Flashcards in Block Summary Questions Deck (280):
An elderly patient who mobilises with a ZF and suffers from CHF, COPD and type 2 diabetes presents to A and E and is found to have a displaced intracapsular hip fracture, what definitive treatment should be given and why?
displaced fracture- unstable, and intracapsular- high risk of AN to femoral head, but patient unfit for a THR- longer op, higher risk of general complications, as requires more than 1 walking stick to mobilise, and has several co-morbidities.
a patient presents with a grossly deformed and swollen ankle in A and E, and is placed into a plaster backslab. Why is this used rather than a full plaster cast?
in order to allow swelling to reduce and not increase the pressure
methods to reduce ankle swelling before ORIF?
ankle elevation above the level of the heart
ice- ensure covered well so as not to burn the skin
apply a plaster backslab
rest the limb
a patient admitted with an ankle fracture, which has been stabilised in a plaster backslab, complains now of pain which is disproportionate to his injury. What 2 important management steps must take place?
removal of the plaster backslab
initial investigations to be undertaken in a patient following ABCDE assessment in A and E after a suspected significantly unstable fracture of both the right tibia and fibula?
Us and Es
group and save
plain X-ray of the right leg (and ankle?)
must assess NV status- palpate pulses and test sensation
standard ankle radiograph views?
mortise- not a true AP, but optimises view of ankle joint- 30 degree oblique projection facing plane of inferior tibiofibular joint, this is best view to show tibiofibular joint separation (diastasis), and allows full visualisation of medial and lateral joint spaces.
mechanism of injury in skiers thumb/ thumb UCL acute injury?
hyperabduction or extension of thumb at the MCPJ
indications for a hinged TKR?
may be used in revision surgery or severe arthritis, have longer stem to allow for more secure fixaton into bone cavity
may be necessary if weakness of main knee ligaments, major bone loss due to arthritis or fracture, or major knee deformity
approximate healing time for surgical neck fractures (2 part fractures) of humerus?
but recovery takes months
shoulder stiffness generally occurs if shoulder immobilised for more than 2 weeks
why might a broad arm sling be used instead of a collar and cuff for a proximal humeral fracture?
if impacted fracture and don't want disimpaction
union more likely with an impacted fracture
most common causative organism in prosthetic joint infections?
presentation of skiers thumb?
pain at ulnar aspect of thumb MCPJ
tment of skiers thumb?
nonoperative- immobilisation for 4-6wks- thumb spica splint
operative- ligament repair or reconstruction if significant instability
4 leg compartments?
how can compartment syndrome be tested for in a patient?
needle manometry to measure intracompartmental pressure
passive hyperextension of the toes or fingers- increased pain in calf or forearm, as ischaemic muscle highly sensitive to stretch
note that aggressive IV fluid therapy required in treatment as myoglobinuria may follow fasciotomy and cause renal failure
why may a pulse still be felt in compartment syndrome?
ischaemia occurs at the capillary level
important blood test in suspected bone malignancy?
bone profile- Ca2+, phosphate, ALP, albumin
rate of failure of a TKR?*
chance of failure in the 1st 10 years is 1% per annum cumulative
2 ways to distinguish between vascular claudication and spinal claudication?
spinal- relieved by leaning forward, vascular- just by rest
spinal- pain same or better when walking uphill, worse in vascular claudication
most common long bone fracture?
along with supracondylar fractures these types of fractures most likely to cause compartment syndrome
mechanism of tibial shaft fracture?
low energy fracture pattern- indirect trauma, result of torsional injury, fibula fracture at different level
high energy pattern- direct forces, significant comminution, fibula fracture at same level, significant soft tissue injury
what tibial fracture is associated with a posterior malleolar fracture?
spiral fracture through distal 1/3 of tibia
symptoms of ptnt presenting with a mid-shaft tibial fracture, and what must be examined?
pain, inability to WB
NV status, status of compartments- palpation, passive movements of toes, pulse and sensation, intracompartmental pressure measurement if indicated
inspect soft tissue envelope for open fracture, contusions, blisters
recommended radiographs in suspected mid-shaft tibial fracture?
full length AP and lateral views of tibia
AP and lateral views of ipsilateral knee and ankle
indications for CT scan in midshaft tibial fracture?
intra-articular fracture extension or suspicion of joint involvement
ankle for distal 1/3 spiral fracture to exclude posterior malleolar fracture
define compartment syndrome
raised pressure within an enclosed fascial space, leading to localised tissue ischemia
type of injury at high risk of compartment syndrome?
causes of compartment syndrome?
reperfusion injury after prolonged ischaemia e.g. in ptnt with critical limb ischaemia who undergoes bypass grafting
compression from tight bandage
prolonged compression in comatose, unprotected patient
importance of postoperative splintage after dermatofasciotomy for compartment syndrome?
splint limb in neutral, or functional, position, espec. if any muscle damage has occurred as contractures may then develop
what do spiral fractures of the tibia and fibula usually result from?
violent twisting injuries in contact sports, e.g. rotational stress applied to foot
nonoperative approach to non-displaced tibial shaft fracture?
closed reduction and stabilisation with above knee POP and split cast
convert to functional brace at 4 weeks
operative approach to displaced tibial shaft fractures?
percutaneous locking plate if inadequate fixation with IM nailing, but if long plate can place superficial peroneal nerve at risk- sensation to dorsum of foot except 1st webspace between hallux and 2nd toe.
IM nailing superior to external fixation as reduced malalignment, quicker time to WB and decreased further surgeries
potential complications of tibial shaft fracture?
popliteal artery injury
peroneal nerve injury- sensation loss and footdrop
tment of undisplaced proximal or fibular shaft fractures?
analgesia and elevation, support in tubigrip or padded bandage
below knee POP and crutches if unable to WB
tment of a Masionneuve fracture?
prox fibular fracture following ankle injury, often MM fracture
will require surgery and short NWB cast for 6 weeks
difference between a dislocation and a subluxation of a joint?
dislocation= complete loss of congruity between articulating surfaces of a joint
subluxation= partial dislocation, in which the articulating surfaces of a joint are no longer congruous but loss of contact is incomplete.
define a ligament sprain
an incomplete teat of a ligament or complex of ligaments responsible for joint stability
what is a dislocation the commonest result of?
name given to stress fracture of 2nd metatarsal?
march fracture- due to its frequency in army recruits
characteristics of greenstick fractures?
buckling of bone on opposite side to causal force as bone less brittle in a child
minimal tearing of soft tissues and surrounding periosteum
where in the body are compression/crush fractures common?
vertebral bodies- due to flexion injuries
heels- following fall from a height
union usually rapid if deformity accepted
common examples of avulsion fractures resulting from sudden muscle contraction?
base of 5th MT=Jones fracture- peroneus brevis
upper pole of patella-quadriceps
importance of correcting irregularities when a fracture is intra-articular?
if persist, may cause secondary OA
why can a fracture close to a joint cause stiffness?
involvement of muscles and tendons which can become bound down by callus
common complications of a fracture-dislocation?
why is it important to visualise both ends of a fractured bone on a radiograph?
look for axial rotation
how can the diagnosis of a hairline fracture help to be confirmed?
redo plain X-ray 2 weeks later
types of 5th metatarsal fractures?**
avulsion fracture of base- occurs with contraction of peroneus brevis, and in inversion injuries
jones fracture- fracture of 5th MT between metaphysis and diaphysis
nerve root for finger flexors (distal phalanx of middle finger)?
nerve root for little finger abduction?
upper limb max total motor score?
50 (25 R and 25 L, 5 for each)
what is a muscle function grading of 5?
normal active movement, full ROM against gravity and full resistance in a muscle specific position expected from an otherwise unimpaired person
what is a muscle function grading of 4?
active movement, full ROM against gravity and moderate resistance in a muscle specific position
what is a muscle function grading of 3?
active movement, full ROM against gravity but not resistance
what is a muscle function grading of 2?
active movement, full ROM with gravity eliminated
what is a muscle function grading of 1?
palpable or visible muscle contraction
what is a muscle function grading of 0?
why might muscle function grading be NT (not testable)?
severe pain such that ptnt cannot be graded
contracture of >50% of range of motion
what is a muscle function grading of 5*?
normal active movement, full ROM against gravity and sufficient resistance to be considered normal if identified inhibiting factors e.g. pain, disuse, were not present.
