Yr 2 management of common orthopaedic conditions (main lecture) Flashcards
Session plan
General principles in Trauma and orthopaedics
- These are pegs to hang your hat/scarf on
- With these principles you should be able to take a history and examine any part of the limbs and hold your own.
We divide MSK into trauma, orthopaedics and rheumatology (will cover later on)
Bone cells
-Osteoclasts are phagocytic cells
Organization of compact/cortical bone: osteons
In cortex where osteons exists and these consist of a haversian canal which has blood vessels nerves and lymphatics.
These canals have concentric lamellae of bone tissue and these contain osteocytes. The osteoblasts and clasts are mainly in the lining of bone so endosteum and periosteum
Structure of long bones
Centre is medulla-spongey part of bone
Outer bit is cortex
Physis one proximally and one distally
When you have a physis, the bit closest to the joint is the epiphysis, just beneath the physis away from the joint is the metaphysis and long aspect of bone is diaphysis.
Trauma/fractures
Mechanisms of Bone Fracture
How can bones break?-trauma eg injury –low-fall from standing height
Abnormal on normal eg marathon
Normal on abnormal-pathological fracture
Pathological or insufficiency – Normal stresses on abnormal Bone: local or general
Pathological fractures can be caused by abnormal density, abnormal mineralization or malignancy,
Pagets disease is an abnormal turnover of the bone
Insufficiency-where bone is weak due to metabolic diseases eg osteoporosis or osteomalacia
Pathological-anything where bone is abnormal
Osteoporosis can be both
Fracture Patterns
Is skin covered over fracture?
Is it just 2 fragments or is it comminuted ie many)
Is it displaced?
Are the Soft Tissues Intact?
- Yes – Closed
- No – Open
Is the break complete?
- Yes – How many pieces?
- 2 – simple
- >2 – comminuted
- No – Greenstick
Are the bony ends aligned?
- Yes – Displaced
- No - Displaced
Fracture Healing
When fractures happen you get bleeding, haematoma formed, cells and cytokines start producing collagen and then then turns into callous, initially type 2 collagen and then callous harden with type 1 collagen
Then osteoclasts and blasts remodel bone based on stresses put on it.
Step 1: Bleeding/Haematoma – prostaglandins/cytokines released; growth factors increase local blood flow – Periosteal supply takes over
Step 2: Granulation Tissue/connective tissue/Fibrous tissue laid down / Soft Callus
Step3: Once fracture is bridged with soft callus- hard callus is formed ( laying down of Osteoid/ bone)
Step4 : Bone is remodelled via endochondral ossification lamellar bone in its place.
Trauma/fractures
What are the clinical signs of a fracture?
What could be damaged?
What is damaged and what is around structure that energy could have damaged
Investigations of fracture
MRI for soft tissue (also getting good at architecture of bone)
CT-architecture of bone
Bone scan-invasive (need dye) and a lot of radiation, so do these rarely, only in bone disease
Describing a fracture radiograph
4th picture of leg is diaphyseal fracture
Middle-between diaphysis and metaphysis so metaphyseal diaphyseal junction
An avulsion fracture is an injury to the bone in a location where a tendon or ligament attaches to the bone
Displacement
Translation-movement occurs in staright line
Or rotation
Injury and healing lecture has more detail on this
Here we have left femur, say fracture is midshaft and distal fragment has moved In straight line away from midline so lateral translation
With angulation again have 3 planes
Coronal plane-from front
Varus-towards midline
Axial plane-from foot upwards, can have internal/extrenal rotation
Describe this radiograph
Describe this radiograph 2
Management of fractures
General principles
May get a question –tibial fracture-what are principles of management and what are order?
Reduction:
Hold
Might hold with plaster or stick pin in bone-traction, don’t do this often as lots of time in bed, better to use fixation
Fixation
Internal-under skin
External-through the skin
Extramedullary-plate on surface of bone
Rehabilitate
Is lower limb-get patient to weight bare
Strengthen muscles and helps remodelling
What types of fixation are these (internal/external; medullary; mono/multiplanar)?
Different types of holding fracture
Plate is on surface of bone so extramedullary fixation but its under the skin so is internal
Pin going through bone is intramedullary internal fixation
External can be in different planes so monoplanar or multiplanar
Reduction-may involve pulling on it, or may have to do an open fixation if doesn’t go back to correct location.
Fracture Complications
Divide into general-affecting whole body, or local-at the fracture site
General include:
- Fat embolus-fat from bone marrow can enter blood and travel to lung etc.
