Week 6 Flashcards
What are the arteries supplying head of femur
Obturator artery
Medial and lateral circumflex arteries
Which artery did the medial and lateral circumflex arteries branch off from
Deep femoral artery
Why does intracapsular hip fracture have a higher likelihood of causing femoral head necrosis
Because intracapsular fracture occurs at neck of femur hence cut off the blood supply to femoral head from the medial and lateral circumflex (hence retinacular arteries) and intramedullary arteries
What is extracapsular hip fracture
Hip fracture that occurs below the intertrochanteric line, below the neck of femur
Where is the intertrochanteric line
anterior aspect of the junction of the femoral neck and shaft
runs slanted between the greater and lesser trochanters
Where is the subtrochanteric line
5 cm below the lesser trochanter
What is the management for high function patient with displaced intracapsular hip fracture
Total hip replacement
What is the management for high function patient with undisplaced intracapsular hip fracture
CHS (compression hip screw)
What is the management for intracapsular hip fracture in elderly patients with co morbidities, low mobility
Hemiarthroplasty
What is the management for young patients with intracapsular hip fracture
CHS (compression hip screw) and see if it heals
If fails -> total hip replacement
What is the management for extracapsular hip fracture at intertrochanteric line
DHS (dynamic hip screw)
What is the management for intracapsular hip fracture at subtrochanteric line
IM nail (intramedullary nail)
Which muscle compartments are most commonly affected by compartment syndrome
Anterior and deep compartments
Fracture at which bone has high risk of causing CS
Tibial shaft fracture
Which compartment is most commonly affected by tibial shaft fractures
Anterior leg compartment
Early symptoms of compartment syndrome
Disproportionate pain
Pain on passive stretch of muscles
Late symptoms of compartment syndrome
pallor
paraesthesia
pulselessness
What is acute compartment syndrome
Increase in pressure in a muscle compartment, causing damage to the surrounding tissues, nerves and vascular supply
At what compartment pressure does it cause significant muscle damage
> 30-40 mmHg
Patients with what injuries can get CS
Tibial fractures
Open fractures
Forearm fractures
Burns
Management of CS
Phone senior ASAP
Release all dressings / cast to skin
Place limb at level of the heart
Why should you place the limb at level of the heart in CS
To reduce the blood pressure needed in the compartment to pump blood back
Where is weber B ankle fracture at
At the level of syndesmosis between the tibia and fibula
Where is weber A ankle fracture at
Below the level of syndesmosis between the tibia and fibula
Where is weber C ankle fracture at
Above the level of syndesmosis between the tibia and fibula
What is the weber classification used for
to assess the stability of the fracture and to determine future management
Management of open fractures
Antibiotics within 3 hours and until the wound is closed
Surgery
What antibiotics are given for open fractuers
IV co-amoxiclav
What antibiotics are given for open fractures in patients who are penicillin allergic
Co-trimoxazole
Metronidazole
What injuries are associated with tibial plateau fracture
Injury to common fibular nerve
Compartment syndrome
Soft tissue injuries of knee joint
How may tibial plateau fractures cause injury to common fibular nerve
Associated proximal fibular fracture
What arteries are at risk of damage due to tibial plateau fracture
Popliteal artery
Anterior tibial artery
Posterior tibial artery
Peroneal arteries
Management for tibial plateau fractures
Plates and screws
Bone graft
External fixator
ORIF
Total knee replacement if all the above fails
Why are plates and screws used in tibial plateau fractures
To elevate the depressed tibia
Why is bone grafting used in tibial plateau fractures
To fill in subchondral space due to loss of bone
management for tibial shaft fractures
Above knee cast
Surgery - IM nail / Internal Fixation / ORIF
Why is IM nail used more commonly than ORIF to fix tibial shaft fractures
Because ORIF can disrupt periosteal blood supply to fracture site, risking non-union, whereas IM nail does less disruption to the blood supply
Why do patients need frequent cast changes and xrays after a tibial shaft fracture
Because the position of the tibia is difficult to control
Management for ankle fractures
Cast
Surgery - ORIF
In any joint dislocations, what must be examined and documented before intervention
Neurovascular supply
What does pulseless arm indicate in a shoulder dislocation
That the vascular supply is damaged
What is the most common type of shoulder dislocation
Anterior shoulder dislocation
How does anterior shoulder dislocation occur
excessive external rotation force or a fall onto the back of the shoulder
What nerve is at risk of damage in anterior shoulder dislocation
Axillary nerve
What are the lesions associated with anterior shoulder dislocation
Bankart lesion
Hill Sach’s lesion
What causes recurrent shoulder dislocations after an anterior shoulder dislocation
Bankart lesions and Hill Sach’s Lesion makes the shoulder joint unstable hence more susceptible to recurrent dislocations
What is Hill Sach’s lesion
