Week 5 Flashcards
How many views do we need for a cervical spine and a scaphoid x ray
3
What are the views we need for a cervical spine xray
lateral
antero posterior
odontoid/open mouth view
What are the views we need for a scaphoid xray
lateral
anteroposterior
two obliques
Symptoms of scaphoid fracture
Tenderness at anatomic snuff box
Pain on compressing the thumb metatarsal
Where is the anatomic snuff box
Between the Abductor pollicis brevis + extensor pollicis brevis and extensor pollicis longus tendons
(when fingers abducted, it is below the thumb)
What is the cortical layer of the bone
dense outer surface of bone
What fracture appearances are there
Cortical extension (extends to the cortical layer of bone)
Spiral
Transverse
Comminuted
Angulation
Displacement
Impaction
Avulsion
What is an angulation fracture
The fracture displaces the bone; the normal axis of the bone is altered so that the distal portion of the bone is pointed into another direction
What is an impaction fraction
when two pieces of a fractured bone are driven into each other
What is an avulsion fracture
When a small piece of bone attached to a ligament or tendon gets pulled away from the main part
What causes avulsion fracture
due to bone is moving one way, and a tendon or ligament is suddenly pulled the opposite way
What can mimic avulsion fractures
Old injuries and normal anatomy
What is the difference between an actual avulsion fracture and an avulsion fracture mimic
An avulsion fracture mimic will be completely corticated whereas an avulsion fracture is not
How to tell if a bone fragment is corticated
Dense outer layer - grey colour on all sides
What bones can mimic avulsion fractures
sesamoid bones
accessory ossification centers
What is the posterior fat pad sign
When an elbow effusion is present, the posterior fat pad at distal humerus will be displaced and become visible (posterior fat pads should not be visible)
What does the fat pad at the elbow look like on xray
Black-ish appearance, black appearance will be next to distal humerus
What do children’s bones do instead of snap and splinter like adult ones when they sustain an injury
Bend or bow
Why don’t children’s bones snap when they sustain an injury
Because their bones are soft
What fractures do children usually get
Buckle fracture
Plastic bowing
Greenstick fracture
What is a buckle fracture and what does it look like
Incomplete fracture that happens when the bone is pressed to the point it bulges out
looks like a bump on the bone
What is a greenstick fracture
Incomplete fracture that happens when the bone is bent to the point it breaks but it doesn’t break all the way through (cracks without breaking completely)
Is avulsion fracture more common in adults or children
Children
Which part of the developing bone is the weakest
growth plate
What can result from a growth plate fracture
Growth deformity such as shorter limb / crooked limb
Where is the growth plate normally located at
It is a lucency between the epiphysis and metaphysis
Fractures in which bone is often associated with injuries in other areas too
femoral fractures
Why should you suspect injuries in other areas too if there is a femoral fracture
Because femoral fractures are high energy injuries
2 Steps management for femoral shaft fractures
- Analgesia + Thomas splint
- Closed reduction + IM nail
How can fat embolism occur in displaced femoral shaft fracture
Fat enters the damaged venous system
What can happen as a result of fat embolism caused by displaced femoral fracture
Hypoxia
Confusion
Acute respiratory distress syndrome
What should you expect if you see a bony ring (such as spinal canal) is injured
there should be 2 or more injuries of the bony ring because it is difficult to disrupt the ring in only one place
Why can wood and plastic splinters be invisible on xrays
Not dense enough; to be shown on the xray, the object needs to be in different density
Which type of shoulder dislocation may not be seen properly on xray AP view
When the humerus dislocates posteriorly
What should you do if you can’t see the posterior shoulder dislocation on AP view
Do oblique view
Which artery can be damaged by supracondylar fracture
