Acute medicine - fractures Flashcards

1
Q

Salter type 1

A

Straight across

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2
Q

Salter type 2

A

Above i.e. through the physis and metaphysis
Most common type (75%)

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3
Q

Salter type 3

A

Low i.e. through the physis and epiphysis

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4
Q

Salter type 4

A

Through i.e. through the physis, metaphysis and epiphysis
HIGH RISK FOR GROWTH PLATE INJURY

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5
Q

Salter type 5

A

ERasure of the growth plate - crush type

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6
Q

4 complications of shoulder dislocations

A

1) Bankart lesion = injury of anterior glenoid labrum
2) Hill-sachs lesion = cortical depression in postero-lateral head of humerus
3) Rotator cuff tear
4) Axillary nerve injury - runs inferiorly to humeral head, wraps around surgical neck of humerus, innervates deltoid and teres minor, needed for >15 degrees shoulder ABduction, sensory for skin over delotid/shoulder

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7
Q

NV assessment in a clavicle fracture

A

Nerve: brachial plexus injury, esp C5-6. Spurling test is specific for cervical root compression but is not sensitive (a negative test does not rule it out).
Vacular: subclavian artery runs closely opposed to the middle third of the clavicle (80% of fractures)

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8
Q

Middle third clavicular fracture management

A
  • broad arm sling for 2 weeks
  • if >12yo or shortened >2cm –> refer to ortho, and follow up with GP/fracture clinic
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9
Q

Lateral third clavicular fracture management

A
  • broad arm sling fro 2 weeks +; if displaced refer to ortho
  • fracture clinic in 5-7 days with xray
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10
Q

Medial third clavicular fracture management

A

Broad arm sling, ortho referral (both displaced and undisplaced) with ortho follow up

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11
Q

Proximal humeral fracture management

A

Immobilsation of shoulder in sling, body swathe or shoulder immobiliser
Follow up in fracture clinic or with GP in 7 days with x-rays to assess for further displacement

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12
Q

Degree of angulation/displacement to accept in prox humeral fractures

A

o 5-12 years - accept 60 degree angulation and 50% displacement
o >12 years - accept 30 degrees angulation and 30% displacement
* Isolated greater tuberosity fractures with displacement in the adolescent are an exception group in which surgical reduction and fixation is usually required.

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13
Q

Humeral fracture associations (transverse, short oblique, spiral)

A

Transvere/short oblique - direct trauma
Spiral - indirect twisting e.g. fall
Spiral in toddler or younger = NAI until proven otherwise

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14
Q

Humeral fracture management

A

reduction rarely required, use a collar and cuff; if mid-shaft, 1 week follow up in fracture clinic

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15
Q

Gartland type 1 location and management

A

Type I is a non displaced fracture. Immobilisation in an above-elbow backslab in 90 degrees elbow flexion with sling for 3 weeks. The backslab and sling should be worn under clothing (e.g. loose fitting shirt) and not through the sleeve
The backslab should extend as high above the elbow as possible (i.e. close to the axilla) and down to the metacarpophalangeal joints (MCP) joints. GP follow up in 3 weeks, no repeat xray required.

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16
Q

Gartland type 2 location and management

A

Type II supracondylar fracture describes a displaced fracture with an intact posterior periosteum. Refer to the nearest orthopaedic on call service for advice, A gentle reduction can be achieved by an anterior push on the distal fragment as the elbow is flexed to 90 degrees
Note the exception is type II injuries with coronal plane deformity (see radiological assessment). These must always be managed by orthopaedics.
Overnight observation and fracture clinic in 7 days post-injury, with xray of distal humerus in backslab

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17
Q

Gartland type 3 location and management

A

Type III supracondylar fracture describes a displaced fracture where both the anterior and posterior periosteum are disrupted. Refer to the nearest orthopaedic on call service, as requires urgent reduction and percutaneous pin fixation.

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18
Q

You are called by the midwife to assess a newborn baby who appears dysmorphic. On examination, there are multiple pterygium, joint contractures and talipes equinovarus.