Injury of the humeral head secondary to anterior dislocation of the shoulder due to it colliding with the glenoid fossa
Where is regimental badge area
The skin covering the lower deltoid muscle
What is regimental badge area sensory assessment used for
To test the function of axillary nerve; axillary nerve supplies sensory information to the regimental badge area hence by assessing the senses in that area after a dislocation, it shows whether the axillary nerve is damaged or not
Signs of anterior shoulder dislocation
Loss of sensory in regimental badge area
Loss of roundness of shoulder
Muscle wasting of the deltoid (prolonged axillary nerve damage)
Positive Hamilton’s ruler sign
What is Hamilton’s ruler sign
When a ruler touches both the acromion and lateral epicondyle
Positive = dislocated shoulder
What is a light bulb sign
Xray sign of posterior shoulder dislocation; when the humeral head dislocates, it will also be internally rotated, giving a light bulb shape in AP xray
Management of joint dislocations
Reduction
Reassess neurovascular function
Repair
Rehabilitate (physio)
Management of shoulder dislocations (not delayed presentation)
Closed reduction under sedation -> reassessment of neurovascular function -> rehabilitation
Management of shoulder dislocations with delayed treatment
Open reduction surgery
Who has the highest risk of recurrent shoulder dislocation
Those under 20 years old ; recurrence rate decreases with age
What can a displaced fragment resulting from intra-articular radial and ulnar fracture cause
blocks full extension of the arm
Management of elbow dislocation
Closed reduction under sedation
Sling
rehabilitation
Management of elbow dislocation + radius / ulnar fracture
ORIF if radial head or neck fractured
ORIF + screws if coronoid process is fractured
Surgery to remove bone fragments if it is blocking full extension
What causes elbow instability and recurrent elbow dislocations
Damage to bony architecture of the elbow - fractures of the radial head / neck / coronoid process / epicondyle
Why should you have a high index of suspicion of other fractures when there is 1 identified fracture of radius / ulnar
Because the forearm bones and the ligaments joining them form a ring structure; a bony ring structure will have multiple injuries
Types of forearm fracture-dislocations
Monteggia
Galeazzi
What is Monteggia’s Fracture
Fracture of ulna associated with dislocation of radial head at elbow
What is Galeazzi’s fracture
Fracture of the radius associated with dislocation of ulnar at elbow
GRIMUS
Site of fracture and whether the dislocation is inferior / superior
Galeazzi
Radius
Inferior
Monteggia
Ulnar
Superior
GRUsome MURder
Galeazzi
Radial fracture
Ulnar dislocation
Monteggia
Ulnar fracture
Radial dislocation
What is peri-lunate dislocation
Dislocation of a carpal bone around lunate
What other conditions can be caused by peri-lunate dislocation
Carpal tunnel syndrome
Damage to median nerve
What bones does cortical bone tissue cover
Long bones only
What bones does periosteum cover
All bones
Difference between children’s bones and adults’ bones
Presence of growth plate
Thicker periosteum
More elastic
Can remodel themselves and correct angulation
Why do children’s fractures heal more easily than adults’
Thicker periosteum
How does thicker periosteum help heal the child’s bone quicker
Often stays intact with injury because it is thick -> stabilize the fracture
It also has a rich supply of osteoblasts -> promotes healing
Why is surgical remodeling of the bone not often used in children’s fracture and dislocation
Because they can remodel the bones easily and correct angulation
At what age should we start considering a child’s fracture as an adult’s fracture and why
12-14 ; once they hit puberty
Because after they hit puberty, there is less chance of remodeling / correcting angulation by themselves
What is Salter Harris classification used for
Links patterns of physeal (growth plate) fractures to prognosis
What is Salter Harris I pattern
Transverse fracture at physis, separating epiphysis and metaphysis
What is Salter Harris II pattern
Fracture of the physis up to the metaphysis
What is Salter Harris III pattern
Intraarticular fracture that crosses physis and exits through ephiphysis at joint space
What is Salter Harris III pattern
What is salter Harris IV pattern
Fracture extending upwards from joint line, cutting through physis and out the metaphysis
What is Salter Harris V
When the physis is compressed / crushed
Which salter harris pattern is the most common
Salter harris II
Which salter harris pattern will / may lead to growth arrest
Salter V
Salter IV
Salter III
Why may the fast healing of children’s bones be a disadvantage
Malaligned fragments become solid sooner
What type of elbow fracture is common in children
Supracondylar fracture
Injury mechanism of extension elbow fracture in children
Heavy fall onto outstretched hand
Management of undisplaced supracondylar fractuer
Splint
CRITOL
Sequence of ossification around the elbow
Capitellum
Radial Head
Internal (medial) epicondyle
Trochlea
Olecranon
Lateral epicondyle
What sign on xray may be seen in an elbow fracture
Posterior fat pad sign
Management of angulated / rotated / displaced elbow fracture in children
Closed reduction with pinning wires to prevent deformity
What structures can be damaged by a severely displaced extension fracture of the elbow