brachial artery
What should you do if you still can’t spot scaphoid fracture after 3 different views
Repeat xray 10 days after
MRI
What can scaphoid fracture cause
Damage to scaphoid blood supply, causing necrosis and leads to early osteoarthritis
Necrosis of which pole can be caused by scaphoid fracture
Proximal pole
Management of undisplaced scaphoid fracture
Cast
Where does the blood supply for scaphoid come from
Distally from a branch of radial artery
Which devices can show soft tissue injuries
Ultrasound
MRI
Which ring-like bones usually have more than 1 site of injury when damaged
Pelvic ring
Spinal ring
Tibia and fibula
Radius and ulna
Pelvic ring fractures usually occur in
Elderly people with osteoporosis after a minor fall
Which structures are usually affected by pelvic fractures
pubic rami
sacrum
What are the soft tissues of the knee that you must examine as well and why
Patellar tendon
Quadricep tendon
Suprapatellar fat space
avulsion fracture can indicate soft tissue injury
What other clinical finding is usually accompanied with soft tissue injury of the knee
effusion filling suprapatellar space
Which artery can be disrupted by knee dislocation
Popliteal artery
Which structure of the tibial plateau is usually affected
lateral condyle
What injury mechanism causes tibial plateau fracture
valgus force (force coming into contact with outer side of knee) with foot planted
Extensor mechanism (quadriceps and patellar tendon) injuries of the knee can be seen by which device
Ultrasound
Which knee injuries can be shown in MRI
Meniscal tears
ACL/PCL/LCL/MCL
hyaline cartilage damage
What clinical presentation can be shown by displaced, torn meniscus
Locked knee
Which device can show complex ankle fractures
CT
What is a talar dome lesion
Injury at the upper part of talus - could be cartilage injury / the underlying talus bone
What do calcaneal compression fractures look like
Loss of central peak and increased bone density
What injury mechanism causes calcaneal compression fracture
Axial compression e.g. falling from height onto the heel
What is a common fracture mimic in the foot
Longitudinal accessory ossification center of the 5th metatarsal
What is a common fracture mimic in the leg
Fabella ; sesamoid bone posterior to distal femur
What conditions can predispose to tendon rupture
Diabetes
Rheumatoid Arthritis
Steroid use
Which nerve is at risk of damage due to anterior dislocation of glenohumeral joint and why
Axillary or Radial nerve because the posterior cord is behind the glenohumeral joint
Which cord of the brachial plexus is behind the glenohumeral joint
Posterior cord which branches to axillary and radial nerve
Which neck of the humerus is most prone to fractures
Surgical neck
Where is the anatomical neck of the humerus located at
The groove between the humerus head and the greater tuberosity
Which nerve is at risk of damage due to fracture of the surgical neck of humerus and why
Axillary nerve because it is a circumflex nerve around the surgical neck of the humerus
Which muscles are supplied by the axillary nerve
Deltoid
Teres minor
Function of the teres minor muscle
It is a rotator cuff muscle
It helps with external rotation
Function of the deltoid muscle
Abduction of the arm
What happens when the axillary nerve is damaged
Difficulty / Inability to lift your arm
Muscle weakness
Muscle wasting
Paraesthesia
Numbness
Pain
What is the classical sign of radial nerve damage
Wrist drop
Loss of sensation at dorsal web space
Fracture in which location can cause damage to the radial nerve
Fracture of humerus around its shaft
What artery is at risk of damage if there is a humeral shaft fracture and why
Deep brachial artery because it lies near the radial groove
Management of undisplaced proximal humeral fracture
Non-operatively with collar and cuff
How may the triceps brachii be involved in fracture of the humerus
Proximal fracture at the shaft of the humerus can damage the branch of radial nerve that innervates the triceps brachii, causing loss of function of the triceps
Wasting of which muscles can be caused by ulnar nerve injury
Adductor Pollicis
Hypothenar eminence
What are mucous cysts of the hand