- Can have blood clot in that limb
- Or blood clot can travel from limb, so thromboembolic pulmonary pathology
- Systemic infection in form of sepsis
- Traction-have to lie in bed for 2 months so chest infections as not breathing as deeply, pressure sores as one position, hence this isn’t preferred
Local Complications of fractures
Urgent-immediate-think muscles, veins, nerves, tendons, plaster can be on too tight and can trap nerve
Early-within 30 days
Late-after 30 days
algodystrophy, also known as complex regional pain syndrome (CRPS),-stiffness of muscles and abnormal pain response due to long term bone problem
Fractured neck of femur
Need to know this!
Common due to osteoporosis leading to insufficiency fractures
Want to know their risk factors and cormorbidities for doing operation
Nof Anatomy: label these parts
Intertrochanteric line inbetween
Capsule attaches to Intertrochanteric line line at front and half way up the neck on the back
Types of NoF fractures by location: can you label? Intra or extracapsular?
Subcapital and transcervical fractures are considered intracapsular fractures.
=transcerviacal fracture
Hard to say if extra or intra
2-completely out of position so displaced, but 1 is not
If extracapullar fracture-risk of bone dying is low
If intra-risk of head of femur dying is higher so might want to chuck head away and replace it, except for younger placements as they will have these replacements for years
Neck of femur management:
Extra-fix
Intra- if displaced-depends on age of patient
How do we classify joints?
Articular surface of hip joint is bits that move against itself, so even an intracapsular fracture can be extraarticular as may not directly affect the joint surface
Fibrous-in skull and in tubia and fibula in ankle
Cartilaginous-where true bit of cartilage between joints eg between vertebra in spine
Components of a synovial joint
Has an articular surface which is made up of hyaline cartilage
They also have a capsule which is fibrous structure made up of collagen
Synovium produces synovial fluid
Cartilage:
Articular cartilage is trying to reduce friction so has specialized cells called chondrocytes, it has arrangement of cells more horizontal
Extracellular matrix
Joint diseases - overview
Osteoarthritis-mainly disease of articular cartilage
Rhematoid is inflammation of synovial membrane
Radiographic changes in Rheumatoid Arthritis vs.
In both-joint space can be narrowed
Sclerosis is extra bone formation
Osteoarthritis has mainly thick bone at surface but in RA it is mainly thin here
Pathophysiology
Can result in inflammation but this is a late bit of the disease and there are lots of inflammatory mediators of the disease. Inflammation occurs after articular surface has been damaged
Can result due to obesity or after trauma where surface is no longer smooth so will wear out fater
Analgesics, injections and sometimes surgery
Risk factors:
Weight and obesity and estrogen deficiency are modifiable, some are not modifiable eg gender or age or trauma
Osteoarthritis
How do patients present?
Assessment for any joint
- Look
- Feel
- Move
- Special tests
Look
Valgus deformity as distal bit going away from midline
Valgus is a term for outward angulation of the distal segment of a bone or joint. (Think you move away from valgor things!)
Coronal plane
Knee replacement scar
Feel
Palpation there is a small effusion
Move
Special tests
Special tests
Think would be valgus ie distal limb going out as it was the medial cruciate lig at knee attaching it.
In summary
Plan
More wear produces more bone and as get more wear get more fluid entering joint space
Patient lying down vs standing up
Important to stress the limb by weight bearing
OA management
In management of anything say conservative or operative
Normal ankle of right and on left arthritic ankle joint and they put screws through so joint not moving so no pain, although have stiff joint can still weight bear better than replacing joint which can’t take much weight.
Bone infection
Bacteria seeded on metal from surgery so could be secondary or direct bacteria into blood
If chronic infection can get weight loss
Bacteria in joint start eating away and ligaments, synvium, lots of pus, red hot painful, hard to move
Septic arthritis
Can come from cut, insect bite etc
Emergency as bugs eating joint surface
Investigations
The indium white blood cell scan, is a nuclear medicine procedure in which white blood cells are removed from the patient, tagged with the radioisotope Indium-111, and then injected intravenously into the patient. The tagged leukocytes subsequently localize to areas of relatively new infection.
Treatment
Bone infection-takes a lot of antibiotics to clear it as bone doesn’t have great blood supply
Some joint examination tips
Shoulder
Shoulder conditions
Hip
Hip Conditions:
Knee
Knee conditions
Spine:
Bone infection
Investigations
Treatment:
Synovial Joints:
functional types
Classified according to shape and how they move
Ankle hinge-as moves in one direction
Knee-modified hinge joint as there are some other forms of movement too
How are synovial joints stabilized?
How much of these contribute in each joint vary eg in hip-bone congruity big, tendons and lug small
Shoulder-bony-small factor but tendons and lig big factor
Session Plan: common conditions, exam questions, principles of management
