When is a fracture considered to be ‘open’?
when there is a direct communication between the fracture site and the external environment
most often through the skin – however, pelvic fractures may be internally open, having penetrated in to the vagina or rectum
may become open by either an “in-to-out” injury, ( sharp bone ends penetrate the skin from beneath) or an “out-to-in” injury, where a high energy injury (e.g. ballistic injury or a direct blow) penetrates the skin
What are the most common open fractures?
tibial, phalangeal, forearm, ankle, and metacarpal
Why is the rate of infection so high following open fractures?
direct contamination, reduced vascularity, systemic compromise (such as following major trauma) and need for insertion of metalwork for fracture stabilisation
What should you check for on examination of an open fracture?
neurovascular status
overlying skin / tissue loss
evidence of contamination - marine, agricultural, and sewage contamination is of the highest importance
identify need for plastics early
The Gustilo-Anderson classification can be used to classify open fractures. Outline Types 1 through to 3C
Type 1: <1cm wound and clean
Type 2: 1-10cm wound and clean
Type 3A: >10cm wound and high-energy, but with adequate soft tissue coverage
Type 3B: >10cm wound and high-energy, but with inadequate soft tissue coverage
Type 3C: All injuries with vascular injury
How can open fractures be managed?
- rescucitation and stabilisation
- realignment and splinting
- reassess neurovascular status
- broad spectrum abx and tetanus vaxx if not up to date
- photograph wound and remove gross debris
- dress wound with saline-soaked gauze
Definitive surgical management of open fractures requires debridement of the wound and the fracture site, removing all devitalised tissue present.
When should this happen?
either immediately if contaminated with marine, agricultural, or sewage material, or <12-24 hours in all other cases
early surgical exploration by vascular if evidence of vascular compromise
When should soft tissue coverage of open fractures happen?
within 72 hours, or as guided by plastic surgeon advice
What is compartment syndrome?
critical pressure increase within a confined compartmental space
any fascial compartment can be affected, however the most common sites affected are in the leg, thigh, forearm, foot, hand and buttock
What is the pathophysiology of compartment syndrome?
typically occurs following high-energy trauma, crush injuries, or fractures that cause vascular injury
- can also be due to tight casts, DVT, and post-reperfusion swelling
Fascial compartments are closed and cannot be distended so extra fluid = increase in the intra-compartmental pressure
veins compressed first, then nerves, then arteries as pressure matches the diastolic pressure
The most reliable symptom of compartment syndrome is severe pain. Describe this pain.
Aggravating factors?
severe pain, disproportionate to the injury
not readily improved with initial measures (such as analgesia, elevation to the level of the heart, and splitting a tight cast)
pain is made worse by passively stretching the muscle bellies traversing the affected fascial compartment
Compartment syndrome is a clinical diagnosis. What diagnostic test can be used when there is uncertainty?
intra-compartmental pressure monitor
used in atypical presentations or if the patient is unconscious / intubated
CK may also aid diagnosis
What are normal compartmental pressures?
0-8 mmHg
How should compartment syndrome be managed?
early recognition and immediate surgical treatment via urgent fasciotomies
other steps:
Keep the limb at a neutral level with the patient
High flow O2
Augment BP with bolus of IV crystalloid fluids ( transiently improves perfusion of the affected limb)
Remove all dressings / splints / casts, down to the skin
Opioid analgesia
What should be done post-fasciotomy?
skin incisions are left open and a re-look is planned for 24-48 hours - assess for any dead tissue that needs to be debrided
Monitor renal function closely, due to the potential effects of rhabdomyolysis or reperfusion injury
What is osteomyelitis?
infection of the bone - mostly acute bacterial origin
in adults, the vertebrae are the most commonly affected bones (in children, long bones)
caused by haematogenous spread, direct inoculation (such as following an open fracture or penetrating injury), or direct spread from nearby infection (such as a contiguous joint)
Most common causative organism of osteomyelitis?
staph aureus most common
P. aeruginosa - intravenous drug users
Salmonella spp - patients with sickle cell disease
Risk factors for osteomyelitis?
diabetes mellitus
immunosuppression (such as long term steroid treatment or AIDS)
alcohol excess
IVDU
What is Potts disease?
infection of the vertebral body and intervertebral disc by Mycobacterium tuberculosi
Patients will present with back pain +/- neurological features
MRI gold standard investigation
X-rays are often performed for osteomyelitis although they have poor accuracy - any signs tend to only be visible from ~7-10 days post-initial infection.
What might they show?
What other investigations can be performed?
osteopaenia, periosteal thickening, endosteal scalloping, and focal cortical bone loss
Definitive diagnosis can be achieved through MRI imaging
Gold standard diagnosis is from culture from bone biopsy at debridement (or curettage where there are associated ulcers) - important to check for TB and fungus in immunosuppressed
How can osteomyelitis be managed?
If the patient is clinically well, patients will require long-term IV abx (>4 weeks) tailored to any cultures available
If the patient clinically deteriorates, the limb shows evidence of deterioration, or imaging shows progressive bone destruction, then surgical management may be required
Complications of osteomyelitis?
septic arthritis or soft tissue infections
overwhelming sepsis
recurrence of infection - esp with early discontinuation of abx
children may develop growth disturbances as a result of premature physeal closure
How will patients with chronic osteomyelitis present?