ASIA nerve root hip flexion?
ASIA nerve root knee extension?
ASIA nerve root ankle DF?
ASIA nerve root ankle PF?
ASIA nerve root long toe extension?
what is considered alongside muscle function grading of particular muscle groups in LL motor ASIA assessment?
voluntary anal contraction
how are key sensory points for ASIA classification established?
area where nerve roots do not overlap
how is sensation scored on ASIA chart?
what is the single neurological level?
lowest segment where motor and sensory function is normal on both sides, and is the most cephalad of the sensory and motor levels determined in steps 1 and 2
what does an ASIA impairment scale (AIS) of E mean?
ptnt with a documented SCI is found to have recovered normal function on follow up
3 subgroups of type III open fractures?
IIIA: adequate soft-tissue coverage of fracture despite high-energy trauma or extensive laceration or skin flaps, more than 10 cm high energy, includes segmental or extensively comminuted fractures even if wound less than 10cm.
B: inadequate soft-tissue coverage with periosteal stripping, soft-tissue reconstruction necessary- need for free or regional soft tissue flap for coverage
C: any open fracture assoc. with vascular injury requiring repair
what score can be used to predict need for future amputation in patient with an open fracture?
mangled extremity score
a score of 7 or more is highly predictive of amputation
what score can be used to assess risk of pathological fracture in patients with metastatic bone cancer?
Mirel's risk score
human fight bite injury common over dorsum of hand, over 3rd or 4th MCPJS, what is it therefore important to assess the integrity of?
extensor tendon function- get ptnt to extend fingers, espec, as can be overloooked with proximal tendon retraction
dog bite injuries often don't cause fracture, what are indications for radiographs in assessing human bite injuries?
look for foreign body e.g. tooth fragment, and for fracture
tment of human bite injury?
irrigation and debridement
ABx- IV, then oral for 7 days when discharged e.g. co-amoxiclav-BS, effective against both staph and strep
how can bacteria get into a joint to cause septic arthritis?
direct inoculation from trauma or surgery
contiguous spread from adjacent osteomyelitis
how might AVN of proximal scaphoid be visible on X-ray?
proximal pole bone sclerosis
why might a periosteal reaction be noted on a radiograph?
callus formation in a fracture, or a slow growing tumour- cortex thick and dense, has wavy or uniform appearance
infection, trauma, osteoid osteoma- cortex may appear lamellated, amorphous or sunburst-like.
define a bankart lesion
avulsion of the anteroinferior glenoid labrum from the glenoid
common in recurrent anterior shoulder joint instability
how long is pharmacological VTE prophylaxis continued for in orthopaedic surgery?
until ptnt no longer has significantly reduced mobility
MOA of LMWH in VTE prophylaxis in ptnts undergoing elective TKR?
inhibits factor Xa in the clotting cascade by binding to antithrombin III, inducing a conformational change in the molecule which allows it to more readily inhbit factor Xa
what condition are heal spurs associated with?
why is septic arthritis so damaging to a joint?
causes irreversible cartilage destruction, which will cause permanent pain in the joint
most common causative organism in septic arthritis?
why might culture for gonococcal infection be performed in young, otherwise healthy ptnt presenting with an erythematous, painful, swollen knee joint?
may have septic arthritis caused by neisseria gonorrhoea
characteristic findings of joint aspirate in septic arthritis?
cloudy or purulent
WBC more than 50,000/L
glucose less than 60 per cent of serum glucose
how can effects of ABx tment of septic arthritis be monitored?
serum WBC, CRP and ESR levels
operative tment required for septic arthritis?
irrigation and drainage- washout
RFs for adult osteomyelitis?
recent trauma or surgery
IC patients e.g. RA, cirrhosis, splenectomy, steroid use, DM
illicit IV drug use
gold standard for directing ABx therapy in osteomyelitis tment?
complications of adult osteomyelitis?
persistence or extension of infection
malignant transformation (Marjolin's ulcer)- most commonly SCC
how is serum lactate of relevance in ptnt admission with suspected hip fracture?
serum lactate been found to be a prognostic indicator in hip fracture patient, with an elevated venous serum lactate on admission following hip trauma indicating that the patient should be identified as having a higher mortality risk and may benefit from targeted medical therapy.
venous lactate of 3mmol/L or more associated with twice the odds of death in hospital compared to matched individuals
and a 1mmol/L increase in venous lactate associated with a 1.2 increased risk of in hospital mortality
considerations in describing a distal radial fracture?
intra or extra articular
comminute or non-comminuted
displacement- radial height (normal=11mm), angle of inclination (22 degrees) and angulation (volar tilt of 11 degrees)
ulna- fracture or subluxation
presenting features of CE syndrome?
urinary and faecal incontinence, urinary= overflow incontinence following PNS disruption to bladder necessary for detrusor contraction
lower extremity sensorimotor changes
causes of nerve root compression in CE syndrome?
spinal epidural haematoma
well known complication of spinal surgery?
causes of spinal canal narrowing in neurogenic claudication?
IV disc narrowing
osteophyte formation, degenerative vertebrae
hypertrophy of ligamentum flavum- located in posterior portion of vertebral canal, connecting adjacent laminae- located between transverse and spinous processes of vertebrae
operative surgery for spinal stenosis?
spinal decompression- laminectomy
can use an X-stop if ptnt unfit for laminectomy
non-oeprative- instructions on posture, pain analgesia e.g. NSAIDs and injection of corticosteroid and LA
examination findings in CES?
lower limb weakness, bilateral, and sens distrubances
reduced or absent sensation to pinprick in S2-S4 perinanal region
reduced anal tone on PR exam
urgent decompression surgery within 48 hrs of onset of symptoms, laminectomy and discectomy
alternative to MRI in CES investigation in ptnt with a pacemaker?
use of pharmacological VTE prophylaxis in hip fracture ptnts?
LMWH start on admission, stopped 12 hrs before surgery, and restarted 6-12 hrs post surgery
fondaparinux sodium- synthetic and selective factor Xa inhibitor, given 6hrs after surgical closure
UFH if severe renal impairment or established renal failure, same timings as LMWH
continue for 28-35 days post surgery
enoxaparin use in orthopaedic surgery?
40 mg once daily SC, initial dose 12 hrs before surgery in hip fracture ptnts, started 6-12 hrs after surgery in elective hip and knee replacements
CIs to pharmacological VTE prophylaxis?
recent haemorrhagic stroke
active gastric or duodenal ulceration
uncontrolled hypertension- 230/120 mmHg or higher
elements of a halux valgus deformity?
lateral deviation and rotation of hallux
prominence of medial side of head of 1st metatarsal (bunion)- may also be an overlying bursa and thickened soft tissue
overcrowding of lateral toes can occur, and sometimes over-riding
4 acute presentations of shoulder pathology?
acute calcific tendonitis
parsonage-turner syndrome= brachial neuritis- inflammation of BP, causes sudden onset shoulder and arm pain, followed by weakness and/or numbness
what should the midline of the patella line up with in the foot?
midline of the 2nd toe
what are yellow flag signs in back pain presentation, and give examples
psychosocial factors shown to be indicative of long term chronicity and disability
e.g. social or financial problems
a negative attitude that back pain is harmful or potentially severely disabling
tendency to depression
fear avoidance behaviour and reduced activity levels
an expectation that passive rather than active tment will be beneficial
in ASIA classification of SCI, how is complete and incomplete injury defined?
in terms of sacral spaing
so complete injury= no voluntary anal contraction, all S4-S5 sensory scores=0 and no deep anal pressure
otherwise injury is incomplete
what is the ASIA impairment scale if injury complete?
no sensory or motor function is preserved in sacral segments S4-S5
what is the ASIA impairment scale if motor injury incomplete?
sensory function preserved below the neurological level and includes S4-S5, no motor function preserved more than 3 levels below the motor level on either side of the body
what are AIS C and D in ASIA impairment scale classification?
if motor injury incomplete, and less than half of the key muscles below the single neurological level are graded 3 or better (3- active movement, full ROM against gravity) then AIS= C, and if more than half then AIS=D
to be either, ptnt must have voluntary anal sphincter contraction or sacral sensory sparing with sparing of motor function more than 3 levels below motor level for that side of body.
why is the lateral foot important for flexibility?
flexible support from fibula, lateral collateral ligaments and the tibio-fibular syndesmosis, whereas deltoid ligament very strong and medial malleolus attached to tibia
fibula= no WB function
radiographs for a clavicle fracture?
oblique- 30 degrees cephalic tilt
3 most common primary bone cancers?
age group commonly affected by chondrosarcoma?