a type of ganglion (outpouchings of synovial fluid) that occurs at DIP
Where do mucous cysts usually occur on hands
DIP
Which condition is associated with mucous cysts
Osteoarthritis
What possible symptoms can mucous cysts cause
Nails can grow irregularly due to the cyst growing near nail beds
May be painful
May rupture and release discharge
Management of mucous cysts
Nothing
Excision only indicated if it causes pain / at risk of rupturing
What are ganglions
Outpouchings of synovial fluid
Where do ganglions occur
DIP (mucous cyst)
Wrist
knee
foot and ankle
What is the ganglion present at the knee called
Baker’s cyst
Management of ganglions
Nothing
needle aspiration or surgery if causing localised discomfort
What is the problem of needle aspiration for ganglions
High recurrence rate
What should you beware of when performing needle aspiration of volar ganglion cyst
Radial artery is nearby
What is a pulley
ligamentous strap that keeps tendons close to the bone to create an optimal line of pulling
Tendons glide smoothly through the pulleys during flexion and extension
What causes trigger finger
1) Tendonitis of a flexor tendon to a digit, causing nodular enlargement of the tendon usually distal to A1 pulley
2) The nodule passes under the pulley when you flex your finger but cannot pass back under the pulley when you want to extend your finger
3) causes pain and discomfort when forcefully try to regain extension
Which fingers are usually affected by trigger finger
Middle and ring fingers
Management of trigger fingers
Nothing - often resolves itself
Steroid Injection
Splints
Surgery
When is surgery indicated in trigger finger
In recurrent cases
Borders of the carpal tunnel
Base - carpal bones forming an arch
Roof - flexor retinaculum
Contents of the carpal tunnel
Median nerve
9 tendons
What are the tendons in carpal tunnel
1 x flexor pollicis longus
4x flexor digitorum profundus
4x flexor digitorum superficialis
Branches of the median nerve
Recurrent
Palmar digital
Innervation of palmar digital branch of median nerve
Sensory innervation to palmar skin and dorsal nail beds of the lateral 3 1/2 digits
Motor innervation to the 2 lateral lumbricals
Innervation of recurrent branch of median nerve
Motor innervation to the thenar eminence
What sign can be presented on the hand due to median nerve damage
Hand of benediction
Describe the presentation of hand of benediction and how does it occur
Hand of benediction - ask the patient the make a fist but they can’t flex their first 3 fingers
This is because the palmar digital branch of median nerve supplies the 2 lateral lumbricals which are involved in flexion of index and middle fingers. The recurrent branch supplies the thenar eminence which is involved in flexion of the thumb.
Carpal tunnel syndrome mainly affects ____ and how?
Median nerve; neuropathy due to compression
What causes carpal tunnel syndrome
Fibrosis of the flexor tendons
Anatomically small carpal tunnel
Lesions
Inflammation
RA
Fluid retention
Fractures of the wrist
Which group of people is often affected by carpal tunnel syndrome and why
Pregnant women due to fluid retention
Symptoms of carpal tunnel syndrome
Pain
Paraesthesia
Weakness of the thumb
Clumsiness of thenar area
Muscle wasting at thenar area
Sensory loss
What exacerbates the symptoms of carpal tunnel syndrome
Flexion and extension of the wrist
At which point of the day does the symptoms of carpal tunnel syndrome get worse
Night
What are the examinations testing for carpal tunnel syndrome
Phalen’s test
Tinel’s test
Describe Phalen’s test
ask patient ti hyperflex their hands and hold the dorsal surfaces together
Pain = positive
Describe Tinel’s test
Percussion over the median nerve
Tingling sensation / pain = positive
Management of carpal tunnel syndrome
Wrist splints at night
Steroid injections
Carpal tunnel decompression surgery
What tendons are affected in DeQuervain’s tendinopathy
Abductor pollicis longus
Extensor pollicis brevis
Which group of people are most commonly affected by DeQuervain’s tendinopathy and what may be the reason
Pregnant women
Due to repeatedly picking up their babies
Symptoms of DeQuervain’s tendinopathy
Wrist pain on the radial side
Swelling or tenderness at the radial styloid