How can it be managed surgically?
localised ongoing bone pain and non-specific infection symptoms (e.g. malaise or lethargy)
may be a draining sinus tract and they may have difficulties in mobility
Mx: local bone and soft tissue debridement for definitive source control, alongside extensive long-term abx
What is a radiculopathy?
a conduction block in the axons of a spinal nerve or its roots
motor axons = weakness
sensory axons = parasthesia
What is the distinction between radiculopathy and radicular pain
Radiculopathy is a state of neurological loss and may or may not be associated with radicular pain.
Radicular pain is pain deriving from damage or irritation of the spinal nerve tissue, particularly the dorsal root ganglion.
What can cause radiculopathy?
most commonly due to nerve compression
Intervertebral disc prolapse
- repeated minor stresses on lumbar spine that predispose to rupture of the annulus fibrosus and sequestration of nucleus pulposus
Degenerative diseases of the spine
– spinal canal stenosis
- 80% of the population over 55 years old have degenerative changes between C5/6 and C6/7
Fracture – either trauma or pathological
Malignancy – most commonly metastatic
Infection – extradural abscesses, osteomyelitis (most commonly TB (‘Pott’s disease’), or Herpes Zoster
What can you assess for on examination of cauda equina syndrome?
pinprick sensation in the perianal dermatomes (reduced)
anocutaneous reflex (diminished or absent)
anal tone (reduced)
rectal pressure sensation (reduced)
Red flags for CES?
Faecal incontinence
Urinary retention (painless, with secondary overflow incontinence)
Saddle anaesthesia
Red flags for infection as a cause of radiculopathy?
Immunosuppression
Intravenous drug abuse
Unexplained fever
Chronic steroid use
Red flags for fracture as a cause of radiculopathy?
Chronic steroid use
Significant trauma
Osteoporosis or metabolic bone disease
Red flags for malignancy/mets as a cause of radiculopathy?
New onset after 50 years old
Systemic symptoms
Hx of malignancy
The differential diagnosis for radicular pain should include pseudoradicular pain syndromes: these are conditions that do not arise directly from nerve root dysfunction, but cause radiating limb pain in an approximate radicular pattern.
Give some examples
*REVIEW CARD
Referred pain
Myofascial pain
Thoracic outlet syndrome
Greater trochanteric bursitis
Iliotibial band syndrome
Meralgia paraesthetica
Piriformis syndrome
Most IV disc prolapses can be managed non-operatively. What are the indications for surgery?
unremitting pain despite comprehensive non-surgical management
progressive weakness
new or progressive myelopathy (compression of the spinal cord)
What can be used for symptomatic mx of radiculopathy?
Amitriptyline is usually first line, or pregabalin and gabapentin as alternatives
benzodiazepines (often diazepam) or baclofen for muscle spasms
physio
What is degenerative disc disease?
the natural deterioration of the intervertebral disc structure
Often related to ageing :
Progressive dehydration of the nucleus pulposus
Daily activities causing tears in the annulus fibrosis
Injuries or pathology resulting in instability
What are the cascade of changes seen degenerative disc disease?
- Dysfunction – outer annular tears and separation of the endplate, cartilage destruction, and facet synovial reaction
- Instability – disc resorption and loss of disc space height, along with facet capsular laxity, can lead to subluxation and spondylolisthesis
- Restabilisation – degenerative changes lead to osteophyte formation and canal stenosis
What are the potential signs of degenerative disc disease?
local spinal tenderness or contracted paraspinal muscles, hypomobility, or painful extension of the back or neck
Further disease progression may demonstrate signs of worsening muscle tenderness, stiffness, reduced movement (particularly lumbar region), and scoliosis
What is Lasègue test?
also known as the straight leg raise , used to assess for disc herniation in patients presenting with lumbago
with the patient lying down on their back, the examiner lifts the patient’s leg while the knee is straight
A positive sign is when pain is elicited during the leg raising +/- ankle dorsiflexion or cervical spine flexion
When is imaging warranted for suspected degenerative disc disease?
Red flags present
Radiculopathy with pain for more than 6 weeks
Evidence of a spinal cord compression
Imaging would significantly alter management
MRI spine is the gold standard investigation however the majority of cases do not require imaging
When are spine radiographs recommended?
history of recent significant trauma, known osteoporosis, or aged over 70 years
Analgesia and physiotherapy is the mainstay of management. When would referral to pain clinic be indicated?
continued pain after 3 months despite analgesia
What is the most commonly used classification system for fractures of the cervical spine?
AO classification
Give some differentials for patients presenting with cervical neck pain
fracture, cervical spondylosis, cervical dislocation, or whiplash injury
What is a Jefferson fracture?
burst fracture of the atlas, usually unstable
It is caused by axial loading of the cervical spine resulting in the occipital condyles being driven into the lateral masses of C1.
They are often associated with head injuries - think ‘silly Jeff diving headfirst into the shallow end’
What is a Hangman’s fracture?
also called traumatic spondylolisthesis of the axis
fracture through the pars interarticularis of C2 bilaterally, usually with subluxation of C2 on C3
caused by cervical hyperextension
What are odontoid peg fractures?
common cervical fractures, most common in older patients
What is the imaging for suspected cervical spine fractures?
Perform a CT scan in adults, if suggested by Canadian C-spine rules
Perform MRI for children, if suggested by Canadian C-spine rules
How should C-spine fractures be managed?
