Upper and lower limb injury Flashcards

1
Q

X-ray principles

A

The more a site absorbs x-ray the more white it becomes: air is black, soft tissue is grey, bone is white

Fracture lines are usually black unless bone impacts/ overlaps another bone in which case it appears sclerotic/ darker

To assess an x-ray look at all available views, use step by step approach and compare to past x-rays

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

How to describe a fracture

A
  • Oxford handbook method:
  • age of patient and how it occurred
  • say whether it is compound and Gustilo type
  • name the bone (specify right/left; whether dominant hand)
  • position of fracture (e.g. proximal, supracondylar)
  • type of fracture (simple, spiral, communicated, crush)
  • intra-articular involvement
  • deformity (displacement, angulation) from anatomical position
  • grade/classification of fracture
  • presence of complications (e.g. pulse absent, paraesthesia, tissue loss)
  • other injuries and medical problems
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

How to describe a long bone fracture

A

Site: which bone and which part of the bone

Open/ closed

Fragments

Direct of fracture e.g. transverse, oblique, spiral

Articular surface involvement? Risk of subsequent osteoarthritis

Position of major fragments: the anatomical position of the distal component compared to the proximal component

Rotational deformity: has the fragment rotated?

Supracondylar: above the condyles of the femur/ epicondyles of the humerus

Intercondylar

Intertrochanteric: priximal femur between greater/ lesser trochanters

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Steps of describing a fracture - simple

A

1. Describe radiograph: name, what, where, why, when

2. What type of fracture?

Direction: transverse, oblique, spiral

Salter Harris classification if it involves the growth plate

3. Where is the fracture?

Diaphysis: shaft

Metaphysis: widening portion next to growth plate

Epiphysis: end of the bone adjacent to the joint

4. Is it displaced?

Describes what happened to the bone during the fracture

Body assumed to be in anatomical position and the injury is described in terms of the distal component in relation to the proximal component

5. Anything else going on?

Joint involvement? Another fracture? Underlying bone lesion?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is the Salter-Harris classification?

A

Only applies to children - this classification system does not apply to the well-developed bones of adults

Describes the patterns of fractures that occur through the growth plate of a long bone

Used to describe the fractures and predict the outcome as well as guiding management

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Discuss the Salter-Harris classification fracture types

A

Class 1-5

SALTR = MNEMONIC

Type 1: separation through the physis (growth plate)

S = SLIPPED

Type 2: fracture through the physis that extends ABOVE the physis into the metaphysis

A = ABOVE

Type 3: Fracture through the growth plate that extends into the epiphysis and involves the joint space, the fracture is lower in relation to growth plate

L = LOWER

Type 4: Through the growth plate, metaphysis and epiphysis

T = THROUGH

Type 5: Crush injury to growth plate, area is rammed together

R = RAMMED

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Discuss type 1 Salter-Harris fractures

A

SLIPPED

5-7% fractures

Describes a slipping or separation of the growth plate

Does not involve bone, only the growth plate

Good prognosis - generally heals without surgery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Discuss type 2 Salter-Harris fractures

A

ABOVE

Occurs across growth plate (physis) and then ABOVE into metaphysis

Most common form of fracture - 75%

Good prognosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Discuss type 3 Salter-Harris fractures

A

LOWER

Fracture passes along physis and then down through the epiphysis

Poorer prognosis - often an unstable fracture and can require operative management

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Discuss type 4 Salter-Harris fractures

A

THROUGH

Passes through epiphysis, physis and metaphysis

Prognosis is variable, can be unstable and operative management should be considered

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Discuss type 5 Salter-Harris fractures

A

RAMMED

Crushing injury damages the growth plate via compression

Worst prognosis of all 5 SH types

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Fracture types

A

Simple: single, transverse fracture with 2 main fragments

Oblique: single, oblique fracture with 2 main fragments

Spiral: twists around long bone

Greenstick: seen in children, incomplete fracture

Comminuted: complex, >2 fragments - like someone has crunched the fracture site

Crush, wedge, burst, impacted

Avulsion: bony attachment of ligament or muscle is pulled off

Pathological

Stress: due to repetitive injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Outline what open fractures are

A

A fracture is open when there is direct communication between the fracture site and the external environment

Most common open fractures: tibial, phalangeal, forearm, ankle and metacarpal

Consider the following consequences:

Skin: small wound to significant loss of skin meaning plastics may be needed to create a flap

Soft tissue: ranging from very little tissue loss to significant muscle, tendon, ligament loss which will require reconstructive surgery

Neurovascular: nerves and vessels may be compressed, go into spasm, be intimally dissected or transected

Infection: rate of infection following open fracture is high

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is the Gustilo classification?