  • Meckel-Gruber syndrome
  • Ellis Van Creveld syndrome
  • Escobar syndrome
  • Trisomy 18
  • Larsen syndrome
  • Trisomy 21
  • Potter sequence
  • Hecht syndrome
A

Correct answer:Escobar syndrome
Explanation:
This syndrome is also known as multiple pterygium syndrome. Pterygium describes webbed skin. There is also a lack of muscle movement in utero which leads to contractures and deformities such as talipes equinovarus (clubfoot).

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19
Q

You are called by the midwife to assess a newborn baby who appears dysmorphic. On examination, there is talipes equinovarus. You are unable to examine the palate because you cannot open the mouth wide enough to obtain a clear view.

  • Meckel-Gruber syndrome
  • Ellis Van Creveld syndrome
  • Escobar syndrome
  • Trisomy 18
  • Larsen syndrome
  • Trisomy 21
  • Potter sequence
  • Hecht syndrome
A

Correct answer:Hecht syndrome
Explanation:
Also known as trismus-pseudocamptodactyly syndrome. Mutations in the MYH8 gene lead to short muscles and tendons and subsequent limited range of movement. The mouth is particularly affected.

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20
Q

You are called by the midwife to assess a newborn baby who appears dysmorphic. On examination, there is a cardiac murmur and congenital vertical talus.

  • Meckel-Gruber syndrome
  • Ellis Van Creveld syndrome
  • Escobar syndrome
  • Trisomy 18
  • Larsen syndrome
  • Trisomy 21
  • Potter sequence
  • Hecht syndrome
A

Correct answer:Trisomy 18
Explanation:
Also known as Edwards syndrome. Both Edwards syndrome and Ellis Van Creveld syndrome can present with cardiac abnormalities but congenital vertical talus (commonly known as “rocker-bottom feet”) is associated with Trisomy 18.

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21
Q

An 11-month-old boy presents with a limp. His mum tells you that there has been no history of trauma. He has had a runny nose for the past three days, but no fever. He is usually well. On examination, there are no obvious abnormalities. The boy limps but doesn’t seem to be in pain. You request bloods for FBC and CRP and an x-ray. The FBC shows lymphopaenia with a CRP of 30. There is a hairline spiral tibia fracture on x-ray. When you discuss the results with his father, he tells you that his son tripped down two steps yesterday, but that he hadn’t mentioned it because he didn’t think he had hurt himself at the time and it didn’t seem significant at the time. Which of the following is the most likely diagnosis?
* a)Malignancy.
* b)Osteomyelitis.
* c)Toddler’s fracture.
* d)Non-accidental injury.

A

A: Incorrect. You should always consider malignancy in your differential diagnosis for limp, but this child is otherwise well, with no red flags and reassuring bloods, and the x-ray does not support the diagnosis.
B: Incorrect. Not all cases of osteomyelitis will present with fever but most are painful and/or will cause the child to be unwell. It can present with vague symptoms so it should be considered. The x-ray does not support the diagnosis.
C: Correct. Commonly occurs in children who are just starting to walk or become active. The mechanism of injury may be very minor and not noticed by the parents. The initial x-ray may be normal or the fracture may be mistaken for a nutrient vessel. The blood results can be explained by the viral URTI.
D: Incorrect. You should always consider NAI in any child with a fracture – especially if the history is not clear. However, toddler’s fracture often presents without any obvious mechanism of injury.
The correct answer is C.

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22
Q

Ossification centres of the elbow

A

CRITOE (1,3,5,7,9,11)
Capitellum at 1 year
Radial head at 3 years
Internal (medial) epicondyle at 5 years
Trochlear at 7 years
Olecranon at 9 years
External (lateral) epicondyle at 11 years

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23
Q

Investigations and management of a SUFE

A

A slipped upper femoral epiphysis (SUFE)is the commonest cause of hip pain in the adolescent age group (10-15 years).
* Males are more frequently affected than females by 2:1
* It may be bilateral in 30% of cases
* Positivefamily history,obesityandhormonalabnormalitiessuchas hypogonadism,hypothyroidismandhypopituitarism are well known associations
The pathology is a stress fracture through the upper femoral growth plate resulting in a progressive slip of the femoral head over the femoral neck. The affected limb shortens and externally rotates as the deformity increases with time.
If this condition is left untreated it may result in severe limb shortening, fixed external rotation and stiffness of the hip. This may then be followed by early onset of osteoarthritis in adulthood. Needs surgical management.
In a small number of cases sudden catastrophic failure of the growth plate may occur, resulting in severe deformity and loss of blood supply to the femoral head (avascular necrosis) with serious long-term sequelae.
A frog-leg lateral x-ray will confirm.