3-point C-spine immobilisation initially to prevent damage to spinal cord
Non-operative management can be appropriate for stable injuries:
Rigid collars or halo vests
Unstable fractures are usually treated operatively by fusing across the injured segment of the spine to the uninjured segments above and below
What is the most common area for a spinal fracture?
thoracolumbar junction (T11–L2)
What 3 columns can the spine be split into when assessing the stability of a fracture?
Anterior column – anterior longitudinal ligament and the anterior half of the vertebral body and disc
Middle column – posterior half of the vertebral body and disc, and posterior longitudinal ligament
Posterior column – comprised of the posterior elements (the posterior ligamentous complex, including the facet joint capsule, ligamentum flavum, and interspinous and supraspinous ligaments) and the intervening vertebral arches
What are the 3 types of thoracolumbar fracture according the AO classification?
Type A – compression injuries
Type B – distraction injuries
Type C – translation injuries
Which patient group do clavicle fractures occur in?
very common fractures
mainly adolescents and young people
second peak in 60+ age group due to osteoporosis
How can clavicle fractures be classified?
Allman classification
Type I (75%)– fracture of the middle 1/3 of clavicle (weakest segment)
- generally stable
Type II (20%)– fracture involving the lateral 1/3 of the clavicle
-when displaced, often unstable
Type III (5%) - medial 1/3 of the clavicle
- commonly associated with multi-system polytrauma
- as the mediastinum sits directly behind this fracture site, they can be associated with neurovascular compromise, pneumothorax, or haemothorax
How do clavicle fractures usually displace?
The medial fragment will often displace superiorly, due to the pull of the sternocleidomastoid muscle, whilst the lateral fragment will displace inferiorly from the weight of the arm
Due to the subcutaneous location of the clavicle, it is important to specifically look for open injuries or threatened skin. How does ‘threatened’ skin present?
tented, tethered, white, and non-blanching skin
How are clavicle fractures assessed?
How are they managed?
Healing time?
X-rays - both anteroposterior and modified-axial views
Tx: usually conservative
- sling to support elbow and improve deformity
- early mobilisation of shoulder to prevent frozen shoulder
- surgery for open fractures or bilateral fractures to enable weight bearing
Usually heal in 4-6 weeks
Major complication of clavicle fractures?
non-union - most associated with distal 1/3 fractures
also neurovascular injury and pneumothorax
Most common site of shoulder fracture?
Risk factors?
proximal humerus
majority of proximal humeral fractures are low energy injuries in elderly patients (FOOSH) due to osteoporosis
Same as for other osteoporotic fractures:
older female, early menopause, long term steroids, recurrent falls
How might proximal humerus fractures present?
How would you investigate?
elderly patient following FOOSH
pain around the upper arm and shoulder, with restriction of arm movement and an inability to abduct their arm
damage to the axillary nerve can result in loss of sensation in the lateral shoulder (“Regimental Badge”) and loss of power of the deltoid
Investigations:
trauma: urgent bloods incl G&S
pathology suspected: calcium and myeloma screen
X-ray: AP, lateral scapular, and axillary views
How should proximal humeral fractures be managed?
Most managed conservatively
initial immobilisation with early remobilisation including pendular exercises around 2-4 weeks
requires correctly applied polysling that allows their arm to hang- gravity will aid the reduction of the fragments
Surgical fixation is indicated in patients with displaced, open, or neurovascularly compromised fractures
What surgical repair would be indicated for proximal humeral fracture patients with multiple segment injuries?
open reduction internal fixation (ORIF) - preferred in a head splitting fracture
intermedullary nailing -preferred if the fracture involves the surgical neck, or if the fracture is combined with a humeral shaft fracture
Complications of proximal humeral fracture?
reduced range of motion - extensive physiotherapy required, often a year of rehab
avascular necrosis of the humeral head following an injury disrupting the blood supply (from the anterior and posterior humeral circumflex arteries) -hemiarthroplasty or reverse shoulder arthroplasty
Shoulder dislocations account for over 50% of major joint dislocations which present to ED - if not managed correctly they can lead to chronic joint instability and chronic pain.
What is the most common type of dislocation?
anteroinferior (95%)
- classically caused by force being applied to an extended, abducted, and externally rotated humerus
posterior much less common
- seizures or electrocution
How do shoulder dislocations present?
painful shoulder, acutely reduced mobility, and a feeling of instability
OE: asymmetry
loss of shoulder contours (from a ‘flattened deltoid’) and an anterior bulge from the head of the humerus
What associated injuries can shoulder dislocations cause?
Bony:
1. Bony Bankart lesions - fractures of the anterior inferior glenoid bone, present in those with recurrent dislocations
2. Hill-Sachs defects- impaction injuries to the chondral surface of the humeral head, occur in anterior glenohumeral dislocations, traumatic dislocations
Labral, ligamentous, and rotator cuff:
1. Soft Bankart lesions- avulsions of the anterior labrum and inferior glenohumeral ligament
2. Glenohumeral ligament avulsion
3. Rotator cuff injuries occur frequently in anterior dislocations
How are shoulder dislocations investigated?
Management?
Investigations:
X-ray: a trauma shoulder series is required - at least 2 views performed - AP, Y-scapular, or axial views
(The Y view is very useful for differentiating between anterior and posterior dislocations)
If labral or rotator cuff injuries are suspected - MRI
Tx:
closed reduction, immobilisation and rehabilitation
broad arm sling for 2 weeks
What sign on x-ray suggests posterior shoulder dislocation?
light bulb sign - humerus fixed in internal rotation
Complications of shoulder dislocation?
chronic pain, poor mobility and recurrence
adhesive capsulitis
nerve damage
rotator cuff injury
The rotator cuff is a group of 4 muscles that support and rotate the glenohumeral joint.