Pain in DeQuervain’s tendinopathy is aggravated by
Gripping / holding objects
Which examination can be used to test for DeQuervain’s tendinopathy
Finkelstein’s test
Pain = positive
Management of DeQuervain’s tendinopathy
Splints
Analgesia
Avoid holding or gripping objects
What is Dupuytren’s contracture
Hyperplasia of palmar fascia, forming nodules then progresses into contracture at MCP and PIP
How does hyperplasia of Dupuytren’s contracture occur
Proliferation of myofibroblast cells and production of abnormal collagen
Which fingers do Dupuytren’s contracture usually affect
Ring and Little fingers
Risk factors of Dupuytren’s contracture
Male
Genetics
Northern European or Scandinavian descent
Alcoholic cirrhosis
Diabetics
Peyronie’s disease and Ledderhose disease
Symptoms of Dupuytren’s contracture
Painless progression
Palpable nodules
Puckered skin
Management of Dupuytren’s contracture
Stretch
Surgery
When is surgery indicated in Dupuytren’s contracture
Stiffening of PIP or more than 30 degress at MCP
What is Paronychia
infection within nail fold
Which group of people are commonly affected by paronychia
Children, especially those that like to bite nails
Management of paronychia
Elevate the affected finger
Antibiotics
Drain / incise
What are the rotator cuff muscles
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
Where is the attachment point of supraspinatus, infraspinatus and teres minor
Greater tuberosity of the humerus
Where is the attachment point of subscapularis
Lesser tuberosity of the humerus
What is the collective function of the rotator cuff muscles
To provide stability to the glenohumeral joint during movement
Compression of the humeral head into glenoid fossa to create a stable point for the deltoid muscle to perform abduction
What is the collective function of the rotator cuff muscles
To provide stability to the glenohumeral joint during movement
Compression of the humeral head into glenoid fossa to create a stable point for the deltoid muscle to perform abduction
Function of supraspinatus
Abduction
Compression of humeral head for abduction
Function of infraspinatus
External rotation
Compression of humeral head for abduction
Function of teres minor
External rotation
Function of subscapularis
Internal rotation
Compression of humeral head for abduction
Which nerve innervates the supraspinatus muscle
Suprascapular nerve
Which nerve innervates the infraspinatus muscle
Suprascapular nerve
Which nerve innervates the teres minor
Axillary nerve
Which nerve innervates the subscapularis
Subscapular nerve
What are the most common shoulder problems in middle aged patients
Rotator cuff tears
Frozen shoulder
What is impingement syndrome
When the tendons of rotator cuff muscles are compressed under the subacromial space during movement
Symptom of impingement syndrome
Pain when lifting arm
Which rotator cuff’s tendon is the most commonly affected in impingement syndrome
Supraspinatus
What are the conditions that can cause impingement syndrome
Tendonitis
Subacromial bursitis
Acromioclavicular OA with inferior osteophyte
What is subacromial bursitis and how does it lead to impingement syndrome
Subacromial bursitis is the inflammation of bursa present underneath the acromion
It can cause the impingement syndrome because the bursa becomes inflamed and thickened, narrowing the subacromial space hence the tendons can get compressed and inflamed
What test can be done to test for impingement syndrome
Hawkins Kennedy test
Describe the Hawkins Kennedy test
- Ask the patient to elevate their arm to 90 degrees and perform forward flexion (like forming L shape)
- Let their arm rest on your arm
- Use your other hand to perform passive internal rotation
Pain = positive test
Management of impingement syndrome
Analgesics - NSAID, Steroid injections into subacromial space
Physiotherapy
Subacromial decompression surgery
How many times can steroid be injected into subacromial space
3
What extent of trauma can cause rotator cuff tears in young/middle aged people
Young - significant trauma
Middle aged - minimal / no trauma, due to degenerate changes
Which rotator cuff’s tendon is the most commonly torn
Supraspinatus