40s and 50s
why is some form of operation always necessary in NOF fractures?
healing poor due to blood supply- retrograde?**
why are talar neck fractures at high risk of AN?
retrograde blood supply
what is the worry with subtrochanteric fractures compared with intracapsular or trochanteric fractures?
blood loss is greater
and fairly common fracture complication= malunion- if marked, may need operative correction
what does X-ray of subtrochanteric fracture show?
fracture through lesser trochanter or below it
prominence of lesser trochanter as limb ER
tment of subtrochanteric fracture and why?
ORIF with intramedullary nail and locking screws, or DHS and long plate
fixation necessary as poor healing of fractures with retrograde b.supply?*
A patient presents with a proximal humeral fracture, they are supporting the injured arm and there is gross bruising gravitating down this arm. What term can be used to describe this bruising, and what 2 other terms may be used do describe bleeding underneath the skin?
ecchymosis (haematoma >1cm)
petechiae and purpura, with purpura being between .three and 1cm
in a pre-op assessment clinic, what investigations would you like to do before an elective knee replacement?
bloods: FBC- look for anaemia to assess need for blood transfusion in surgery, look at WBC as infection CI to surgery
Us and Es- Na+, K+, urea, creatinine- assess renal function, help determine VTE prophylaxis
clotting screen- assess bleeding risk in surgery, ?tranexamic acid dose, important if on aspirin or warfarin. components= PT (and INR), fibrinogen and APTT
G+S- as bleeding risk in surgery, prepare for blood transfusion
ECG- ptnt with angina or prev. MI, older ptnt?
EMRSA swabs- determine ABx prophylaxis in surgery
knee AP and lateral radiographs so up to date X-ray to be used in surgery for determining prosthesis placement?
post-op management instruction to ward after elective TKR?
X2 doses of IV Abx
mobilise fully WB
repeat X-ray and check bloods- ?bleeding and infection
OPD follow up in 6 wks
complications of multiple myeloma?
bone involvement-bony pain, pathological fractures, hypercalcaemia, lytic lesions and bone collapse
low levels of normal Igs, so resultant infections
causes of secondary OA?
CT disease e.g. Marfans, Ehlers-Danlos syndrome
metabolic disease e.g. haemochromatosis, wilson's disease and gout
OA pathophysiology summary?
OA is a degenerative disease that occurs when abnormal stresses are placed on a normal joint or normal stresses act on an abnormal joint, and involves the loss of joint cartilage that normally aids normal joint movement and functioning, leaving the bones to rub against 1 another and be unable to withstand the force placed upon them, producing joint instability.
the cartilage becomes dehydrated and there is loss of proteoglycans, whilst large amounts of matrix metalloproteinases are secreted which break the cartilage down.
the collagen fibres are disorganised and degenerate
plain X-ray findings in OA?
joint space narrowing-asymmetrical-loss of articular cartilage
osteophytes-compensatory bone growth
subchondral sclerosis-reactive bone hardening
subchondral cysts-micro fractures in sclerosed bones leads to synovial fluid breaking through
rheumatoid factor may be positive in RA, what is rheumatoid factor?
an autoantibody (IgM) directed against the Fc portion of IgG
how can RA be diagnosed using the ACR 2010 classification criteria?
joint involvement: 2-10 large joints =1
1-3 small joints =2
4-10 small joints= 3
more than 10 joints (small and large) = 5
serological: low +ve RF or low +ve anti-CCP= 2
high +ve RF or high +ve anti-CCP =3
acute phase proteins: raised CRP/ESR= 1
duration= more than 6 weeks = 1
6 or more total classed as RA
RA radiographic appearance?
symmetrical joint space narrowing
marginal bony erosions
soft tissue swelling
why would recent infections (in last 6 wks) be important to ask about in a suspected case of inflammatory arthritis?
consider/rule out reactive arthritis as a differential-usually self-limiting
summary of osteoporosis pathophysiology?
reduced bone mineral density as result of impaired bone remodelling due to decreased osteocyte viability
abnormally low bone MASS and defects in bone structure, with loss of trabecular definition, cortex thinning and insufficiency fractures.
most common=postmenopausal (primary type 1), loss of oestrogen removes one of the restraints on osteoclast activity, patients more at risk if: smokers, alcohol abuse, low BMI-hx of anorexia nervosa and/or amenorrhoea, lack of weight bearing exercise, FH, nutritional insufficiency, early hysterectomy, oophorectomy, low peak bone mass in 30s
advise women to keep up dietary Ca2+ and vit d around menopause, drink less alcohol, stop smoking, and keep up high level of physical activity, benefits of HRT questionnable plus risk of VTE, breast Ca, uterine Ca and stroke.
can give alendronate bisphosphonate PO once weekly, denosumab-human monoclonal Ab SC 6 mnthly inhibits receptor activator needed for osteoclast differentiation
core treatments in management of OA?
education of the patient
exercise-muscle strengthening and aerobic exercise-espec. important in knee OA to prevent ligament stretching that occurs with quads wasting, causing further instability in the knee and additional damage
weight loss if overweight or obese-reduce joint loading
what test when examining a patient could help in determining if lower limb pain is due to the presence of an IV disc prolapse/herniation rather than spinal stenosis, IC, venous claudication or OA?
straight leg test (L4, L5, S1)- positive if raising the leg with the knee extended causes pain below the knee, which increases on foot dorsiflexion (Lasegue's sign), suggests irritation to sciatic nerve (L4-S3), and main cause is lumbar disc prolapse.
causes of a single acutely inflamed joint?
septic arthritis: bacterial-gram stain and culture and sensitivity, microscopy of synovial fluid aspirate, mycobacterial-ziehl-neelsen staining
crystal arthropathy: gout, pseudogout, gout-synovial fluid analysis under polarising light microscopy-negatviely birefringent crystals of monosodium urate
trauma: fracture, haemarthrosis- consider underlying haemophilia, ACL rupture
other: OA, avascular necrosis
important points to note in history of patient presenting with a single red and swollen joint?
ONSET-seconds to mins- highlights trauma e.g. fracture
hrs-days- more suggestive of infection-septic arthritis, or gout/pseudogout
insidious-indolent infections-slow growing, sequestered within bone, OA
severity-effect on movement
other symptoms: rash, conjunctivitis, arthralgia-?reactive arthritis
systemic features e.g. fever suggesting septic arthritis
IV drug use-septic arthritis
steroid tment e.g. IA injections for OA-avascular necrosis
bleeding diathesis-haemarthrosis e.g. hameophilia, thrombocytopenia-reduced PLT prod as BM failure e.g. infection part. glandular fever (infectious mononucleosis), leukaemia, myeloma, myelofibrosis, or increased PLT destruction e.g. recent heparin treatment e.g. for DVT, AI idiopathic thrombocytopenia purpura, hypersplenism, DIC, HUS, after a massive blood transfusion.
treatment of septic arthritis?
general management-give O2, IV fluids
Abx-empirical antibiotics to be started after joint aspirate taken but BEFORE blood cultures returned to get best functional outcome. Abx should at least cover staph aureus and strep. IV initially for 2-3 wks, then continue oral for at least further 2-4 weeks, recommended tment included flucloxacillin for 4-6wks, clindamycin if pen allergic, vancomycin for 4-6wks if MRSA, cefotaxime or ceftriaxone if gonococcal or gram -ve suspected, for 4-6 weeks.
joint drainage, needle or arthroscopically
radiological imaging-consider infection source?
splint limb in position of function
risk factors for septic arthritis?
immunosuppressive medication e.g. corticosteroids
chronic renal failure
pre-existing joint diease e.g. RA
IV drug abuse
other medical therapy to consider in pt with suspected septic arthritis who is not responding to empirical Abx treatment after 5 days e.g. persisting fever, +ve cultures?
re-examine SF for crystals
arrange Lyme disease serology
consider synovial biospy to rule out fungal or mycobacterial infection
consider reactive arthritis-requires NSAID treatment
most common organisms responsible for prosthetic joint infection?
less than 3mnths post implant= staph aureus
late onset=E coli, proteus mirabilis, staph epidermidis, staph aureus.
mechanical causes of back pain?
cauda equina syndrome
spinal stenosis/spinal claudication
non-mechanical causes of back pain?
malignancy-primary or secondary
infections e.g. spinal TB
inflammatory disease e.g. ankylosing spondylitis, enteropathic arthritis of IBD
cauda equina syndrome
direction in which an IV disc most commonly herniates?
posterolateral, as annulus fibrosus thinner here
complications of IV disc herniation?
cauda equina syndrome
definition of non-union?
fracture not healed by 9 months post occurrence
pressure which would worry you in terms of compartment syndrome?
pressures more than 30mmHg for 6-8hrs can lead to irreversible damage
weber's ankle fracture with best prognosis?
fracture occurs below the distal tibiofibular syndesmosis
what are salter-harris fractures?
these are epiphyseal growth plate fractures, common in children, which are important as can cause premature epiphyseal growth plate closure and so limb shortening and abnormal growth.
primary management of open fractures in the emergency department?