Name these muscles
Supraspinatus – abduction
Infraspinatus – external rotation
Teres minor – external rotation
Subscapularis – internal rotation
Rotator cuff tears are common. How can they be classified?
acute (lasting <3 months) or chronic (lasting >3 months) tears
either partial thickness or full thickness tears
full thickness tears can be further classified into small (<1cm), medium (1-3cm), large (3-5cm), or massive (>5cm or involves multiple tendons) tears
How do patients with rotator cuff tears present?
Differentials?
Risk factors?
pain over the lateral aspect of shoulder and an inability to abduct the arm above 90 degrees
more common in the dominant arm
OE: tenderness over the greater tuberosity and subacromial bursa
DDx: shoulder fracture, persistent glenohumeral subluxation, brachial plexus injury, or radiculopathy
Risk factors: age, trauma, overuse, and repetitive overhead shoulder motions
What specific tests can be used to assess for rotator cuff tears?
Jobe’s test (the “empty can test”, tests supraspinatus)
Gerber’s lift-off test (tests subscapularis)
Posterior cuff test (tests infraspinatus and teres minor)
How should rotator cuff tears be investigated?
Mx?
Investigations:
X ray to exclude fracture
USS for presence and size of tear
MRI
Mx:
< 2 weeks = conservative (physio and analgesia)
> 2 weeks = surgery - arthroscopically (allowing for earlier recovery) or via open approach (preferred in large/complex tears)
Main complication of rotator cuff tears?
Adhesive capsulitis
Adhesive capsulitis (frozen shoulder) is a condition in which the glenohumeral joint capsule becomes contracted and adherent to the humeral head.
Who does it commonly present in?
How can it be categorised?
more common in women
peak onset is between 40-70yrs old
Primary adhesive capsulitis (idiopathic)
Secondary adhesive capsulitis – rotator cuff / biceps tendinopathy, subacromial impingement syndrome, previous surgery or trauma, or joint arthropathy
How does adhesive capsulitis present?
progresses in three stages (an initial painful stage, a freezing stage, and finally a thawing stage)
generalised deep and constant pain of the shoulder that often disturbs sleep
OE: loss of arm swing and atrophy of deltoid
limited range of motion, mainly affecting external rotation and flexion of the shoulder
Adhesive capsulitis is a self-limiting condition, management is typically conservative and rarely requires surgical intervention
DDx for adhesive capsulitis?
Acromioclavicular pathology – a more generalised pain may be present with weakness and stiffness related to pain
Subacromial impingement syndrome (rotator cuff tendinopathy, subacromial bursitis) – preserved passive movement and hx of repetitive overuse/external compression of subacromial space risk factors
Muscular tear – the weakness often persists when the shoulder pain is relieved
Autoimmune disease –polyarthropathy and systemic symptoms
Neck of femur fractures are associated with a high one year mortality and the patient cohort are often elderly with multiple co-morbidities.
How do they present?
What key differential should be considered?
trauma (usually low energy)
acutely painful hip that is shortened and externally rotated with an inability to weight bear
pain may be in groin, thigh or referred to knee
DDx: alternative fracture -pubic ramus fractures, acetabulum, femoral head and femoral diaphysis
Blood supply to the NOF is retrograde.
Which blood vessel is responsible for the majority of the supply?
medial circumflex femoral artery
lies directly on the intra-capsular femoral neck
displaced intra-capsular fractures disrupt the blood supply to the femoral head and can cause avascular necrosis
How can intracapsular fractures be further classified?
Garden classification
I - Non-displaced , Incomplete
II - Non-displaced, complete
III - Complete fracture, partial displacement
IV- Complete fracture fully displaced
Investigations for NOF fractures?
Bloods + CK if long lie suspected
Urine dip, CXR and ECG in elderly patients - cause of fall + pre-op workup
Imaging:
X rays - AP and lateral view of affected hip, AP pelvis
Non-operative conservative management is rarely recommended for NOF fractures, as the benefits of surgical intervention nearly always outweigh the potential conservative management.
What is the surgical tx of displaced subcapital NOF fractures?
Hip Hemiarthroplasty - Replacement of the femoral head and neck via a femoral component fixed in the proximal femur
What is the surgical tx of Inter-trochanteric and Basocervical NOF fractures?
Dynamic Hip Screw (or short IM nail) - lag screw into the neck, a sideplate, and bicortical screws. The lag screw is able to slide through the sideplate, allowing for compression and primary healing of the bone
What is the surgical tx for Non-displaced intra-capsular NOF fractures?
Cannulated hip screws - Three parallel screws in an inverted triangle formation
What is the surgical tx for Sub-trochanteric NOF fractures?
Anterograde Intramedullary Femoral Nail - titanium rod is placed through the medullary cavity of the femur for stabilisation
How should NOF patients be managed post-op?
Complications?
jointly with ortho-geriatricians
early rehab with physios and OTs
Complications:
Immediate - pain, bleeding, leg-length discrepancies, and potential neurovascular damage
Long term - joint dislocation, aseptic loosening, peri-prosthetic fracture, and deep infection/prosthetic joint infection
OA is the most common cause of disability in older adults in the Western World.