A

Most commonly used system to classify open fractures

Uses the amount of energy, the extent of soft tissue injury and the extent of contamination to determine the severity of a fracture

Grade I: Open fracture, wound clean and <1cm

Grade II: Open fracture, wound <10cm without extensive soft tissue damage

Grade IIIA: Open fracture, adequate soft tissue coverage of fracture despite extensive laceration irrespective of the size of the wound

Grade IIIB: Open fracture with extensive soft tissue loss, usually with massive contamination and often needs soft-tissue reconstruction e.g. flap

Grade IIIC: Open fracture, vascular injury needing repair

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Management of open fractures

A

Emergency: debride and lavage within 6hrs

IV antibiotics (broad)

Tetanus vaccine

Amputation is often required following IIIC open fractures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is tetanus?

A

AKA lockjaw, a bacterial infection characterised by muscle spasms

Caused by clostidium tetani which is found in soil, saliva, dust and manure

Those who suffer a significant wound should be given a tetanus vaccine booster

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is subluxation?

A

Sometimes known as a partial dislocation

Partial loss of the congruity of a joint i.e. some parts of the articular surface of the bones contributing to the joint are touching each other

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What is dislocation?

A

Articular surfaces at the joint have lost all contact with each other

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Management of subluxation or dislocation

A

X-ray before reduction unless there is neurovascular compromise

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What is a sprain?

A

Overstretching or tearing of a ligament

Causes pain, swelling and tenderness

Ranges from 1st-3rd degree depending on severity

3rd degree = completely torn, significant laxity and a snapping sound may have been heard

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What is a strain?

A

Muscle-tendon injury

Pain on palpation and on active/ passive contraction

sTrain = Tendon

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What is myositis ossificans?

A

Condition where bone tissue forms inside muscle or soft tissue after injury

Mainly occurs in the muscles of the arms and legs following trauma - mainly seen in young adults

Also seen in paraplegics, often in the absence of trauma

Presentation: painful, tender, enlarging mass often following localised trauma

Shows as an egg shell appearance on CT - often mistaken for osteosarcoma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Management of myositis ossificans

A

Myositis ossificans is benign and treatment is reserved for symptomatic lesions

Management is usally surgical which is often curative

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Types of pathological fractures

A

Pathological fractures = fractures that occur in abnormal bone either spontaneously or following minor trauma that would not otherwise fracture normaly bone

Usually reserved for malignancies but also in other diseases e.g. osteomyelitis, Paget’s, bone cysts etc