A to E assessment
stop external haemorrhage-direct pressure, or apply tourniquet only as last resort
NV examination of the limb, AND DOCUMENT-CRT, dorsalis pedis and posterior tibial pulses ( if lower limb fracture)
analgesia if appropriate, confirm pt allergies, IV opioid co-prescribe anti-emetic
straighten and align limb (if not done prehospital)
RPT NV examination
remove gross contaminants from wound
cover wound with moist (saline), sterile dressing and adhesive film dressing
leave wound undisturbed until pt reached operating theatre
splint fracture if not done prehospital-should span ankle and knee
reassess NV status
IV Abx-1.2g co-amoxiclav or 1.5g cefuroxime 8hrly, or clindomycin 600mg if pt pen allergic, continue until wound debridement, at debridement give 1 dose of amionoglycoside e.g. gentamicin-cover hosp organisms that may cause deep infection e.g. S.aureus and pseudomonas, plus co-amox/cef then continue 1st Abx for no more than 72hr, no more than 24hr if type I fracture. stop by this time or at definitive wound closure, whichever is quicker.
tetanus status check and administer prophylaxis if required
X-rays-2 orthogonal views, 2 joints-knee and ankle
immediate referral to orthopaedic team, must get senior r/v
role of internal fixaton in pelvic fractures?
in some cases, it's thought that the risks of acute resp distress syndrome, fat embolism and other serious post-injury complications may be reduced by early operative stabilisation of fractures. Resp function improved as pt can sit up, reducing abdo pressure on diaphragm with the risks of atelectasis, and less anlgesia required for fracture pain so less risk of subsequent resp depression.
similarly, in damage control, preliminary external fixation of long bone fractures will allow pt to sit up and move around in bed.
epidemiology of perthe's disease?
incidence 1 in 10,000
boys affected 4 X as often as girls
pts usually 4-10 years old
pts often show delayed skeletal maturity
pathogenesis and the pathological process of perthe's disease?
precipitating cause of disease probably hip joint effusion following either trauma (which hx of in half of cases), or a non-specific synovitis
effusion thought to be cause of stretching and pressure on the lateral epiphyseal vessels in the retinacula which may be the source of the entire blood supply to femoral head between 4 and 7yrs of age.
disease=femoral head necrosis, and there are 3 stages to the pathological process that takes 2-4yrs to develop:
1=bone death-following 1 or more ischaemic episodes
2=revascularisation and repair-new bld vessels, new bone laid down on dead trabeculae, some necrotic part resorbed and replaced by fibrous tissue, producing epiphyseal 'fragmentation' on X-ray.
3=distortion and re-modelling-epiphysis may collapse and subsequent growth at head and neck will be distorted. sometimes it ends up flattened (coxa plana) but enlarged (coxa magna) and femoral head is incompletely covered by acetabulum.
how is pyogenic arthritis diagnosis in a child confirmed?
joint aspiration of pus
in dog bites, infected wounds presenting within 12hrs of injury are usually due to which bacterium?
this is usually resistant to erythromycin and flucloxacillin
organism is present in more than 50% of dog bites and is likely to cause tenosynovitis in hand bites especially
why should primary closure be avoided in limb injuries with dog bites where possible?
increased infection risk
why should recent antibiotic use be noted in the hx of a pt with a dog bite?
if recent flucloxacllin or erythromycin, and infection from dog bite still present, means that superinfection with resistant organisms such as pasteurella multocida is more likely.
why would radiography be indicated in a dog bite?
if scalp wounds in children
to exclude embedded teeth or dental fragments
exclude fractures and bony damage
initial wound management procedures in a dog bite?
Irrigate copiously, using tap water or normal saline
Remove foreign bodies (teeth)
Perform a thorough wound toilet and debridement where necessary
then cover with sterile dressing or clean dry cloth
Delay closure of the wound where possible
Raise and immobilise the limb if the injury is associated with (or is likely to cause) swelling
Give antibiotics, depending on the risk factors for infection e.g. cirrhosis, asplenic, mastectomy
With infected wounds, send pus or a deep wound swab for culture (in clinically uninfected wounds, swabbing is unhelpful)
Review bites within 24-48 hours, especially if the bites need antimicrobial prophylaxis
Although tetanus after animal bites is rare, all guidelines in common use advise tetanus prophylaxis, with immunoglobulin and toxoid to be administered to patients with a history of two or fewer immunisation.
patient factors that increase infection risk in a dog bite injury?
alcoholism-increased susceptibility to pasteurella infection
cirrhosis, asplenia-increased risk of capnocytophaga-sensitive to penicillin and ciprofloxacin
steroid therapy, RA, DM, lymphoedema after radiotherapy-all increase risk of pasteurella infection
wound factors increasing infection risk in dog bite injury?
Wounds more than 6 hours old
Previously sutured wounds
Full thickness wounds involving tendons, ligaments, and joints
Bites on limbs, especially hands
indications for referral to specialist care in dog bite injury?
If systemic manifestations of infection are present
If bone, joints, or tendons are affected
If hand bites are serious or the bites require reconstructive surgery
If bites are cranial, especially in an infant
If the patient has severe cellulitis or infection is refractory to oral therapy
likely infective organisms if presentation of dog bite injury more than 24hrs after the event?
staphylococci or anaerobes
when should Abx prophylaxis be used in dog bite injuries, and what should be used?
high risk bites: “High risk” wounds
All bite wounds after primary closure
Bites to hand and wrist
Crush wounds with devitalised tissue
Dog bite injuries to the genitals
“High risk” patients:
RA and prosthetic joints
what Abx can be used if pen allergic as prophylaxis in dog bite injury?
doxycycline plus metronidazole
why is use of a spinal anaesthetic e.g. for NOF fracture surgery, contraindicated in patients on anticoagulant therapy?
high risk of spinal haematoma
why are supracondylar fractures of the humerus more common in children?
thinner olecranon fossa
specific complications of supracondylar fractures of the humerus?
anterior interosseous nerve damage- branch of the median nerve which supplies deep muscles of anterior forearm EXCEPT ulnar half of FDP (supplies all anterior forearm except ulnar half of FDP and FCU?) patient inability to make A-OK sign with inability to flex IPJ of thumb and DIPJ of index finger.
vascular damage-patient may present with cold, pale and pulseless hand, BUT good collateral circulation can maintain circulation
radial nerve injury
ulnar nerve injury
how are open fractures classified?
Gustilo and Anderson classification:
type I: clean wound less than 1cm in diameter, simple fracture pattern, no skin crushing
type II: laceration more than 1 cm (1-10cm?) but without significant soft tissue crushing, including no flaps, degloving or contusion.
type III: A= open segmental fracture of fracture with extensive soft tissue injury but non requirement for soft tissue reconstruction.
B=inadequate soft tissue coverage with periosteal stripping, require soft tissue reconstruction.
C=vascular injury requiring repair.
multiple myeloma managment?
confirmatiory diagnosis with bone marrow biopsy
symptomatic melanoma requires active treatment: symptomatic= clonal plasma cells more than 10% on BM biopsy or in biopsy from other tissues, monoclonal protein (paraprotein) in either serum or urine, and evidence of end-organ damage thought to be related to disorder:
CRAB: hyperCalcaemia-cytokines cause osteoclast dysregulation
Renal impairment-light chains accumulate and block renal tubules
Anaemia-BM overcrowded with plasma cells
Bony lesions- cytokine effects, lytic lesions, pathological fractures e.g. vertebral wedge fractures.
combination chemotherapy e.g. cyclophosphamide/thalidomide/dexamethasone
radiotherapy used if bony pain
if good response to chemo, may be offered autologous stem cell transplant (pt's own stem cells harvested prior to BM being wiped out with chemotherapy).