If the rotator cuff tear is large, which other rotator cuff muscles can be torn
Infraspinatus and Subscapularis
Symptoms of rotator cuff muscle tear
Difficulty in abduction / external rotation / internal rotation of the arm (depends on which tendon torn)
Muscle wasting
What tests can be done to test for subscapularis muscle tendon tear
Gerber’s test
Belly press test
What test can be done to test for supraspinatus / infraspinatus muscle tendon tear
Drop arm test
Describe the Drop arm test
- Passively abduct the patient’s arm
- Ask the patient to hold at that position, stop supporting the arm
- Ask the patient to lower their arm slowly
Positive = cannot lower their arm slowly hence their arm drops
Describe the Gerber’s test
- Stand behind the patient
- Ask the patient to place the back of their hand to mid lumbar spine area
- Ask the patient to lift their hand
- If the patient can perform this, ask the patient to lift their hand again but this time with resistance (press against patient’s hand)
Positive = cannot lift hand with or without resistance / pain while lifting
When is the belly press test used to test for subscapularis tear
An alternative to Gerber’s test when the patient has limited internal rotation ROM
Describe the belly press test
- ask the patient to flex their elbow and place their palm against their upper abdomen area (below xiphoid process)
- Move the patient’s elbow forwards a bit
- Ask the patient to press their palm against their abdomen
Positive = patient needs to compensate by moving their elbow backwards
What imaging tests can be done to assess rotator cuff muscle tears
Ultrasound
MRI
Management of rotator cuff muscle tears
Physiotherapy to strengthen the unaffected rotator cuff muscles
Analgesics
Surgery
What is the problem with rotator cuff repair surgeries
Failure occurs in 1/3 of patients
What is frozen shoulder
Progressive pain and stiffness of the shoulder due to thickening of the shoulder capsule but resolves after 18-24 months
What age group is most commonly affected by frozen shoulder
40-60 years old
What are the phases of frozen shoulder
- Pain
- Pain subsides, Stiffness begins
- Stiffness reduces, start to regain normal ROM
Risk factors for frozen shoulder
Diabetics
Women
Hypercholesterolaemia
Dupuytren’s disease
Previous shoulder surgery causing shoulder to be immobilized for a period of time
What is a key symptom of frozen shoulder
Limited external rotation
Apart from frozen shoulder, which other condition also causes pain, stiffness and limited external rotation of the shoulder and how can you differentiate
Osteoarthritis
OA occurs in older patients
Management of frozen shoulder
Physiotherapy
Analgesics - NSAID / steroid injections / co codamol
Manipulation under anaesthetic / surgical capsular release
What type of steroid injection is given for frozen shoulder
Glenohumeral injection
What causes traumatic shoulder instability
Bankart lesion
Hill Sach lesion
This can lead to recurrent dislocations caused by minimal force/injury
What is the term for tear of labrum
Bankart lesion
What is the likelihood of recurrent dislocations in patients under 20 with previous dislocation and Bankart lesion
80%
Management of traumatic shoulder instability
Bankart’s surgery to repair labrum tear
What causes atraumatic shoulder instability
Hyperlaxity of shoulder ligaments
What causes hyperlaxity of shoulder ligaments
Some people just have it
Repetitive overhead motion
Marfan’s ; Ehlers-Danlos
Which sports requires repetitive overhead motion and causes hyperlaxity
Swimming
Tennis
Volleyball
What type of dislocation can hyperlaxity cause
Multidirectional dislocation
Management of atraumatic shoulder instability
Analgesia
Physiotherapy
What is cellulitis
Infection and inflammation of the dermis and subcutaneous tissue
What are the pathogens causing cellulitis
Beta haemolytic strep
Staphylococci
What type of conditions poses as a risk for cellulitis
Conditions that impairs venous drainage / integrity of the skin barrier
Risk factors for cellulitis
Diabetics
Pregnancy
Obesity
Venous insufficiency
Ulcers / open wounds
What classification is used to describe the severity of cellulitis
Eron classification