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24
Q

Associations with heel spurs

A

Heel spurs,when located on the inferior aspect of the calcaneus, is often associated with plantar fasciitis and ankylosing spondylitis.Enthesitis (inflammation where joint capsules, ligaments, tendons attach to bone) is the hallmark of ankylosing spondylitis. The two areas in the foot involved are the Achilles tendon at the back of calcaneus and the plantar fascia at the base of heel.

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25
Q

A 14-year-old boy presents to ED with left knee pain. He was competing in a basketball game when he had a sudden onset of knee pain and fell to the ground. This has never happened before. On examination, he left knee is swollen and held in 30 degree flexion. Which of the following is INCORRECT?
* a)Tibiofemoral dislocations occur when the foot is planted and there is a twisting force on the knee.
* b)The first line treatment is closed reduction.
* c)Up to 70% recurrence risk.
* d)It is associated with Nail-Patella syndrome.

A

A: Correct. This presentation is more typical of patellar dislocation and often occurs in gymnasts, skaters and basketball players. Tibiofemoral dislocations usually occur after high impact trauma e.g. road traffic accident.
B: Incorrect. It can be reduced immediately on the basketball court or with anaesthetic (e.g. inhaled fentanyl) in ED. Failure to reduce, or an intra-articular fracture, would warrant referral to Orthopaedics.
C: Incorrect. There is up to 70% recurrence risk.
C: Incorrect. Children with nail patella syndrome have dystropic nails and hypoplastic or absent patella. It is an autosomal dominant disorder.
The correct answer is A.

26
Q

Complications of supracondylar fracture (3)

A

Gunstock deformity - also known as cubitus varus deformity. It is a long term and rare complication.
Fishtail deformity - Lateral trochlear avascular necrosis causes this deformity which can present with elbow pain years after initial injury.
Volkmann ischaemic contracture - Supracondylar fractures are particularly at risk of vascular injury and thus compartment syndrome. If this is not identified and treated promptly, children may develop Volkmann ischaemic contracture – fixed elbow flexion, pronated forearm, flexed wrist and extended MCP joint.

27
Q

Pulled elbow reduction

A

There are two methods to reduce a “pulled elbow”. The first is hyperpronation and is thought to be more successful. The second is to hold the forearm supine and then maximally flex at the elbow.
Apply pressure over the radial head, fully pronate the forearm then flex the elbow.

28
Q

2 week old septic arthritis - most likely causative agent?

A

Streptococcus agalacticae (GBS), E coli, listeria

29
Q

2 year old septic arthritis - causative agent?

A

Gram positive - staph aureus, gram negative - Kingella Kingae

30
Q

Choose the most appropriate diagnosis from the following options:
* Juvenile Paget disease
* Sprengel deformity
* Neurofibromatosis type 2
* Marfan syndrome
* Cleidocranial dysplasia
* Neurofibromatosis type 1
* Homocytsinuria
* Klippel-Feil syndrome
You examine a child with scoliosis and note an elevated scapula. There is limited range of movement of the neck.

A

Correct answer:Klippel-Feil syndrome
Explanation:
Congenital fusion of the neck leads to limited range of movement. More than 50% of children will have scoliosis. The classic triad of a short neck, low hairline and limited range of movement of the neck occurs in less than 50%. Sprengel deformity is a congenital deformity where the scapula fails to descend to it’s correct position. Children may have isolated Sprengel deformity but should be assessed for Klippel-Feil syndrome.

31
Q

Choose the most appropriate diagnosis from the following options:
* Juvenile Paget disease
* Sprengel deformity
* Neurofibromatosis type 2
* Marfan syndrome
* Cleidocranial dysplasia
* Neurofibromatosis type 1
* Homocytsinuria
* Klippel-Feil syndrome
You examine a child with scoliosis and hypoplastic clavicles.