RED FLAGS for back pain?
age under 18yrs or over 55yrs
non-mechanical back pain
weight loss, fever, night sweats
hx of malignancy
hx of infection e.g. TB, or steroid use
non-radicular pain, widespread neurology
hx of trauma
CE syndrome: bilateral sciatica
painless* urinary retention
saddle (peri-anal) anaesthesia-any numbness around back passage when opening bowels?
differences between vascular and neurogenic claudication?
vascular: distal to proximal pain
after fixed distance
relieved by stopping and standing
walking uphill likely to worsen pain
pain relieved in seconds
neurogenic: proximal to distal pain
have to sit to relieve pain, jelly legs
walking uphill pain is less-as lumbar spine in flexion which relieves pressure on nerves
relief in mins
assoc. numbness and paraesthesia
vague backache, morning stiffness
what might protrusio acetabuli develop secondary to in later life?
bone softening e.g. paget's disease, osteomalacia
tment only if pain severe or movements markedly restricted, with THR
how does the femoral neck-shaft angle change throughout childhood?
normal angle 160 degrees at birth, decreasing to 125 in adult life
angle of less than 120 is called coxa vara- may be a complication of SUFE, rickets and adult osteomalacia, and can be congenital
for troublesome acquired coxa vara, can correct with intertrochanteric or subtrochanteric osteotomy
how can containment be achieved in perthe's disease?
holding hips widely abducted in a plaster cast or removable brave for at least 1yr
operation-varus osteotomy of femur or innominate osteotomy of pelvis, or both
except in very mild cases, operative containment is tment of choice in children 9yrs and older
differential diagnosis for obese teenage male with pain in or just above the knee?
SUFE-referred pain form hip
tment of pyogenic arthritis of hip, usually seen in children under 2 years of age?
Abx, after joint aspiration for microbiology and sensitivity testing
joint aspirated under GA and if pus withdrawn, arthrotomy adviseable-opening in joint for drainage-Abx instilled locally and wound closed without drainage.
hip kept in traction or splinted in abduction
presentation of transient synovitis of hip in a child?
pain around hip and limp, often intermittent and following activity
restriction of all movements with pain at extremes of range in all directions
x-ray may show slight widening of medial joint space
x-ray changes in perthe's disease?
widening of radiographic joint space
increased radiographic density in bony epiphysis
flattening of epiphysis
false 'fragmentation' and lateral displacement of epiphysis
features o/e of hip OA?
positive Trendelenburg sign
affected leg lies in ER and adduction and appears short-nearly always some fixed flexion-may only be revealed by Thomas' test
muscle wasting-although rarely severe
deep pressure may elicit tenderness
restricted movements, though often painless
*contrast to hip RA:
marked wasting of buttock and thigh
limb similarly held in ER and fixed flexion
all movements restricted AND PAINFUL
how can OA hip stiffness be assessed for in hx?
any difficult putting on socks, cutting toenails?
getting out of a chair or in and out of a car?-part of Oxford hip score-joint specific outcome measure tool used to assess disability in pts undergoing THR and estimated need for surgery.
the pain, numbness and tingling that occurs due to nerve root entrapment in the lumbosacral spine
most common location for an IV disc herniation?
this causes entrapment/inpingement of the S1 spinal nerve
radiculopathy of the spinal nerve L5 causes pain where?
lateral leg, dorsum of foot and big toe
dysfuncton of which muscle can cause adult onset pes planus/planovalgus (flat foot)?
tests for developmental dysplasia of the hip in children?**
ortolani and barlow tests
features of spinal stenosis on examination?
absence of knee jerk (L3, L4) and motor disturbances common
peripheral pulses present (in contrast to vascular claudication-also check temp, CRT)
straight leg raising test hardly ever affected-test very sensitive for sciatic nerve root irritation in IV disc herniation
kemp sign- extension of back worsens unilateral radicular pain from foraminal stenosis
radicular pain not worsened by valsalva as in case with herniated disc
hx: recurrent UTIs in up to 10% due to autonomic sphincter dysfunction-?internal urethral sphincter is contracted under sympathetic stimulation via hypogastric nerves L1-L3, but inhibited by S2-S4 PNS pelvic nerves to allow micturition, but this innervation disturbed in spinal stenosis so sphincter remains closed causing urinary retention in bladder and increased risk of infections.
investigation of choice in spinal stenosis?
MRI or CT, to see space available within spinal canal for neurological structures, as condition involves a decrease in sagittal diameter of the spinal canal
management of spinal stenosis?
mild cases=analgesics, NSAIDs, physio, exercise e.g. stationary bicycle with spine in flexion, epidural injections of steroids
if marked symptoms and pt fit, can do a decompression procedure
what might be the posture of a pt with an IV disc herniation?
may have a protective non-structural scoliosis, and be stooped towards the affected side with the knees bent to relieve pressure on the dura.
treatment for prolapsed IV disc?
analgesia-NSAIDs-topical or oral
surgical discectomy if prolonged or worsening neurological symptoms
how does presentation of conus medullaris syndrome differ to that of cauda equina syndrome?
conus medullaris=urinary retention occurs earlier
what is spondylolysis?
a defect in the pars interarticularis-the part lying between the superior and inferior articular processes of the facet joint, of a vertebra, most commonly L5
most likely result of fractures due to trauma or fatigue, so high incidence among gymnasts, weightlifters, labourers
may be assoc. with sacral spina bifida
along with spondylolisthesis-body of vertebra displaces over another, most commonly forwards, can give rise to low back pain which radiates into buttocks
radicular symptoms, spine tenderness and yperextension painful
management of spondylolysis and spondylolisthesis?
X-ray shows collar on scottie dog appearance, and lateral x-ray shows degree of slippage
MRI if suspected nerve root involvement
often in young people, symptoms resolve with avoidence of sports and use of a corset support
can give analgesia and physio
in more severe cases where significant forward slip, local spinal fusion may be used and nerve release
a pt presents with a suspected shoulder dislocation, what must be examined both before and after any attempt at reduction?
what is 'crush syndrome'?
a general complication of a fracture in which crushing injury to skeletal muscle causes hypovolaemic shock (due to sequestration of water by damaged skeletal muscle cells) and renal failure with skeletal muscle breakdown (traumatic rhabdomyolysis)-myoglobin can cause tubular obstruction and damage (nephrotoxic)
ischaemia reperfusion is main mechanism of injury (when pressure is released from the crushed limb)
uric acid may be raised
clotting studies-look for DIC-treat with FFP, cryoprecipiate (fibrinogen) and PLTs
treat hyperkalaemia-calcium gluconate, insulin and glucose, neb salbutamol and calcium resonium, adequate fluid resuscitation, may need renal dialysis, amputation may be required. if persistent hyperkalaemia with K+ more than 7mmol/L-indication for dialysis.
delayed complications of a fracture (wks-mnths)?
non-union-not healed after 9 months
sudeck's atrophy (complex regional pain syndrome)-A delta and C fibres fire following nociceptor stimulation, increased SNS drive- back to original segment where pain started, which produces vasospasm- causes bit of ischaemia and oedema and temp changes, now become painful so pain pathway stimulated again and more SNS changes occur, so cycle of pain and swelling established. pain is disproportionate to any event the pt has experinced e.g. trauma, fracture
bone avascular necrosis
myositis ossificans-ossification in large muscles following trauma, calcification visible on plain radiograph
how does the stability of ankle fractures relate to their weber classification?
type A = stable
below the level of the talar dome, usually transverse, tibiofibular syndesmosis intact, deltoid ligament intact
medial malleolus often fractured
usually stable if medial malleolus intact: occasionally nonetheless requires an ORIF.
type B = variable stability
distal extent at the level of the talar dome; may extend some distance proximally, usually spiral, tibiofibular syndesmosis usually intact, but widening of the distal tibiofibular joint (especially on stressed views) indicates syndesmotic injury, medial malleolus may be fractured, deltoid ligament may be torn, indicated by widening of the space between the medial malleolus and talar dome
variable stability, dependent on status of medial structures (malleolus/deltoid ligament) and syndesmosis; may require ORIF
type C = unstable
above the level of the ankle joint
tibiofibular syndesmosis disrupted with widening of the distal tibiofibular articulation, medial malleolus fracture or deltoid ligament injury present, fracture may arise as proximally as the level of fibular neck and not visualised on ankle films, requiring knee or full length tibia-fibula films (Maissonneuve fracture)
unstable: usually requires ORIF
normal bony coverage in considering developmental dysplasia of the hip?
normal is more than 58% of femoral epiphysis being covered by the acetabular roof
investigation of choice for DDH?
management of DDH?