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Most common location for pathological fractures
Subtrochanteric femur Humeral head and metaphyseal junction Vertebral body
26
Assessment and management of non-complex fractures
Assess pain: paracetamol, codeine, morphine as appropriate Pre-hospital: traction splint or vacuum splint Imaging: x-ray, MRI is first line for scaphoid fractures
27
Assessment and management of complex fractures
Pain: morphine, ketamine Pre-hospital: saline-soaked dressing, IV antibiotics within 1hr, consider splints and take patient to major trauma centre Vascular injury: lack of pulse, continued blood loss, expanding haematoma Compartment syndrome: occurs particularly in tibial fractures, monitor for 48hrs with regular assessment Imaging: whole body CT for multiple injuries or blunt major trauma
28
Pathophysiology of compartment syndrome
Increased pressure in one of the body's anatomical compartments results in insufficient blood supply to tissue within that space Commonly it is the leg compartments that are affected Can develop after traumatic injury, most commonly following a tibial fracture (2-9% of tibial fractures) Damage or disruption of the blood supply causes tissue ischaemia and inflammation \>\> soft tissue swells, the fascia does not stretch so pressure rises greatly \>\> eventually the tissue within the compartment dies
29
Symptoms of compartment syndrome
Pain: aggravated by passive stretch and not relieved by analgesics Parasthesia: pins and needles, tingling, loss of sensation due to nerve compression Pallor: due to arterial occlusion Pulseless: not often seen until pressure within compartment rises dramatically Paralysis: rare, late finding
30
Management of compartment syndrome
Fasciotomy
31
What are the Ottowa rules of ankle fracture imaging?
**Ottowa ankle rules:** determine the need for x-ray in acute ankle injuries **An ankle X-ray is only required if:** * There is any pain in the malleolar zone; and, * Any one of the following: * Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus, OR * Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus, OR * An inability to bear weight both immediately and in the emergency department for four steps **A foot X-ray series is indicated if:** * There is any pain in the midfoot zone; and, * Any one of the following: * Bone tenderness at the base of the fifth metatarsal (for foot injuries), OR * Bone tenderness at the navicular bone (for foot injuries), OR * An inability to bear weight both immediately and in the emergency department for four steps Only used in those aged 5+
32
What are the Ottowa rules of knee imaging?
Ottowa knee rules determine the need for x-ray in acute knee injuries If any one of the following present, an x-ray is indicated: * Age \>55yrs * isolated patellar tenderness * Tenderness of fibular head * Inability to flex knee to 90o * Inability to weight bear immediately after injury and in the ED
33
What is algodystrophy (Sudeck’s atrophy)?
AKA complex regional pain syndrome Describes an array of painful conditions that are characterised by continuing regional pain disproportionate to known trauma or lesion Features: burning pain, inflammation, pallor and atrophy with limited movement
34
Anatomy of hand bones
**Carpals:** Some Lovers Try Positions That They Can't Handle Lower row: scaphoid, lunate, triquetrum, pisiform Upper row: trapezium, trapezoid, capitate, hamate **Metacarpals** **Proximal, middle and distal phalanges**
35
Lumbrical muscles
Each hand has 4 lumbricals - each associated with 1 finger Denervation results in clawing of the fingers Action: flexion at MCP joint and extension at IP joints of each finger \> the opposing actions are possible because the muscles cross the MP joint on the palmar side but distally insert dorsally (hook round) **Innervation:** Lateral 2 lumbricals = median Medial 2 lumbricals = ulnar
36
Interossei muscles
Located between the metacarpals Divided into dorsal and palmar interossei **All innervated by ulnar nerve** Dorsal interossei: DAB Abduct fingers at MCP joint Palmar interossei: PAD Adduct fingers at MCP joint
37
Nerve supply to hand muscles
Median nerve = thenar muscles (except adductor policis which is ulnar) Median nerve = lateral 2 lumbricals Ulnar = all others
38
Muscles needed for thumb adduction and abduction
Abduction of the thumb = median nerve Adduction of thumb = ulnar nerve UMMMM ADD the thumb
39
Patient cannot adduct thumb - which nerve is affected?
Ulnar
40
Median nerve lesion in hand - sensory and motor consequences
Sensory: numbness/ parasthesia in lateral half of palm and fingers (inc. 1/2 of ring finger) Motor: unable to abduct the thumb against resistance
41
Ulnar nerve lesion in hand - motor and sensory consequences