What are the risk factors for OA of the hip?
Systemic – Increasing age (>45 yrs), obesity, female gender, genetic factors, vitamin D deficiency
Local – History of trauma to the hip, anatomic abnormalities, muscle weakness or joint laxity, participation in high impact sports
How does OA of the hip present?
Pain - most commonly groin, but can be lateral hip or deep buttocks
aggravated by weight bearing and worse at end of day, relieves with rest
stiffness, grinding, crunching
OE: antalgic gait, pain on passive movement, reduced ROM, may have fixed flexion deformity in end stage disease
DDx for hip OA?
Trochanteric bursitis – lateral hip pain radiating down the lateral leg, with associated point tenderness over the greater trochanter
Gluteus medius tendinopathy – lateral hip pain with point tenderness over the muscle insertion at the greater trochanter
Sciatica – low back pain and buttock pain, often radiates down the posterior leg to below the knee. Diagnosis is made with the straight leg raise to produce Lasègue’s sign
Femoral neck fracture – history of trauma or known severe osteoporosis, the patient will be unable to weight bear due to pain and the limb will appear shortened and externally rotated
Signs of hip OA on x-ray?
Narrowing of the joint space
Osteophyte formation
Sclerosis of the subchondral bone
Subchondral bone cysts
Management of hip OA?
Surgical complications?
WL, exercise, pain control (WHO stepladder)
physio to slow disease progression and improve joint mechanics
Surgery: hip replacement (arthroplasty or hemiarthroplasty)
Posterior Approach (to glut medius) – The most common approach as rehabilitation is often fast due to preservation of the abductor mechanism, but risk of sciatic nerve damage
Complications: thromboembolic disease / bleeding, infection, dislocation, loosening of the prosthesis, and leg length discrepancy
How long do modern hip replacements last?
15-20 years
The true pelvis contains the rectum, bladder and uterus in females, as well as the iliac vessels and the lumbosacral nerve roots.
Knowing this, what are the potential complications of pelvic fractures?
life-threatening haemorrhage, neurological deficit, urogenital trauma, and bowel injury
Pelvic ring injuries are most often caused by high energy blunt trauma, such as road traffic accidents or falls from height.
What should you do during your examination?
full neurovascular assessment of the lower limbs including checking anal tone -sacral nerve roots and iliac vessels can frequently be injured
abdo injuries, urethral injuries, and open fractures (incl “internal open fractures” into the rectum or vaginal vault)
look for any surrounding ecchymosis or developing haematoma present (e.g. perineal, scrotal or labial)
What can cause low energy pelvic fractures?
avulsion fractures - reported as a sudden severe pain, poorly localised to the hip/pelvis, felt whilst performing a rapid, powerful movement, such as starting to run
How should suspected pelvic fractures be investigated?
3 X-rays needed to assess pelvic ring - AP, inlet and outlet view
However CT usually performed in trauma setting so negates need for x-ray
Indications for operative management of pelvic fracture?
What may a haemodynamically unstable pelvic fracture patient require?
life threatening haemorrhage, unstable fractures, open fractures, and associated fractures with an associated urological injury
interventional radiology or trauma laparotomy +/- retroperitoneal packing
What is the most commonly used classification for pelvic fractures?
The Young and Burgess classification
Complications following pelvic fractures?
urological injury, venous thromboembolism, and long-standing pelvic pain
The knee joint is the most commonly affected joint by osteoarthritis. How should it be managed?
Initial management is with analgesia and physiotherapy, however total knee replacement (TKR) is the standard treatment for advanced osteoarthritis
TKR lasts for at least 10 years
Partial (unicondylar) replacement may be indicated for those with disease localised to either the medial or lateral compartment
How does patellofemoral OA present?
Anterior knee pain, worse with activities that put pressure on the patella, such as climbing a flight of stairs
How do ACL tears present?
Specific clinical tests?
athlete with a history of twisting the knee whilst weight-bearing
rapid joint swelling (highly vascular ligament rupture = haemarthrosis)
significant pain
Lachman’s Test (more sensitive) and Anterior Drawer Test
How should ACL tears be investigated and managed?
Investigations:
- plain film radiograph (AP and lateral) - exclude bony injuries, any joint effusion, or a lipohaemarthrosis
- Segond fracture (bony avulsion of the lateral proximal tibia) is pathognomic
- MRI scan GOLD STANDARD
Mx:
- RICE
- strength training of quads and cricket pad knee splint for comfort
- surgical reconstruction following ‘prehabilitation’
Complications of ACL tear / surgery?
post-traumatic OA
Which is the most commonly injured ligament of the knee? What is the usual mechanism of injury?
MCL - valgus stabiliser
external rotational forces are applied to the lateral knee, such as a impact to the outside of the knee
MCL injuries can be graded from one to three:
Grade I – mild injury, minimally torn fibres and no loss of MCL integrity
Grade II – moderate injury, incomplete tear and increased laxity of the MCL
Grade III – severe injury, complete tear and gross laxity of the MCL
How does an MCL tear present?
On examination?
hearing a ‘pop’ with immediate medial joint line pain
swelling after a few hours
OE:
increased laxity when testing the MCL via valgus stress test
extremely tender along joint line but may be able to weight bear
Management of MCL tear?
Complications?