Pavlik harness-a dynamic flexion abduction orthosis for an infant up to 6mnths of age, usually leads to hip stability within 4 wks, but should be continued until hip X rays and clinical examination normal
closed reduction for older patients, and open reduction for much older patients or in those where closed reduction failed
how can looking at shenton's line help in DDH?
if superolateral migration of proximal femur due to DDH then line drawn along inferior margin of superior pubic ramus and continued along inferomedial aspect of proximal femur will be discontinuous
mainstay of frozen shoulder treatment?
graduated shoulder exercises
steroid injections into shoulder cuff may be helpful where pain a part. problem
if no improvement with approp. tment within 4 mnths may manipulate shoulder under GA or arthroscopic capsular release to restore movements in stiff joint
what score can be used to assess joint hypermobility in patients with recurrent dislocations of the shoulder joint?
score of 5/9 or more defines joint hypermobility, also used in examining in a pt with suspected ehlers danlos syndrome-CT disease in which genetic mutations in disrupt collagen formation*
score: passive hyperextension of each little finger to more than 90 degrees-1 point each
passive abduction of each thumb to surface of forearm-1 point each
hyperextension of each elbow to more than 10 degrees-1 point each
hyperextension of each knee to more than 10 degrees-1 point each
forward flexion of trunk with knees fully extended and palms flat on the floor-1 point
mechanism of injury commonly in anterior dislocation of the shoulder?
FOOSH- with arm in ER, abduction and extension, this is a common mechanism in the eldely
anterior dislocation also occurs with direct blow from behind
most commonly traumatic when people fall with an extended and abducted arm in combination with a posteriorly directed force
proportion of shoulder dislocations which are anterior?
what might an inferior dislocation of the humeral head (RARE-less than 1%) be mistakingly diagnosed instead of?
shoulder pseudo subluxation: apparent inferior displacement on humeral head due to capsular distension secondary to a haemarthrosis or large effusion
why is it important to identify a proximal humeral fracture in dislocations of the shoulder joint?
as attempts at reduction might further displace this fracture
what further investigation might be required if AP, lateral/axillary and Y/transcapular X-rays identify shoulder dislocation and you suspect rotator cuff tear?
MRI-good at visualising soft tissue anatomy
how will pts with an anterior dislocation of shoulder present holding their arm?
usually in ER and slight abduction
other radiograph injuries to look out for in shoulder dislocation?
proximal humeral fracture/head fracture/neck fracture
greater tuberosity fracture
what should an unexplained posterior shoulder dislocation raise the suspicion of?
mechanism of injury in posterior shoulder dislocation?
rarer (2-4% of dislocations)
may occur with an epileptic fit or electrocution injury
generally caused by forces with arm held in IR and adduction
epidemiology of shoulder dislocations?
peak in males between 20 and 30 years of age, asoc. with contact sports?
and females 61-80 years due to susceptibility to falls
presentation of a patient with an anterior dislocation of shoulder joint, and features on examination?
usually hx of trauma with pain in shoulder an inability to move it
loss of deltoid contour
arm held in ER and slight abduction
humeral head palpable anteriorly, and anterior bulge may be seen in thinner patients
abduction and IR resisted-e.g. pt unable to touch opp. shoulder
compare radial pulses to test for axillary artery integrity
check sensation over regimental badge area to test integrity of axillary nerve-superolateral cutaneous nerve of arm
assess radial nerve function-ebow, wrist and figner extension weakness, and sensation in 1st webspace in dorsum of hand
median nerve-ok sign, sensation lateral border index finger
ulnar nerve- push little fingers together with all other fingers in abduction-testing abductor digiti minimi from hypothenar compartment, also froment's sign- pt asked to grip paper between thumb and index finger-if thumb flexes then use of FPL instead of adductor pollicis.
examine rotator cuff after reduction
should also check for C spine injury if direct blow to shoulder
why will a a fracture dislocation of shoulder usually require surgery?
risk of avascular necrosis to humeral head?
management of shoulder dislocation?
analgesia-e.g. entonox, morphine, give opioid and BZD when attempting reduction
check NV status
X-ray, at least 2 views, pre and post reduction
reduce dislocation-can be difficult due to muscle spasm occurring soon after dislocation, closed usually adequate if no assoc fracture-check X-rays, posterior often requires operative reduction, possible with arthroplasty
post reduction, recheck NV status and rpt X-rays-ensure no fractures, confirm adequate reduction and ensure no injuries have been missed
operation may be required if tear in joint capsule prevents stable reduction or soft tissue intervenes, primary surgical repair has been supported for young adults who have had acute traumatic shoulder dislocations, and who will continue to engage in demanding physical activity
immobillise for 3-4 weeks post reduction e.g. in a broad arm sling for anterior dislocation of shoulder to hold arm in IR and stop ER progressing to recurrent dislocation
ensure pt has adequate analgesia to take home
r/f to physiotherapy
F/U in clinic to assess NV status e.g. sensation over RBA, rotator cuff movements-assess for stiffness
complications of anterior shoulder dislocation?
anatomical lesions: hill-sachs and bankhart's lesions
N/V damage: axillary nerve damage-cool, pulseless limb, axillary haematoma, sensation loss over RBA and loss of motor and sensory function in hand
rotator cuff tears, and stiffness
recurrent dislocations-80-94% risk if dislocation under 20yrs of age, definite need for referral to orthopaedic surgeon to consider stabilisation surgery if 2 or more dislocations in a young person
assoc fractures e.g. humeral head, greater tubersoity and clavicle
presentation of a posterior dislocation of the shoulder?
arm held in IR and adduction
posterior bulge may be present, and humeral head may be palpable below acromion
attempted abduction and ER painful
inability to supinate
NV injury uncommon
what conditions are we suspecting if all movements of shoulder joint worsen the pain, restricting movment?
frozen shoulder (adhesive capsulitis)
if some movements worsen pain, more likely impingement
how is tetanus status managed when a patient presents with an open fracture?
if pt fully immunised but not had a booster for more than 5 yrs give 0.5ml toxoid IM
if not fully immunised, give toxoid and Ig (passive immunity)-250 U of IM Ig if adult patient
what is the mangled extremity score?
was developed to discriminate between salvageable and doomed limbs in lower extremity trauma
score of 7 or more highly predictive of amputation
causes of knee swelling?
synovitis e.g. trauma-tearing or stretching of synovial membrane, infections-inflammatory response causes increase fluid secretion by synovial membrane, RA-thickened and dysfunctional membrane
haemarthrosis-following acute injuries where vascular structures torn
pyarthrosis-infection, very painful knee rapid tense swelling and w.spread tenderness with resistance to movement, pyrexia and general malaise, TB-profound quads wasting, gonococcal-great pain and tenderness often apparently out of proportion to local swelling and other signs, treat all knee infections with splintage-reduce pain,swelling and further damage, and Abx.
why is strengthening the quadriceps muscle so important in any condition of the knee joint, including OA?
with quadriceps wasting due to lack of use, the knee becomes unstable, causing the ligaments to stretch and precipitating further injury causing pain.
if external fixation for an open fracture is to be converted to internal fixation, when must this be performed by? (similarly to timescale for definitive wound closure)?
within 1 week
presentation of chronic anterior cruciate ligament laxity?
this results from old injuries, and can cause problems from acute, chronic or recurrent tibial subluxations
may be hx of knee giving weigh, episodic pain and functional impairment
often quadriceps wasting and effusion, and secondary OA may develop
intesen quads and hamstring building usually advised as 1st measure
ligament reconstruction may be needed in resistant cases.
how can the posterior cruciate ligament of the knee be damaged?