Sensory: paraesthesia over median palmar surface (including 1/2 of ring finger), paraesthesia over dorsal surface of hand including 1/2 ring finger Motor: inability to adduct and abduct fingers, inability to flex ring and little fingers at MP joint and extend fingers at IP joint, inability to adduct the thumb Leads to ulnar claw
42
Radial nerve lesion in hand - motor and sensory consequences
Motor: radial nerve has no motor function in the hand Sensory: reduced sensation in dorsum first web space
43
Mallet finger injury
Due to extensor avulsion - the distal extensor tendon can either pull off a bit of bone or the tendon can rupture leading to a bend at the DIP joint and the inability to extend finger **Fractures only present in 25%** Causes: usually due to ball sports when ball hits tip of extended finger Management: splinting for 6-8 weeks + exercises or surgery to repair the deformity
44
Volar plate fracture
Volar plate of the proximal interphalangeal joint is vulnerable to hyperextension injury Ligament tear or intra-articular fractures can occur Classified using the Eaton criteria Treatment depends on size of fragment and degree of damage, usually conservative with finger splinting
45
What can cause a spiral fracture of a phalanx or metacarpal?
46
Boxer's fracture
4th or 5th metacarpal neck fracture Due to a blow with a clenched fist Management: K-wire fixation
47
Bennet's fracture
Base of first MC joint (base of thumb), joint surface usually involved Causes: direct blow to a bent thumb e.g. during boxing/ martial arts Management: Spica cast for 3-4 weeks for non-displaced, stable fractures Operative management for unstable fractures
48
Colles' fracture
Distal radial fracture - fall on an oustretched hand Most common type of dital radial fracture, seen in all age groups esp. elderly women Mechanism: proximal row of carpal bones transfers energy into distal radius Management: usually closed reduction and cast immobilisation, ORIF is considered when fracture unstable Complications: nerve damage, compartment syndrome, malunion, arthritis, reflex sympathetic dystrophy
49
Smith's fractures
Reverse Colles' - distal radial fracture with anterior displacement Causes: fall on flexed wrist or direct blow to back of wrist Management: closed reduction apart from typr 3 which requires closed reduction
50
Barton's fracture
Fractures of the distal radius with additional dislocation of the radiocarpal joints (essentially Colles' or Smith + dislocation) Dorsal = Barton Volar/ palmar = reverse Barton (aka Smith type 3) Management: ORIF usually, sometimes conservatively managed
51
Galeazzi fracture
Fracture of the distal part of the radius with dislocation of the radioulnar joint + an intact ulnar Mainly occur in children aged 9-12
52
Monteggia fracture
Fracture of the ulnar shaft with dislocation of the radial head Mainly occur in children 4 types according to Bado classification
53
Most commonly fractured carpal bone
Scaphoid
54
Scaphoid fractures
Common, tricky to diagnose and can result in significant functional impairment 70-80% of all carpal bone fractures Most common in teenagers and young adults following FOOSH Presentation: pain around dorsal wrist and or anatomical snuffbox, dorsum of wrist may be oedematous Investigations: MRI is 1st line, x-rays miss 5-20% of scaphoid fractures in the acute setting Management: cast, internal fixation if displaced Complications: non union occurs in 5-15% - leading to arthritic change, avascular necrosis occurs in ~30% due to damage of radial artery
55
Olecranon head fracture
Fracture of the proximal ulna - fairly common, can occur in the elderly following sudden pull of triceps Account for 10-20% of elbow fractures Usually fairly obvious on x-ray as they are displaced due to the pull of the triceps Management: guided by degree of displacement Non-operative: \<2mm displacement, immobilisation in 60-90 degree elbow flexion Operative: \>2mm displacement, tension band wiring, olecranon plating \*\*Check for ulnar nerve damage\*\*
56
Radial head/ neck fracture
50% of elbow fractures Radial head fracture most common in adults Radial neck fracture most common in children Management: immobilisation if non-displaced, displaced fractures refer to ortho \*30-50% children with a proximal radial fracture have another fracture
57
What is the fat pad sign?
Potential finding on elbow x-ray which suggests a fracture at the elbow It is caused by displacement of the fat pad around the elbow joint Both anterior and posterior fat pad signs exist If you see a fat pad - suspect fracture
58
Discuss the anterior fat pad sign