A

Correct answer:Cleidocranial dysplasia
Explanation:
Children have delayed closure of the cranial sutures, dental abnormalities and hypoplastic clavicles.

32
Q

Choose the most appropriate diagnosis from the following options:
* Juvenile Paget disease
* Sprengel deformity
* Neurofibromatosis type 2
* Marfan syndrome
* Cleidocranial dysplasia
* Neurofibromatosis type 1
* Homocytsinuria
* Klippel-Feil syndrome
You examine a child with scoliosis and hear a cardiac murmur. The Beighton score is 8.

A

Correct answer:Marfan syndrome
Explanation:
The Beighton score is used to assess hypermobility. The maximum score is 9 and a score of >4 suggests hypermobility. The murmur is suggestive of aortic regurgitation.

33
Q

Movements innervated by the radial nerve

A

OK sign (also the anterior interosseous nerve)
Thumbs up
Wrist extension (wrist drop)
Radial muscles - triceps, supinator, brachioradialis, all wrist/finger/thumb extensors

34
Q

Movements innervated by the ulnar nerve

A

Spread fingers against resistance
Grip a piece of paper firmly between middle and ring fingers
Ulnar muscles - flexor carpi ulnaris, flexors of distal phalanx of ring and little fingers, all intrinsic hand muscles except thenar group

35
Q

Movements innervated by the median nerve

A

Thenar muscles - abductor pollicis brevis, flexor pollicis brevis, opponens pollicis, lumbricals (to index and middle fingers)

36
Q

Seymour fracture

A

A Seymour fracture is type II Salter-Harris DIP fracture seen in the presence of a subungual haematoma.
Most nailbed injuries with DIP fractures do not require prophylactic antibiotics but Seymour fractures do.
The proximal edge of the nail plate is raised which means that it is superficial to the eponychial fold – so the lunula of the affected nail appears larger and the whole affected nail appears longer.
It is held flexed and can develop into “mallet finger”.
Most nailbed injuries can be managed in ED, but children with Seymour fractures should be referred to Orthopaedics/Plastics for review.

37
Q

Septic arthritis in a child with sickle cell anaemia

A

Salmonella (gram positive)

38
Q

Septic arthritis in child with recent varicella infection

A

Group A strep (gram positive)

39
Q

Humeral fractures in newborns - epi, type and management

A

Clavicular fractures are the most common fractures in neonates (approx. 1 in 1000) but humeral fractures are the commonest long bone fracture and occur approx. 2 in 10,000.
Most are proximal, transverse and complete. Neither clavicular or humeral fractures require casting but the humerus should be splinted by long sleeve top or stretchy wrap. The elbow should be held in flexion, rather than extension, to prevent rotational deformities.

40
Q

SCIWORA

A

Suspected cervical injury without radiological abnormality - children in whom you have a high suspicion of injury, but the x-ray and CT are normal.
While CT will pick up most c-spine injuries, approximately one in five injuries will be missed and only seen on MRI.
C-spine USS is not an appropriate investigation.

41
Q

Galeazzi fracture

A

Galeazzi fracture is very rare in children but describes a fracture of the shaft of the radius with dislocation of the distal radioulnar joint.

42
Q

Menteggia fracture

A

Ulnar shaft fracture with dislocation of the radial head

43
Q

Waddell’s triad

A

Head injury, thoraco-abdominal injury, femoral fracture

44
Q

Antalgic gait, out-toeing, shortening of affected limb, pain in groin/thigh/knee. External rotation of leg in hip flexion.