Grade1 : RICE
Grade 2: analgesia, knee brace, return to full exercise in 10 weeks
Grade 3: analgesia with a knee brace and crutches, any associated distal avulsion = surgery considered, return to full exercise in 12 weeks
Complications: instability in the joint and damage to the saphenous nerve.
What is a Colles’ fracture?
extra-articular fracture of the distal radius with dorsal angulation and dorsal displacement, within 2cm of the articular surface
also includes an avulsion fracture of the ulnar styloid
typically fragility fracture caused by FOOSH
What is a Smith’s fracture?
extra-articular fracture of the distal radius with volar angulation of the distal fragment (the reverse of a Colles fracture), with or without volar displacement
caused by falling backwards and planting the outstretched hand behind the body, causing a forced pronation type injury
What is a Barton’s fracture?
intra-articular fracture of the distal radius with associated dislocation of the radio-carpal joint
described as volar (more common) or dorsal (less common), depending on whether the volar or dorsal rim of the radius is involved
The neurological examination for a suspected distal radius fracture should include the following nerves being assessed:
Median nerve:
motor – abduction of the thumb
sensory – radial surface of distal 2nd digit
Anterior interosseous nerve: opposition of the thumb and index finger (OK sign)
Ulnar nerve:
motor – adduction of the thumb (‘Froment’s Sign’) sensory – ulnar surface of the distal 5th digit
Radial nerve:
motor – extension of IPJ of thumb
sensory – dorsal surface of 1st webspace
DDx for distal radius fractures?
Forearm fracture (such as Galeazzi or Monteggia fractures)
Carpal bone fractures
Tendonitis or tenosynovitis
Wrist dislocation
Which 3 measurements on X-ray help to diagnose distal radius fractures?
Radial height <11mm
Radial inclination <22 degrees
Radial (volar) tilt >11 degrees
CT or MRI can be used for more complex fractures
Management of distal radius fractures?
traction and manipulation under anaesthetic - under conscious sedation with a haematoma block or Bier’s block
Stable and successfully reduced fractures = below-elbow backslab cast, then radiographs repeated after 1 week to check for displacement
Significantly displaced or unstable fractures can require surgical intervention (or intra-articular step of the radiocarpal joint >2mm) = open reduction and internal fixation
The main complications following distal radius fractures are:
Malunion- poor realignment leads to a shortened radius compared to the ulnar, leading to reduced wrist motion, wrist pain, and reduced forearm rotation
- can be treated with corrective osteotomy
Median nerve compression, more common in patients who heal in a significant degree of malunion
Osteoarthritis, especially with intra-articular involvement from the original fracture
What is carpal tunnel syndrome?
Risk factors?
compression of the median nerve within the carpal tunnel of the wrist, due to a raised pressure within this compartment
pain, numbness, and paresthesia in the lateral 3½ digits
palm is often spared, due to the palmar cutaneous branch of the median nerve branching proximal to the flexor retinaculum and passing over the carpal tunnel
RF: female gender, increasing age, pregnancy, obesity, and previous injury to the wrist
Aggravating and relieving factors for carpal tunnel?
worse during night
symptoms can often be temporarily relieved by hanging the affected arm over the side of the bed or by shaking it back and forth
What can be seen on examination of carpal tunnel?
sensory symptoms can be reproduced by either percussing over the median nerve (Tinel’s Test) or holding the wrist in full flexion for one minute (Phalen’s Test)
late stages- weakness of thumb abduction (due to denervation atrophy of the thenar muscles) and / or wasting of the thenar eminence
DDX for carpal tunnel?
Cervical Radiculopathy
- C6 nerve root involvement may produce similar sxs however will likely have an element of neck pain / involve the entire arm length
Pronator teres syndrome (median nerve compression by pronator teres)
- extend to the proximal forearm and sensation of the palm will also be reduced
Flexor carpi radialis tenosynovitis
- distinguished by tenderness at the base of the thumb
Investigation and management of carpal tunnel?
Complications of surgery?
Clinical diagnosis
uncertain cases - nerve conduction studies
Mx:
wrist splint at night
hand therapy
steroid injections
carpal tunnel release surgery in persistently symptomatic pts
Complications of carpal tunnel surgery include recurrence, persistent symptoms (from incomplete release of ligament), infection, scar formation, nerve damage, or trigger thumb.
Ankle fractures are a common injury, more common in younger males or older females. How can they be classified?
isolated lateral malleolar fractures, isolated medial malleolar fractures, bimalleolar fractures and trimalleolar fractures (medial + lateral + posterior)
Weber classification for lateral fractures:
Type A = below the syndesmosis
Type B = at the level of the syndesmosis
Type C = above the level of the syndesmosis
more proximal = more unstable so Type C almost always need surgery
Investigations and management of ankle fractures?
X-ray (ankle must be fully dorsiflexed for this)- AP and lateral view, check for evidence of talar shift
If complex fracture - CT
Mx:
immediate fracture reduction, below knee back slab
Conservative management will often be opted for in:
Non-displaced medial malleolus fractures
Weber A fractures or Weber B fractures without talar shift
Those unfit for surgical intervention
Surgery: ORIF
- for displaced or open or talar shift
What are ankle sprains?
ligamentous injuries
classified into high ankle sprains (which are injuries to the syndesmosis) or low ankle sprains, which are injuries to the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL)
present following an inversion injury on a plantarflexed ankle with fingertip tenderness distal to the malleoli
What is Achilles tendonitis?