AKA sail sign Describes elevation of the anterior fat pad caused by elbow joint effusion (effused with blood in the joint - haemarthrosis) Elevation of the anterior fat pad usually indicates the presence of an intra-articular fracture Adults anterior fat pad sign: radial head fracture Children anterior fat pad sign: supracondylar fracture
59
Why are the anterior and posterior fat pads raised in elbow fractures?
Bleeding into joint - hemearthrosis, pushes pads up and makes them visible on x-ray
60
Important when assessing a dislocated elbow
Distal pulses and sensation Brachial artery and median + ulnar nerves my be damaged
61
Most common type of elbow dislocation?
Postero-lateral dislocation \> Meaning the distal portion moves poerto-laterally
62
Supracondylar fractures
Most common in children Elbow may be grossly swollen but triangular relationship between olecranon and epidondyles is characteristically preserved (differentiating this from a dislocation) Check distal pulses and sensation Immobilise with POP and give analgesia Refer to ortho if displaced as ORIF or manipulation may be required
63
What causes shaft of humerus fractures?
Fall onto outstretched hand or onto the elbow Can also occur due to excessive twisting during an arm wrestle Provide analgesia and support fracture with POP Refer if displaced, comminuted or ir NV conplications are suspected
64
What causes popeye sign?
Complete long head of biceps tendon tear - causes distal migration of the head of the biceps Causes a low biceps bulge above the elbow on attempted elbow flexion against resistance Management: analgesia + sling followed by exercises, surgery is rarely indicated
65
What is lateral epicondylitis?
AKA tennis elbow Follows repetetive strain to common entensor tendon at the lateral epicondyle Dorsiflexion of the pronated wrist against resistance will cause pain Management: NSAIDs, ice, rest, avoid aggravating movements, if prolonged refer for steroid injection
66
What is medial epicondylitis?
AKA golfer's elbiw Causes pain and swelling over common flexor origin at medial epicondyle Flexion of supinated wrist against resistance will cause pain Patients may have reduced grip strength and 60% have ulnar nerve neuritis Same treatment as for tennis elbow
67
What is olecranon bursitis?
Inflammation, swelling and pain in the olecranon bursa Elbow movements are not usually limited Can be caused by gout, infection, blood (hx of blunt trauma followed by golf-ball sized lump with full range of movement) Can be aspirated (e.g. if thinking infective) or treated with NSAIDs and rest - avoid aspiration if possible becuse drainage can result in secondary infection
68
Which nerve is compressed in cubital tunnel syndrome?
Ulnar nerve - entrapment at the elbow
69
Anterior shoulder dislocation
Humeral head dislocated to lie anteriorly and inferiorly to the glenoid **Examination:** - Step off deformity at the acromion with a palpable gap below the acromoin - Humeral head palpable anteroinferiorly to glenoid - Evidence of NV compromise - check sargeant stripe area) Management: pain releif, temporary swing, x-ray then reduce under sedation or GA
70
Posterior shoulder dislocation
Uncommon and easy to miss Results froma blow onto the anterior shoulder or a fall into the internally rotated arm, can also occur during seizures or after an electric shock Presentation: Internally rotated shoulder Light bulb sign on x-ray - can appear normal but careful inspection shows an abnormally symmetrical humeral head
71
Discuss acromio-clavicular joint injury
Common injuries usually following falls onto the shoulder Look for swelling, tenderness or a palpable step over the AC joint **Grade 1:** minimal separation, only AC ligaments involved **Grade 2:** Obvious subluxation but some apposition on bony ends **Grade 3:** complete dislocation of the AC joint indicating rupture of the conoid and trapezioid ligaments in addition to AC ligaments Management: analgesia and support using a borad sling \> Arrange follow up for grade 2&3 injuries, some patients benefit from internal fixation
72
Which of the rotator cuff muscles is most commonly torn?
Supraspinatus Suspected tears are treated conservatively with analgesia and support in a broad sling Arrange follow up for patients with significantly reduced ROM, complete tears may require surgical repair Inability to actively abcut to 90% at ~10 days suggests a complete tear - apparent on MRI
73
What is most commonly impinged in shoulder impingement?
Supraspinatus and its tendon Neer's impingement test: fully abducting the striaght arm will recreate symptoms la injection into the subacromial bursa should help with pain but will not improve strength or range of movement Corticosteroids can also be injected but repeated injection can lead to tendon rupture
74
What is adhesive capsulitis?
