Upper and lower limb injury Flashcards
X-ray principles
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 to describe a fracture
- 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 to describe a long bone fracture
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
Steps of describing a fracture - simple
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?
What is the Salter-Harris classification?
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
Discuss the Salter-Harris classification fracture types
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
Discuss type 1 Salter-Harris fractures
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
Discuss type 2 Salter-Harris fractures
ABOVE
Occurs across growth plate (physis) and then ABOVE into metaphysis
Most common form of fracture - 75%
Good prognosis
Discuss type 3 Salter-Harris fractures
LOWER
Fracture passes along physis and then down through the epiphysis
Poorer prognosis - often an unstable fracture and can require operative management
Discuss type 4 Salter-Harris fractures
THROUGH
Passes through epiphysis, physis and metaphysis
Prognosis is variable, can be unstable and operative management should be considered
Discuss type 5 Salter-Harris fractures
RAMMED
Crushing injury damages the growth plate via compression
Worst prognosis of all 5 SH types
Fracture types
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
Outline what open fractures are
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
What is the Gustilo classification?
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
Management of open fractures
Emergency: debride and lavage within 6hrs
IV antibiotics (broad)
Tetanus vaccine
Amputation is often required following IIIC open fractures
What is tetanus?
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
What is subluxation?
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
What is dislocation?
Articular surfaces at the joint have lost all contact with each other
Management of subluxation or dislocation
X-ray before reduction unless there is neurovascular compromise
What is a sprain?
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
What is a strain?
Muscle-tendon injury
Pain on palpation and on active/ passive contraction
sTrain = Tendon
What is myositis ossificans?
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
Management of myositis ossificans
Myositis ossificans is benign and treatment is reserved for symptomatic lesions
Management is usally surgical which is often curative
Types of pathological fractures
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
Most common location for pathological fractures
Subtrochanteric femur
Humeral head and metaphyseal junction
Vertebral body
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
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
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
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
Management of compartment syndrome
Fasciotomy
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+
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
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
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
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
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
Nerve supply to hand muscles
Median nerve = thenar muscles (except adductor policis which is ulnar)
Median nerve = lateral 2 lumbricals
Ulnar = all others
Muscles needed for thumb adduction and abduction
Abduction of the thumb = median nerve
Adduction of thumb = ulnar nerve UMMMM ADD the thumb
Patient cannot adduct thumb - which nerve is affected?
Ulnar
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
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
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
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
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
What can cause a spiral fracture of a phalanx or metacarpal?
Boxer’s fracture
4th or 5th metacarpal neck fracture
Due to a blow with a clenched fist
Management: K-wire fixation
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
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
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
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
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
Monteggia fracture
Fracture of the ulnar shaft with dislocation of the radial head
Mainly occur in children
4 types according to Bado classification
Most commonly fractured carpal bone
Scaphoid
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
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**
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
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
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
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
Important when assessing a dislocated elbow
Distal pulses and sensation
Brachial artery and median + ulnar nerves my be damaged
Most common type of elbow dislocation?
Postero-lateral dislocation
> Meaning the distal portion moves poerto-laterally
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
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
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
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
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
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
Which nerve is compressed in cubital tunnel syndrome?
Ulnar nerve - entrapment at the elbow
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
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
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
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
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
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
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,
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
Upper limb boney anatomy revision
Important to consider in patient with pelvic fractures
Associated bladder or urethral damage
Rectal and vaginal injuries
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
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
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
Pelvic bony anatomy
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
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
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
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
Important to check for following saccral fracture
Sacral nerve root damage
- Saddle anaesthesia
- Decreased anal tone
- Limb weakness
- Bladder dysfunction
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
Is a suspected coccygeal fracture routinely x-rayed?
No - clinical diagnosis
Complications are unusual unless grossly displaced
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
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’
What is the classification system of intracapsular femoral fractures?
Garden classification
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
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
What is given to stop bleeding in femoral shaft fractures?
TXA IV
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
Pain management in femoral shaft fractures?
IV opioids
Femoral nerve block
Fascia iliaca block
Patient has rapid onset, tense swelling in their knee - thoughts?
Acute haemarthrosis
Can drain 50-100ml blood from the knee
Questions to ask about knee injuries
- Mechanism of injury
- Previous surgery
- Other joint problems
- Swelling, locking, clicking
Which rules should be followed when deciding whether to x-ray a knee
Ottowa knee rules (see prev. card)
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
Which direction does the patella usually dislocate?
Laterally
Reduction can be done using entonox
Which muscle attachment may be damaged following patella dislocation?
Vastus medialis
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
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
Management of cruciate ligament rupture
Give analgesia and refer to ortho
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
What might cause an acutely locked knee?
Underlying meniscal tear/ foreign body in knee joint
Give analgesia and refer for arthroscopy
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
Which classification system is used for tibial plateau fractures?
Schatzker
What is Osgood-Schlatter’s disease?
Inflammation of the patellar ligament/ underlying physis at the tibial tuberosity
Causes pain and swelling over tibial tuberosity
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
Test for Achilles rupture
Thompson/ Simmonds test
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
Other than injury and overuse, what is a known cause of Achilles tendinopathy?
Familial hypercholesterolaemia
Are steroid injections recommended for Achilles tendinopathy?
No - associated with increased risk of rupture
Bony ankle anatomy
Talus, navicular, cuneiforms, cuboid and calcaneus = tarsals
Metatarsals
Phalanges
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
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
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
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 🐎 🐎
Lisfranc injury management
Check for pulses
Support in POP and refer if there are multiple displaced or dislocated fractures
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
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
Death related to hip fracture
10% die within one month
25–30% die within 12 months
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
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
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
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
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
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.
What is Phalen’s test?
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
Fracture reduction often requires 3 people - why?
- Provides counter-traction
- Reduces fracture
- Applies plaster
What is Froment’s sign?
Test for ulnar nerve palsy
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