RF?
inflammation of the Achilles (calcaneal) tendon
The classical case of tendonitis or rupture occurs in an unfit individual who has a sudden increase in exercise frequency - ‘weekend warriors’
Other risk factors include poor footwear choice, male gender, obesity, or recent fluoroquinolone use (for tendon rupture)
What are the most commonly used indicators of a clinical Achilles tendon rupture?
How can it be diagnosed?
Simmonds test (loss of plantarflexion) and a palpable ‘step’ in the Achilles tendon
Clinical diagnosis or USS
What is the most common cause of infracalcaneal pain?
How can it be diagnosed?
Mx?
Plantar fasciitis
Clinical diagnosis
X ray to look for plantar heel spur - abnormal loading
MRI for fascial thickening
Initial management is conservative, however corticosteroid injections or plantar fasciotomy can be considered if no improvement
Features of L3 nerve root compression?
Sensory loss over anterior thigh
Weak hip flexion, knee extension and hip adduction
Reduced knee reflex
Positive femoral stretch test
Features of L4 nerve root compression?
Sensory loss anterior aspect of knee and medial malleolus
Weak knee extension and hip adduction
Reduced knee reflex
Positive femoral stretch test
Features of L5 nerve root compression?
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
Features of S1 nerve root compression?
Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test
When should sciatica be referred for an MRI?
4-6 weeks of conservative management and no improvement
how may supraspinatus tendonitis (subacromial impingement) present on x-ray?
calcification of the supraspinatus tendon consistent with prolonged inflammation
patient will likely exhibit the ‘painful arc’
Twisting sporting injuries followed by delayed onset of knee swelling and locking are strongly suggestive of what?
menisceal tear
McMurrays test will be positive
Arthroscopic menisectomy is the usual treatment
rupture of which ligament will cause the tibia to lie back on the femur?
PCL rupture
mechanism = hyperextension injuries (e.g. knee hitting dash)
paradoxical anterior drawer test
How does Chondromalacia patellae present?
Teenage girls, following an injury to knee e.g. Dislocation patella
Typical history of pain on going downstairs or at rest
Tenderness, quadriceps wasting
How do tibial plateau fractures occur?
Occur in the elderly (or following significant trauma in young)
Mechanism: knee forced into valgus or varus, but the knee fractures before the ligaments rupture
Varus injury affects medial plateau and if valgus injury, lateral plateau depressed fracture occurs
In a child with an asymptomatic, fluctuant swelling behind the knee the most likely diagnosis is what?
Baker’s cyst
How does facet joint pain present?
May be acute or chronic
Pain worse in the morning and on standing
On examination there may be pain over the facets. The pain is typically worse on extension of the back
How does spinal stenosis present?
Usually gradual onset
Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as ‘aching’, ‘crawling’.
Relieved by sitting down, leaning forwards and crouching down
Clinical examination is often normal
Requires MRI to confirm diagnosis
Any patient presenting with symptoms of intermittent claudication not worsened by increasing exertion =
neurogenic not ischaemic
Severe sharp back pain worse on movement with positive straight leg raise test - what is the diagnosis and mx?
prolapsed disc
arrange physio, no need to scan unless red flags
How should discitis be investigated?
MRI imaging
Assess for endocarditis e.g. with transthoracic echo or transesophageal echo
A 23-year-old rugby player falls directly onto his shoulder. There is pain and swelling of the shoulder joint. The clavicle is prominent and there appears to be a step deformity. Dx?
Acromioclavicular joint (ACJ) dislocation
Dupytren’s contracture presents with thickening of the palm and an inability to full extend the metacarpophalangeal joints, usually the little and ring fingers. What can cause it?
manual labour
phenytoin treatment
alcoholic liver disease
diabetes mellitus
trauma to the hand
commonly used method of analgesia for patients with a neck of femur fracture?
iliofascial nerve block
aim of this is to reduce the use of opioids analgesics e.g. morphine, which is particularly helpful in elderly patients
Increasing hip pain at rest, together with increased serum calcium and alkaline phosphatase are most likely to represent what?
metastatic tumour to bone
Chondrosarcomas do occur in the pelvis but are not associated with increased serum calcium and typically have a longer history
A 73-year-old man presents with pain in the right leg. It is most uncomfortable on walking. On examination he has a deformity of his right femur, which on x-ray is thickened and sclerotic. His serum alkaline phosphatase is elevated, but calcium is within normal limits.
This is a typical hx of which condition?
Paget’s disease
Likely cause of bone pain with:
1. normal ALP and calcium
2. raised ALP but other parameters normal
3. raised ALP and calcium
- osteoporosis
- paget’s disease of the bone
- mets to bone
What is an essential part of the management for all ankle fractures?
they should be promptly reduced to remove pressure on the overlying skin and subsequent necrosis
Extracapsular hip fracture (subtrochanteric fracture) should be managed using what?
intramedullary device
In paediatric practice, fractures may also involve the growth plate and these injuries are classified according to the Salter-Harris system.
Outline Salter Harris classes 1-5
I - Fracture through the physis only (x-ray often normal)
II - Fracture through the physis and metaphysis
III - Fracture through the physis and epiphysis to include the joint
IV - Fracture involving the physis, metaphysis and epiphysis
V - Crush injury involving the physis (x-ray may resemble type I, and appear normal)
Straight through physis
Above
Lower
Through all 3
Everything crushed
injury pattern of a greenstick fracture?