AKA frozen shoulder Occurs when **glenohumeral joint capsule becomes contracted and adherent to the humeral head** resulting in shoulder pain and reduced ROM Features: generalised & deep pain, joint stiffness, reduced function, loss of arm swing, atrophy of deltoid, limited ROM (mainly affecting external rotation and flexion of shoulder) Investigations: isially a clinical diagnosis, MRI may show thickening of joint capsule More common in diabetics Management: self limiting, analgesics, joint injections, surgery in extreme cases to remove capsular adhesions
75
What is a virtual fracture clinic?
Patient's notes and x-rays are reviewed and a decision make about management - this is then conveyed to the patient via the phone Allows patients to have targeted treatment to suit their needs e.g. advice + discharge,
76
Advice given to patients discharged following minor fracture/ injury
Depends on the fracture type but general advice: - Number for fracture clinic if there are any concerns following disharge - Number for ED - used during non-'office' times - Avoid sports - If still sore or swollen after 3 weeks, contact fracture clinic to arrange follow up - Use simple painkiller e.g. paracetamol/ ibuprophen if needed
77
Upper limb boney anatomy revision
78
Important to consider in patient with pelvic fractures
Associated bladder or urethral damage Rectal and vaginal injuries
79
Examination of a patient with a suspected hip fracture
Examine pubis, iliac bones, hips and sacrum for tenderness, bruising, swelling or crepitus Avoid log rolling Apply pelvic binder Look for wounds esp. in perineum Send for CT then do PR examination and insert catheter
80
How do we classify pelvic injuries?
Tile classification Type A: stable injuries inc. avulsion fractures, isolated pubic ramus fractures, iliac wing fractures or stable fractures elsewhere in pelvic ring Type B: Rotationally unstable but vertically stable B1: Open book antero-posterior compression fractures causing separation of the pubic symphysis and widening of one or both sacrioiliac joints B2: Ispilateral compression injury resulting in pubic rami fractures on one side and compression sacroiliac injury on the other B3: Contralateral compression injury resulting in oubic rami fractures on one side and compression sacroiliac injury on the other Type C: Rotationally unstable and vertically unstable. Pelvic ring completely disrupted at 2+ points, associated with massive blood loss and very high mortality
81
Treatment of pelvic fractures
Stable, type A: pain relief and bed rest until able to mobilise (3-6weeks). Isolated pubic ramus fractures are common and oftrn missed in elderly Unstable type B and C: resuscitate as appropriate, correct hypovolaemia, anticipate coagulopathy and ensure blood is avaiable as massive transfusion may be needed. Minimise movement but support the fracture using pelvic binder or splint. Involve seniors Interventional radiology is useful in patients with active arterial pelvic haemorrhage
82
Pelvic bony anatomy
83
Acetabular fracture
Often accompanies traumatic hip dislocation Posterior rim fractures are most common Complications: massive haemorrhage, sciatic nerve damage, myositis ossificans and secondary OA Imaging: CT better than x-ray
84
What is central dislocation of the hip?
Serious acetabular fracture where the head of the femur is driven through the acetabular floor Occurs following fall or force directed along femur length e.g. car dashboard
85
How does the leg appear when the hip is posteriorly dislocated?
Short + internally rotated Hip flexed and adducted Although this may not be the case if there is a femoral shaft fracture
86
Causes of dislocated hip prosthesis?
Can occur following minor trauma/ no trauma e.g. crossing legs or flexing hip to 90 degrees Occurs in 3% of total hip replacements
87
Important to check for following saccral fracture
Sacral nerve root damage - Saddle anaesthesia - Decreased anal tone - Limb weakness - Bladder dysfunction
88
What are Shenton lines?
Shenton line is an imaginary curved line drawn along the inferior border of the superior pubic ramus (superior border of the obturator foramen) and along the inferomedial border of the neck of femur. This line should be continuous and smooth Interruption of the Shenton line can indicate (in the correct clinical scenario): - Developmental dysplasia of the hip (DDH) - Fractured neck of femur
89
Is a suspected coccygeal fracture routinely x-rayed?
No - clinical diagnosis Complications are unusual unless grossly displaced
90
What are intracapsular fractures of the femur?
Fracture in the head/ neck of the femur Can occur following relatively minor trauma, esp. in the elderly Can disrupt the blood supply to the femoral head and cause avascular necrosis
91