A

SUFE

45
Q

Classification of SUFE (2)

A

Ability to weight bear - stable = weight bear, unstable = unable to, even with crutches
Duration of symptoms - acute, chronic (>3 weeks, most common), acute on chronic

46
Q

Most common RF for SUFE

A

Male, obesity, 14yo male or pre-pubertal 12yo female, bilateral in 20-50%

47
Q

Complications of SUFE

A

osteonecrosis, chondrolysis, osteoarthritis, impingement

48
Q

Shorter leg, post significant (adolescent) or minor (child) trauma

A

Hip dislocation
* With an anterior dislocation, the leg is abducted and externally rotated
* With a posterior dislocation, the leg is usually abducted and internally rotated and the hip in a flexed

49
Q

Shortened and externally rotated leg after high impact trauma

A

NOF fracture
Complications - AVN, coxa vera (neck shaft angle <120 degrees), growth arrest, chondrolysis, infection

50
Q

Toddler fracture

A
  • Toddler fractures occur in young ambulatory children (from 9 months to 3 years)
  • A toddler’s fracture is a spiral or oblique undisplaced fracture of the distal shaft of the tibia with an intact fibula
  • The periosteum remains intact and the bone is stable
  • These fractures occur as a result of a twisting injury
    Supportive management, can use a backslab or above knee walking cast for 4 weeks
    Follow up = fracture clinic in 2 weeks with xray
51
Q

Undisplaced tibial shaft fracture

A

Above knee cast for 4-6 weeks
Fracture clinic in 1 week with xray

52
Q

Displaced tibial shaft fracture +/- fibular shaft fracture

A
  • Closed reduction with above-knee cast for 4-6 weeks (age and healing-dependent), non-weight bearing
  • Unstable fractures may require general anaesthesic, manipulation and plaster GAMP) or fixation in theatre
53
Q

Backpack palsy

A

Upper brachial plexus
Painless arm and/or shoulder weakness, sensory loss in the same distribution, full recovery over few months

54
Q

Erb palsy - cause, nerves, muscles, deformity,

A
  • Undue separation of the head from the shoulder: birth injury, fall on shoulder, during anaesthesia
  • Nerve roots involved = mainly C5 and partly C6
  • Muscles paralysed: biceps, deltoid, brachialis and brachioradialis; partly supraspinatus, infraspinatus and supinator
  • Deformity: arm hangs by the side, adducted and medially rotated; forearm extended and pronated
  • Disability: loss of abduction + lateral rotation in shoulder, flexion/supination of forearm, biceps/supinator jerk loss
    > loss of sensation over small area over lower part of deltoid
55
Q

Klumpke paralysis

A

Lower trunk of brachial plexus - mainly T1/C8
Cause of injury: undue abduction of the arm e.g. clutching something with hand after a fall from a height, birth injury
Muscles paralysed: Intrinsic muscles of the hand (T1), ulnar flexors of the wrist and fingers (C8)
Deformity: claw hand (hyperextension at MCP joints, flexion at IP joints)
Disability: claw hand, analgesia/anaesthesia along ulnar border of forearm/hand with warmness (arteriolar dilation) & does not sweat (loss of sympathetic activity)
- Sometimes associated Horner’s syndrome = ptosis, miosis, anhydrosis, enophthalmos and loss of ciliospinal reflex

56
Q

Ankle Salter-Harris type 1 and 2 fibula: management

A
  • Below-knee cast, non-weight bearing
  • Fracture clinic within 7-10 days with x-ray
57
Q

Undisplaced distal tibia physeal

A

Immobilise in above-knee cast, non-weight bearing
For Salter-Harris type III and IV, discuss with orthopaedic on call service whether CT scan is required to confirm that fracture is truly undisplaced
Fracture clinic within 7 days with x-ray

58
Q

Displaced distal tibia physeal

A

Closed reduction with above-knee cast, non-weight bearing.
> If reduction not anatomic, discuss with orthopaedic on call service
> For Salter-Harris type III and IV, refer to orthopaedic on call service
If closed reduction, fracture clinic within 5 days

59
Q

Tillaux and triplane fracture <2 mm displacement

A

Tillaux: Salter-Harris III fracture of the anterolateral distal tibia epiphysis
Triplane: complex salter harris IV fracture pattern in multiple planes
- Above-knee cast, non-weight bearing + fracture clinic within 7 days
- Discuss with orthopaedic on call service whether CT scan is required to confirm that fracture is truly undisplaced

60
Q

Tillaux and triplane fracture >2 mm displacement

A

Tillaux: Salter-Harris III fracture of the anterolateral distal tibia epiphysis
Triplane: complex salter harris IV fracture pattern in multiple planes
Refer to orthopaedic on call service. Typically requires operative management