Brachialis muscle
Brachial artery
Median nerve
Ulnar nerve
What sign cannot be made by the patient due to severely displaced extension fracture of the elbow and why
They cannot make an OK sign
Because Flexor pollicis longus and lateral aspect of flexor digitorum profundus cannot function due to damage of ulnar and median nerve
Which branch of median nerve supplies FPL and lateral aspect of FDP
Anterior interosseous branch
Which nerve innervates the medial aspect of FDP
Ulnar nerve
What should be checked when there is an elbow fracture
Radial pulse
Capillary refill
Nerve function
Management of pulseless elbow fracture in children
Closed reduction and wiring
If the pulse does not return -> emergency surgery
What signs should raise your suspicion of child abuse
Rib fractures
Scapular fractures
Genital injuries
Femoral fractures in children under 2 years old
History doesn’t match with injury
Multiple trips to A&E for different sites of injuries
Inconsistent history
Metaphyseal fracture in infants
Management of Galezzia / Monteggia fractures in children
Plates and screws
Why isn’t cast and manipulation used in Galezzia / Monteggia fractures in children
High rate of re dislocation
What are toddler’s fractures
Undisplaced spiral fracture in tibial shaft
Common in toddlers
Management of toddler’s fractures
Cast
Injury mechanism of distal femoral fracture
Fall onto flexed knee in osteoporotic bone
Management of distal femoral fracture
Plate and Screws
Around what % of patients with previous patellar dislocation experience recurrent patellar dislocations
50%
How to prevent further patellar dislocations
Physiotherapy strengthening vastus medialis
What lower limb fractures usually occur in osteoporotic bone
Distal femur
Tibial plateau
Which type of tibial plateau fracture is more common
lateral tibial plateau
Stress from which direction causes lateral tibial plateau fracture
Valgus stress
What ligaments are damaged in lateral tibial plateau fracture
MCL and ACL
Why are open fractures common in tibial shaft fractures
Because tibia shaft is subcutaneous (i.e. quite superficial)
Management of extra-articular distal tibia fracture
IM nail if not too distal
Plating if too distal
What are Pilon fractures
Intra-articular distal tibial fractures
Injury mechanism of Pilon fractures
Fall from height
This causes the talus to be driven into distal tibial articular surface
What type of fractures can Pilon fractures be
Comminuted / impaction fractures at articular surface
Management of Pilon fracture
Temporary external fixation -> internal fixation once swelling settles
Common injury mechanisms of ankle injuries
Inversion injury
Rotational force on planted foot
What are the requirements for requesting an xray for ankle injury
Severe localized tenderness at distal tibia / fibula
Inability to weight bear for 4 steps
Types of ankle fractures
Stable / Unstable
What counts as a stable ankle fracture
Distal fibular fracture with no medial fracture / rupture of deltoid ligaments
What counts as an unstable ankle fracture
Distal fibular fracture with rupture of deltoid ligaments
What signs would suggest rupture of deltoid ligaments
Swelling and bruising at medial side of ankle
What xray signs would suggest rupture of deltoid ligaments
Talar shift
Talar tilt
Asymmetric increased space around the talus
What condition can be caused by talar shift
Post trauamatic OA
Because talar shift greatly increases the ankle joint contact pressures
Management of stable ankle fracture
Walking cast / splint
Management of unstable ankle fracture
ORIF
Injury mechanism of calcaneal fractures
Fall from height landing on heel
Management of calcaneal fracture
ORIF
Why is ORIF controversial for calcaneal fractures
Because there is risk of wound breakdown (re-opening) and wound healing problems
Where does the body of talus get its blood supply from
Anastomotic ring around the neck and head formed by anterior tibial, posterior tibial and peroneal arteries
Displacement of fracture of talus / subluxation or dislocation of talus can cause
AVN of the talar body due to disruption of blood supply
What can be caused by AVN of the talus body
Secondary osteoarthritis
What is Lisfranc fracture-dislocation
Fracture at the base of the 2nd metatarsal in the foot with dislocation of the base of the 2nd metatarsal
Signs of Lisfranc fracture-dislocation
Very swollen, bruised foot
Unable to weight bear
Xray may look normal
Injury mechanism of avulsion 5th metatarsal fracture
Inversion injury causing peroneus brevis tendon to pull a small fragment of bone away from its main part
Management of avulsion 5th metatarsal fracture
Walking cast
Supportive bandage
Stout boot
Is it problematic if non union occurs in 5th metatarsal
No because it forms a stable fibrous non-union which is asymptomatic
What is a Jones fracture
When the fracture occurs at proximal diaphysis of the 5th metatarsal
Why is Jones fracture problematic
Because the area of the fracture has poor blood supply and higher risk of non-union
What technique is used to reduce chronic pain in multiple displaced fractures in the metatarsals
K wires
Rupture of which tendons can usually be treated conservatively
Achilles tendon
Long head of biceps
Distal biceps
Rotator cuff
Rupture of which tendons are usually treated surgically
Quadriceps tendon
Patellar tenodn
