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