When to suspect a hip fracture in an elderly person
- Sudden inability to weight bear (may be no hx of trauma) - Unable to weight bear and pain in the knee (hip may not be painful) - 'Gone off feet'
92
What is the classification system of intracapsular femoral fractures?
Garden classification
93
Patient has a fractured shaft of femur - what are your concerns?
Enormous force required to break a femoral shaft - Think about pathological fracture - Think about multi-system trauma
94
Complications of femoral shaft fractures
Marked blood loss - up to 1.5L without visible swelling Fat embolism ARDS Splinting and early definitive treatment reduces incidence of complications
95
What is given to stop bleeding in femoral shaft fractures?
TXA IV
96
What are supracondylar lower limb fractures?
Fractures involving the distal 3rd of the femur Often go through the articular surface and affect the knee joint
97
Pain management in femoral shaft fractures?
IV opioids Femoral nerve block Fascia iliaca block
98
Patient has rapid onset, tense swelling in their knee - thoughts?
Acute haemarthrosis Can drain 50-100ml blood from the knee
99
Questions to ask about knee injuries
- Mechanism of injury - Previous surgery - Other joint problems - Swelling, locking, clicking
100
Which rules should be followed when deciding whether to x-ray a knee
Ottowa knee rules (see prev. card)
101
Discuss management of patella fractures
Vertical fractures: immobilise with POP, give crutches and arrange ortho follow up Transverse fractures: tend to displace due to quadriceps pull - refer to ortho for probably ORIF
102
Which direction does the patella usually dislocate?
Laterally Reduction can be done using entonox
103
Which muscle attachment may be damaged following patella dislocation?
Vastus medialis
104
What is dislocation of the knee?
This does not refer to patella dislocation - it is a rare, severe disruption of the ligamentous structures and soft tissues of the knee Reduction requires IV analgesia and usually ga or sedation Important to check pulses and sensation Compartment syndrome is a recognised complication
105
Cruciate ligament rupture
Pain + swelling can make eliciting 'classical signs' tricky Often an audible **pop** is heard: suggests **anterior cruciate injury** **Anterior cruciate tears:** - Audible pop - Associated with medial collateral and/ or medial meniscus injury - Indicated by positive draw test - Look for avulsion of anterior tibial spine where anterior cruciate attaches **Posterior cruciate tears** - Tibia may sag backwards - Posterior tibial spine may be avulsed
106
Management of cruciate ligament rupture
Give analgesia and refer to ortho
107
Collateral ligament tears
Tenderness over medial or lateral collateral ligament with pain on stress testing indicates collateral ligament injury Degree of laxity indicates the grade of injury **Grade 1:** local tenderness, no laxity - analgesia + physio, recovery in 2-4 weeks **Grade 2:** Local tenderness with minor laxity with a definite end point to the laxity - analgesia, crutches, quadriceps exercises + ortho follow-up **Grade 3:** major laxity, complete rupture - consider POP, give crutches, analgesia, quadriceps exercises and ortho follow-up
108
What might cause an acutely locked knee?
Underlying meniscal tear/ foreign body in knee joint Give analgesia and refer for arthroscopy
109
What is a tibial plateau fracture?
Fracture of the proximal end of the tibia Caused by falls onto extended leg, seen in pedestrians injured by car bumpers Adopt low threshold for CT scan to clarify nature and extent of injury Manage: immobilise, analgesia, refer to ortho, these fractures often require elevation ± ORIF Admit patients with acute haemarthrosis
110
Which classification system is used for tibial plateau fractures?
Schatzker
111
What is Osgood-Schlatter's disease?
Inflammation of the patellar ligament/ underlying physis at the tibial tuberosity Causes pain and swelling over tibial tuberosity
112
Which class of antibiotics is associated with Achilles tendon rupture?
Fluoroquinolones esp. ciprofloxacin Also associated with steroid injection of the tenon area and oral steroids
113
Test for Achilles rupture
Thompson/ Simmonds test
114
Management of Achilles rupture
Conservative: POP for 6 weeks + analgesia with the ankle in plantar flexion and knee flexed to 45 degrees Surgical: often done in young patients and athletes
115
Other than injury and overuse, what is a known cause of Achilles tendinopathy?
Familial hypercholesterolaemia
116
Are steroid injections recommended for Achilles tendinopathy?
No - associated with increased risk of rupture
117
Bony ankle anatomy
Talus, navicular, cuneiforms, cuboid and calcaneus = tarsals Metatarsals Phalanges
118