when in a flexed knee the tibia is forcibly pushed backwards e.g. in tibia striking dashboard in car accident
presentation of degenerative meniscus lesions in middle-age?
sharply localised tenderness in the joint line with no remembered traumatic incident
just an awkward twist when getting out of a chair can be enough to teat meniscus when the fibrocartilage is weak
occurs due to loss of elasticity in menisci through degenerative changes assoc. with aging which give rise to horizontal cleavage tears
presentation of meniscus tears in young adult?
hx of a twisting strain during sport to a flexed weightbearing leg
meniscus is trapped and commonly splits longitudinally, and its free edge may displace inwards towards joint centre (bucket handle tear-initial split extends both ways)
full extension prevented-physiological joint LOCKING, painful elastic resistance felt if attempt to straighten knee
want to preserve as much of meniscus as possible in treatment to prevent instability and secondary OA
often only torn part of meniscus excised, major tears however may require total meniscectomy
periphery of meniscus-best b.supply, detachments here may be repaired with direct suture.
presentation of meniscal cyst?
often hx of blow on side of knee over meniscus
they are tender and restrict menisci mobility, making them more likely to tear
usually excised, may also need meniscectomy
clinical features of spinal stenosis?
pt with backache complains of aching and/or numbness and paraesthesia in the thighs, legs or feet (bilateral usually, but sometimes unilateral if an asymmetrical stenosis or intervertebral root canal stenosis.
symptoms come on after standing upright or walking 5-10 mins (although not fixed distance to bring on symptoms as with vascular claudication) and consistently relived by sitting or squatting (pt doesn't just stop walking as with vascular) with spine somewhat flexed.
lower limb neurolog signs may be found on exam, should check upper limbs for signs of polyneuropathy, and lower limbs for PVD-check pulse, temp, CRT.
defining pain charcteristics in sciatica?
pain radiation below the knee
leg pain worse than back pain
classic pain feature of mechanical back pain?
pain worse when sitting or lying down, better when patient stands up
mechanical=origin is spinal column, vertebrae or soft tissue
best reliable investigation for diagnosing meniscal tear?
MRI-look for changes in signal density
note plain X-rays are normal
overall tment of meniscal tears?
in adults with degenerative tear that may not be assoc with any remembered traumatic incident, symptoms may resolve without surgery
can initially advise PRICE: protect from further injury, rest (crutches for 1st 24-48hrs), ice for initial 48hrs, compression with knee brace or splint if necessary, elevation
analgesia e.g. NSAIDs
r/f to physio if mild to moderate symptoms
early r/f to orthopaedic surgeon if ACL tear suspected
post 6-8wks of physio rehabilitaton and pain persiting and interfering with work and activities, r/f to orthopaedic surgeon
in terms of surgery, usually arthroscopic and partial meniscectomy preferred to total in terms of LT favourable results, usually displaced meniscus portion cleanly excise, if peripheral tear (where good b.supply) may do operative repair e.g.with direct suture or partial replacement with biodegradeable scaffold
medial meniscectomy preferred, try and preserve lateral meniscus as lateral meniscectomy more likely to cause OA
after meniscectomy, functional activities can be restarted after 1 week, running from days 10-14, rehabilitation takes 3-4 weeks
after repair, may need crutches for up to 1 month to keep weight off the knee, rehabilitation can take up to 3 mnths
results of meniscectomy are questioanble and procedure itself poses risk of further cartilage destruction and knee joint OA
post op physio very important part of tment
improve congruity and stability of the knee joint, improving articulation between femur and tibial plateau
shock absorbers, distributing load during weight bearing
control complex rolling and gliding actions of joint
how do menisci shape differ from 1 another?
lateral- more sharply curved, resembles more of an O which is incomplete medially
treatment of sprains and partial knee ligament tears?
intact fibres splint torn ones so spontaneous healing occurs
active exercise from start due to adhesions risk-torn fibres stick to intact fibres and to bone
haemarthrosis aspiration can ease pain and necessary if skin threatened
ice packs intermittently
heavily padded bandage or functional brace
allow weight bearing
treatment of complete knee joint ligament tears?
isolated MCL or LCL tears can be treated same as sprains and partial tears with active exercise from start, ice, knee protection with heavily padded bandage or functional brace, and haemarthrosis aspiration if required
isolated ACL tears can be treated with early operative reconstruction if professional sportsman, knee must be able to go through full motion range before op
usually follow conservative tment, wear cast-brace until symptoms subside then encourage movement and muscle-strengthening exercises
recurrent instability may then need ligament reconstructiion
if combined ACL and collateral ligament injury, start tment with joint bracing and physio to get good movement range before ACL reconstruction, collateral usually doesn't require this
if combined injuries involving PCL, all damaged structures usually require repair
conservative management of knee OA?
advise that something can be done
focus on core treatments-weight loss, education and muscle strengthening and aerobic exercise-notable benefit in knee OA, pace activity, and offer individualised self-management plans.
insoles-podiatrists, or OT or physio
walking aids, and personal care aids e.g. bath aids, stair rails, chair and bed raisers-OT
oxford hip score corresponding to high likelihood that surgical intervention is required?
indications for r/f for assessment for knee joint replacement in knee OA?
joint symptoms (pain, stiffness, reduced function) which are refractory to non-surgical treatment and have significant impact on patient's quality of life-walking ability, climbing stairs, night pain
r/f before prolonged and established functional limitation and pain
r/f for arthroscopic lavage and debridement only if knee OA with clear hx of mechanical locking
surgical options for hip OA?
THR or hip resurfacing arthroplasty
synovial fluid aspirate features in septic arthritis?
opaque yellow fluid
WCC more than 80 000/mm^3
more than 90% of WCC neutrophils (if bacterial)
why is a DEXA scan recommended in women with distal radial fractures?
in women over the age of 50 these are commonly result of osteoporosis-DEXA scan will reveal a T score of -2.5 or less
distal radial fractures in osteoporosis are predictors of subsequent fractures
can then implement OP treatment: smoking cessation, maintaining exercise, reduce alcohol, Ca2+ and vit D supplements, bisphosphonates e.g. once weekly alendronate
normal volar tilt and angle of incincation of distal radial articular surface?
11 degrees volar tilt
22 degrees angle of inclination
disruption to these, along with radial height (normally 11mm) corresponds with displaced distal radial fractures
characteristics of a colle's fracture?
fracture through distal 2cm of the radius, with dorsal and radial displacement of distal fragement, and dorsal tilt
also look for articular involvement, and fracture of ulnar styloid process
tment undisplaced colle's fracture?
dorsal rigid splint applied for 1-2 days until swelling resolved, then cast completed
cast can usually be removed after 4 weeks to allow mobilisation
tment of median nerve injury in colle's fracture?
nerve may be compressed by swelling in carpal tunnel, will present as paraesthesia and numbness in radial 3 and a half digits
if mild symptoms, may resolve with release of dressings and arm elevation
if severe or persistent-lasting more than 1-2 days, transverse carpal ligament should be divided (carpal tunnel release).
how to reduce a displaced colle's fracture?
reduce under anaesthesia (haematoma block)
apply traction in length of bone, then press on dorsum while manipulating wrist into moderate flexion, ulnar deviation and pronation, to push dorsal fragement into place.
then check position with x-ray (PA and lateral)
if satisfactory, can apply dorsal plaster slab/backslab (doesn't extend around full circumference), extending from just below elbow to the metacarpal necks and 2/3 way around wrist circumference
keep arm elevated for next few days
start shoulder and finger exercises as soon as possible
recheck position by x-ray 10 days later as often fracture re-displaces in cast, if so must re-manipulate within 1st 2 weeks
can discard slab after 5 weeks when fracture ususally united
why is radial shortening and angulation important to know in a distal radial fracture?
helps ascertain degree of displacement and requirement for ORIF, as disruption increases likelihood of malunion as loss of congruity between articular surfaces, predisposing to early OA development.
in terms of what is acceptable:
dorsal tilt less than 5 degrees
radial height less than 5mm shortening
angle of inclination less than 5 degrees change
what tendon is most likely to rupture with distal radial non-displaced fractures?
treat with tendon transfer of 1 of index finger extensor tendons (EI)
complications of distal radial fractures e.g. colle's?
median nerve and ulnar nerve injury
assoc. radioulnar and carpal injuries, ligament strains often source of pain and weakness long after fracture healed
EPL tendon rupture
complex regional pain syndrome-early signs are swelling and tenderness of finger joints
joint stiffness-must encourage active movement
what score is used to define osteopenia (low bone masss), osteoporosis and severe osteoporosis?