Unilateral cortical breach only
How may fat emboli present?
post-trauma esp long bone fractures
Respiratory:
Tachycardia
Tachypnoea, dyspnoea, hypoxia usually 72 hours following injury
Pyrexia
Dermatological:
Red/ brown impalpable petechial rash
Subconjunctival and oral haemorrhage/ petechiae
CNS :
Confusion and agitation
Retinal haemorrhages and intra-arterial fat globules on fundoscopy
Simmonds’ triad is used to examine for an Achilles tendon rupture. What does it include?
It includes palpation of the Achilles tendon (examining for a gap), observing for an abnormal angle of declination (i.e. the foot is more dorsiflexed than the other), and performing the calf squeeze test.
Investigation for Cauda Equina?
MRI spine within 6 hours
Phalen’s test is used to asses carpal tunnel syndrome. What does this involve?
The patient’s wrist is held in maximum flexion (reverse prayer sign) for 30-60 seconds. The test is positive if there is numbness in the median nerve distribution
Children and young people with unexplained bone swelling or pain:
consider very urgent direct access X-ray to assess for bone sarcoma (within 48 hours)
Colle’s key points?
Dorsally Displaced Distal radius → Dinner fork Deformity
Colle’s complications?
early:
median nerve injury: acute carpal tunnel syndrome presenting with weakness or loss of thumb or index finger flexion
compartment syndrome
malunion
rupture of the extensor pollicis longus tendon
late:
osteoarthritis
complex regional pain syndrome
common cause of lateral knee pain in runners?
iliotibial band syndrome
If scaphoid fracture is suspected, but imaging is inconclusive, how should you proceed?
Referral to orthopaedics and repeat imaging in 7-10 days
Leriche syndrome is atherosclerotic occlusive disease involving the abdominal aorta and/or both of the iliac arteries.
How does it present?
Classically, it is described in male patients as a triad of symptoms:
- Claudication of the buttocks and thighs
- Atrophy of the musculature of the legs
- Impotence (due to paralysis of the L1 nerve)
A scaphoid fracture is a type of wrist fracture, typically arises as a result of a fall onto an outstretched hand (FOOSH).
Why are they so high risk?
80% of the blood supply is retrograde - derived from the dorsal carpal branch (branch of the radial artery)
risk of avascular necrosis
How do patients with scaphoid fractures present?
pain over the radial aspect of wrist (base of thumb) and loss of grip strength
OE:
maximal tenderness over anatomical snuffbox
wrist joint effusion
pain on telescoping of thumb
pain on ulnar deviation of wrist
How should scaphoid fractures be investigated and managed?
Investigations:
X-ray: ‘Scaphoid views’: posterioranterior (PA), lateral, oblique (with wrist pronated at 45º) and Ziter view
MRI definitive to confirm dx
Mx:
immobilisation with a Futuro splint or standard below-elbow backslab
review by orthopods
undisplaced = cast for 6-8 weeks
displaced = surgery
De Quervain’s tenosynovitis is a common condition in which the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed. It typically affects females aged 30 - 50 years old.
How does it present? Mx?
pain over radial styloid process and painful abduction of thumb against resistance
Mx:
analgesia
steroid injection
immobilisation with a thumb splint (spica) may be effective
Which drug tx can cause Dupytren’s contracture as a side effect?
phenytoin
Outline the different types of hip dislocation
Posterior dislocation (90%): affected leg is shortened, adducted, and internally rotated
Anterior dislocation: affected leg is usually abducted and externally rotated. No leg shortening
Central dislocation
Mx of hip dislocation?
ABCDE
Analgesia
Reduction under GA within 4 hours to reduce the risk of avascular necrosis
Long-term management: Physiotherapy to strengthen the surrounding muscles
Complications of hip dislocation?
Sciatic or femoral nerve injury
Avascular necrosis
Osteoarthritis: more common in older patients
Recurrent dislocation: due to damage of supporting ligaments
What is meralgia parasthetica?
syndrome of paraesthesia or anaesthesia in the distribution of the lateral femoral cutaneous nerve
Hx:
Sxs over upper lateral aspect of thigh
Burning, coldness, tingling, or shooting pain
Numbness
Deep muscle ache
Usually aggravated by standing, and relieved by sitting
OE:
Symptoms reproduced by deep palpation just below the ASIS (pelvic compression) and by hip extension
What is the most common upper limb injury in children under the age of 6? Mx?
Subluxation of the radial head (pulled elbow)
distal attachment of the annular ligament covering the radial head is weaker in children at this age
Mx:
analgesia and passive supination of the elbow joint whilst the elbow is flexed to 90 degrees
Which finger joint most commonly dislocates?
PIP
In what ways can a PIP joint dislocate?
Laterally - damages collateral ligaments
Dorsally - damages flexor tendon , can cause swan neck deformity
Volarly - damages extensor tendon
How can you investigate and manage phalanx dislocations?
examine : Elson’s test, lateral stress test, sensation testing
X-ray
Splinting
What causes knee dislocations? How should you investigate and manage?
usually high energy injury e.g. knee hitting dash - high risk of neurovascular damage e.g. to popliteal artery
neurovascular assessment and x-ray
Mx:
reduce and stabilise ASAP
assess limb perfusion - cap refill and peripheral pulses, can do doppler USS
can do delayed ligamentous reconstruction