Management of cellulitis
Rest
Elevation
Analgesia
Antibiotics - oral or IV
What antibiotics are used to treat cellulitis
Oral Penicillin +/- flucloxacillin
IV flucloxacilin / clindamycin / vancomycin
What antibiotics are used to treat cellulitis if the patient is allergic to penicillin
Erythromycin
Clarithromycin
Management of abscess
Drain - if there’s pus, let it out
Antibiotics
Rest, elevation, analgesia
Types of septic arthritis
Native joint infection
Prosthetic joint infection
How do pathogens enter and cause septic arthritis
Haematogenous spread
Direct inoculation - during surgery / open wound / animal bites
From neighbouring infection
Which heart infection can lead to septic arthritis
Infective endocarditis
Mechanism of septic arthritis
Infection -> joint effusion -> increase in intraarticular pressure damaging vascular supply -> spread through blood -> systemic infection
Symptoms of septic arthritis
Acute monoarthropathy
Decreased ROM
Swelling
Systemic upset
Raised WCC and inflammatory markers
Arthroplasty of which joint is more susceptible to septic arthritis
Knee
Why is prosthetic septic arthritis more difficult to treat with antibiotics
Because the presence of foreign substance enhances bacteria’s ability to form biofilm
Prosthetic septic arthritis that occurred less than 3 months after surgery indicates
that the infection was acquired during surgery
What is the likely causative pathogen for a prosthetic septic arthritis that occurred <3 months after surgery
S aureus
E coli
What is the likely causative pathogen for a prosthetic septic arthritis that occurred 3 - 12/24 months after surgery
Coagulase negative staph
Prosthetic septic arthritis that occurred more than 12 or 24 months after surgery indicates
That the infection was not related to surgery, most likely from haematogenous spread
What is the likely causative pathogen for a prosthetic septic arthritis that occurred 12/24 months after surgery
S aureus
Strep
E coli
Which pathogen is most common in IVDU causing septic arthritis
Pseudomonas aeruginosa
Which pathogen is most common in young sexually active patients causing septic arthritis
Neisseria gonorrhoeae
Investigation for septic arthritis
Joint aspiration ideally before antibiotics but do not let this delay prescribing antibiotics to patients if there is already a highly indicative pathogen and the patient is deteriorating
Management for septic arthritis
Sepsis 6 bundle
3 in - antibiotics ; IV fluids; oxygen
3 out - blood cultures ; urine output ; lactate
Surgery: arthroscopic drainage
What is the most common pattern of proximal humeral fracture
Fracture at surgical neck + medial displacement of the humeral shaft
Why may there be displacement of humeral shaft in proximal humeral fracture
Due to pull of pectoralis major muscle
Should you be worried about a displaced humeral shaft due to proximal humeral fracture
If it is minimally displaced, no need to worry as the position of displaced bone improves after muscle spasm ends
Management of undisplaced proximal humerus fractures
Sling
Internal fixation (surgery)
When is proximal humeral shaft treated surgically
If persistently displaced fractures
Proximal humerus fractures are common in what type of injuries and in which group of people
Low energy injuries in patients with osteoporotic bones
What can occur if the humeral head undergoes AVN after proximal humeral fracture
Cause chronic pain
Which type of proximal humeral fractures may require shoulder replacement
Comminuted fracture
Head splitting fracture
What ligaments are ruptured in subluxation of acromioclavicular joint
Acromioclavicular ligaments
What ligaments are ruptured in dislocation of acromioclavicular joint
Acromioclavicular ligaments + coracoclavicular ligaments
What are the coracoclavicular ligaments
Conoid
Trapezoid
Up to what degrees of humeral shaft displacement can be accepted
Up to 30 degrees of angulation
Management of humeral shaft fractures
Humeral brace
Internal fixation + IM nail
Management of most intraarticular fractures
ORIF
Which direction of elbow dislocation is the most common
Posterior direction
Management of uncomplicated elbow dislocations
Closed reduction
Sling after surgery