Management of ankle sprains
Initial res, elevation and consider ice for 10-15min periods for first 2 days Weight bear as soon as symptoms allow but elevate at all other times Expect recover in ~4 weeks Give crutches if patient unable to weight bear despite analgesia Review after 2-4 days, if unable to weight bear consider immobilisation in case for 10 days
119
Long-term complications of ankle sprains
Not trivial injuries, often results in instability, peroneal nerve injury Encourage early mobilisation as it is loss of proprioception that is associated with instability
120
What is a potentially serious consequence of weeks of immobilisation in a cast?
VTE Consider prophylaxis with LMWH **Use a scoring system to assess risk and give:** **- Dalteparin if eGFR \>30** **- Enoxaparin if eGFR \<30**
121
What is a Lisfranc injury?
Foot injury where one of metatarsals becomes displaced from tarsus (7 bones which make the posterior aspect of the foot: talus, calcaneus, cuboid, navicular and three cuneiforms) Direct cause: something falls on foot and crushes it Indirect cause: sudden rotational force on a plantarflexed foot e.g. falling off horse but foot stuck in stirrup 🐎 🐎
122
Lisfranc injury management
Check for pulses Support in POP and refer if there are multiple displaced or dislocated fractures
123
Important to rule out if a patient has a calcaneal fracture
Calcaneal fractures most often occur due to a fall from height straight onto heels (often bilateral) Always rule out injuries to spine, pelvis, hips and knees Fractures can be hard to find so request specific calcaneal x-rays If you suspect a calcaneal fracture clinically but can't see it on x-ray, request a CT or given analgesia and crutches and review in 7-10 days
124
Most common site for metatarsal stress fractures
2nd MT shaft Treat symptomatically with analgesia, elevation, rest Suggest paddle insole as firm shoes may be more uncomfortable Expect recovery in 6-8 weeks
125
Death related to hip fracture
10% die within one month 25–30% die within 12 months
126
What is gallows traction?
A method of treating fractures of the thigh bone (femur) in young children. Skin traction is applied to both legs and the child is suspended from a beam so that the buttocks are just clear of the bed
127
What is the Weber classification of ractures used for?
Ankle fracture classification depicting where a fracture has occurred in relation to the tibia and talus bones (ankle joint) Weber A: Below the tibiotalar joint Weber B: at the level of the tibiotalar joint Weber C: Above the tibiotalar joint
128
What is a pilon fracture?
Caused by axial compression which drives the tibia into the talus Pilon = pestle (the end of the tibia looks like a pestle) Usually comminuted and displaced with extensive soft tissue swelling Needs emergency ortho consult
129
Flexor digitorum profundus injury
This tendon flexes the MP, PIP and TIP joints If this tendon is injured in isolation there is loss of flexion of the TIP joint only. The PIP and MP joints can still be flexed by the flexor digitorum superficialis tendon
130
Flexor digitorum superficialis injury
This tendon flexes the MP and PIP joints It's action is independent of the adjacent fingers and thus it can flex the finger when the adjacent fingers are held in an extended position If only the FDS is severed and the FDP in intact then the finger cannot be flexed while the adjacent fingers are held in the extended position
131
What is Tinel's sign?
Tinel's sign (also Hoffmann-Tinel sign) is a way to detect irritated nerves. It is performed by lightly tapping (percussing) over the nerve to elicit a sensation of tingling or "pins and needles" in the distribution of the nerve. Percussion is usually performed moving distal to proximal.
132
What is Phalen's test?
133
What cuses Boutonierre deformity?
Mechanism * caused by rupture of the central slip over PIP joint from * laceration * traumatic avulsion (jammed finger) * capsular distension in rheumatoid arthritis
134
Fracture reduction often requires 3 people - why?
1. Provides counter-traction 2. Reduces fracture 3. Applies plaster
135
What is Froment's sign?
Test for ulnar nerve palsy
136
What is a central slip injury?
Central slip injury: sometimes called a boutonniere deformity, part of the tendon which straightens the middle joint of the finger has been injured As the extensor mechanism of the hand crosses over the PIP joint, it branches into 3 bands: the central slip and 2 lateral bands (Figure 2). The central slip attaches to the middle phalanx and the lateral bands attach to the distal phalanx Treated with splinting, if not treated patient will not be able to extend/ straighten finger and the joint can stiffen and remain in a boutonniere position