T score: standard deviations are used to compare bone density with that of a young healthy individual. Z score-comparison with someone of that age.
osteopenia: hip BMD between 1 and 2.5 SD below young adult reference mean (T score less than -1 but greater than -2.5)
osteoporosis: T score -2.5 or less, hip BMD 2.5 SDs or more below young adult reference mean
severe osteoporosis: T score -2.5 or less in presence of 1 or more fragility fractures
investigations in suspected osteoporosis to address underlying causes and rule out differentials?
FBC and ESR/CRP-macrocytic anaemia, raised ESR in multiple myeloma, normocytic and raised in RA
TFTs-look for hyperthyroidism, LFTs-chronic liver disease, Us and Es-CKD, serum Ca2+-unlikely raised due to OP, raised with underlying cause e.g. hyperparathyroidism, multiple myeloma
bone profile-Ca2+, PO43-, ALP, albumin
elderly pt with back pain-?metastases-blood PSA in men, ?hx breast Ca in women
testosterone/gonadotropins in men
serum Igs and paraproteins, urine bence-jones' proteins-light chain portion of IgG produced in multiple myeloma
may consider serum protein electrophoresis in some cases
X-ray-good for vertebral compression fractures
DEXA=gold standard for diagnosis, dual energy X-ray absorptiometry, incorrect diagnosis can occur with OA, osteomalacia of soft tissue calcification. However, many fragility fractures in those with BMD above defined level, so FRAX tool used for assessing risk of OP fragility fracture in next 10 yrs in those aged between 40 and 90.
CT-assess fracture extent, CT guided biopsy if malignancy strongly suspected
MRI if radicular pain or lower extremity motor or sensory loss
advice on taking bisphosphonates in osteoporosis?
poorly absorbed so must be taken separately from food
risk of oesophageal irritation so must be taken sitting up with plenty of water, take 1st thing on a morning on empty stomach
person must not lie down, eat or take other oral medication for at least 30 mins afterwards
BMD should be measured every 2-5 years
at some point should be a 'drugholiday' as inhibiting osteoclast medated bone resorption interferes with bone remodelling which may weaken bone over time, predisposing to fractures e.g. atypical femoral fractures, at 5 years should r/v need for treatment and risks.
management options for vertebral compression fractures?
percutaneous vertebroplasty-injection of bone cement into vertebral body, and balloon kyphoplasty-inflation of balloon like device into vertebral body to restore height before injection of bone cement, if severe ongoing pain after recent unhealed spinal fracture despite pain tment and pain confirmed to be coming from site of fracture.
3 components to the lateral collateral ligament of the ankle?
anterior talofibular ligament
posterior talofibular ligament
when should X-ray be done for pt with ankle injury?
pain around malleolus
inability to take weight on ankle immediately after injury
inability to take 4 steps in emergency department
bone tenderness at posterior edge or tip of either of the malleoli or the base of the 5th metatarsal.
how is collateral ligament damage suggested in ankle X-ray?
displacement or tilting of talus
how are ankle fractures classified?
Weber classification-based on level of fibula fracture:
A=fibular fracture below tibiofibular syndesmosis, syndesmosis left intact
B=fibular fracture at level of tibiofibular syndesmosis, so often anterior fibres of tibiofibular ligament disrupted, and assoc. with medial malleolous fracture or medial ligament disruption.
C=fibular fracture above tibiofibular syndesmosis, worst prognosis.
clinical features of ankle fracture?
hx of twisting injury, typically inversion, causing severe pain and inability to stand on that leg-unable to WB, and immediate swelling and bruising soon after. deformity may be obvious.
why will non-operative treatment often suffice for weber's A ankle fractures?
this involves fibula fracture below level of tibiofibular syndesmosis, so as syndesmosis remains intact, ankle wil be stable once malleolar fractures reduced and immobilised.
how is ankle fibular fracture best treated if medial injury or significant fibular displacement?
diastasis-fibula separation from tibia with disrupted tibiofibular syndesmosis should be reduced and secured with a screw (diastasis screw), then need immediate post op X-ray to confirm talus position in mortise as if even slightly laterally displaced, medial collateral ligament-primary restraint to anterolateral talus displacement, must be explored and any obstructing tissue removed.
components to managing ankle fracture in a diabetic patient?
DM induced peripheral neuropathy is an independent RF for post op complications in ankle fractures
poor blood supply often delays healing
therefore require prolonged periods of immobilisation, attention to tight glucose control and may need alternative operative techniques.
definitive tment isolated medial malleolar fractures?
if undisplaced, plaster immobilisation for 6 weeks
displaced require accurate reduction and internal fixation with 1 or 2 screws, tibiofibular diastasis may require open reduction and transverse screw fixation.
post op management of ankle fractures?
ankle and foot immobilised in below-knee cast or supported in special boot
pt often allowed to walk about partial WB with aid of crutches
stable low-level fractures-support usually discarded after 4-6 weeks, and exercises encouraged
cast for longer if unstable and operatively treated
complications of ankle fractures?
joint stiffness: physio is key to recovery. pt must walk correctly in plaster, and when plaster removed, must until circulatory control regained use a compression stocking and elevate leg whenever not being used actively
complex regional pain syndrome: long-lasting aching and recurrent swelling, treat with anti-inflammatories, active exercises and physio, elevation, amitriptyline, sympathetic block.
OA: malunion from incomplete reduction
differentials for wrist pain and swelling?
OA-radiocarpal joint and 1st CMCJ, RCJ-usually looks normal but wrist tender and movements restricted and painful, usually previ intra-articular injury e.g. distal radial fracture, 1st CMCJ-pain and swelling around proximal end of thumb metacarpal, tenderness localised to CMCJ 1cm distal to radial styloid process, local injection of corticosteroid can improve pain.
wrist RA-wrist radial deviation and fingers ulnar deviation, pain, swelling and tenderness, MCPJ swelling-loss of valleys when pt asked to make a fist, may be CTS due to flexor synovitis treated with flexor retinaculum release
de quervain's tenosynovitis-pain and sometimes swelling localised to radial side of wrist, tendon sheath thick and hard, tenderness most acute at very tip of radial styloid, stab of pain over radial styloid in finkelstein's test, can do corticosteroid injection into tendon sheath, sometimes combined with wrist splintage, resistant cases may need splitting of thickened tendon sheath, must be careful not to damage radial nerve dorsal sensory branches.
hand of benediction vs. ulnar claw?**
ulnar claw=ulnar nerve injury at the wrist-los of innervation to medial 2 lumbricals-normal flex at MCPJs and extensions IPJs, but retain innervation to ulnar half of FDP, so little and ring finger MCPJ hyperextension and IPJ flexion, with flexion of DIPJs not seen with ulnar nerve injury at elbow, deformity always present.
hand of benediction-median nerve injury with visible deformity when pt asked to make a fist.
treatment of rotator cuff syndrome?
conservative: physio, active exercises in position of freedom
short course of NSAIDs
if fail, before marked disability, consider 1 or 2 injections of corticosteroid into SA space
if symptoms do not subside after 3 mnths of conservative tment, or recur persistently after each tment course, operation considered- inidcation more if partial RC tear or full thickness tear in younger patient, =decompression-removal of acromion, CA ligament and ACJ osteophytes, athroscopically can have earlier rehabilitation due to no need to detach deltoid.
pain at end of abduction often indicates what?
which ligament of the ankle joint is more likely to get damaged?
lateral ligament: as weaker than medial, and resists inversion.
what diagnosis is suggested from lumbar spine radiograph showing a single central radiodense line?
appearance due to ossification of supraspinous and interspinous ligaments=dagger sign
bamboo spine=complete fusion of anterior and posterior elements of vertebrae
cause of trochanteric bursitis (greater trochanteric pain syndrome)?
repeated movement of iliotibial band
causes of avascular necrosis?
trauma e.g. fracture to waist of scaphoid-b.supply cut off to proximal pole of scaphoid, need below elbow backslab
LT steroid use
investigation of choice for avascular necrosis?
causes of dupuytren's contracture (palmar fascia thickening) other than alcoholic liver disease?