Monday [24/01/22] Flashcards
(122 cards)
1
Q
What is compartment syndrome? [3]
A
- particular condition that may occur following fractures [or following ischaemia repercussion injury in vascular patients]
- characterised by raised pressure within the closed anatomical space
- raised pressure will eventually compromise tissue perfusion -> necrosis
2
Q
Two main fractures causing compartment syndrome [2]
A
- supracondylar fracture
- tibial shaft fracture
3
Q
Features of compartment syndrome [5]
A
- pain, especially on movement [even passive]; excessive analgesia should raised suspicion for compartment syndrome
- parasthesia
- pallor may be present
- arterial pulsation may still be felt as necrosis occurs as a result microvascaulr compromised
- paralysis of the muscle group may occur
[so basically limb ischaemia 6Ps]
4
Q
Does the presence of a pulse r/o compartment syndrome? [1]
A
Nope
5
Q
Dx for compartment syndrome [2]
A
- Measurement of intracopartemntal pressure; pressure in excess of 20mmHg are abnormal, >40mmHg diagnostic
- compartment syndrome will typically not show any pathology on an XR
6
Q
Tx for compartment syndrome [5]
A
- essentially prompt and extensive fasciotomties
- In the lower limb the deep muscles may be inadequately decompressed by the inexperienced operator when smaller incisions are performed
- Myoglobinuria may occur following fasciotomy and result in renal failure and for this reason these patients require aggressive IV fluids
- Where muscle groups are frankly necrotic at fasciotomy they should be debrided and amputation may have to be considered
- Death of muscle groups may occur within 4-6 hours
7
Q
When do Colles’ fractures occur? [1]
A
FOOSH
8
Q
What is Colles’ fractures described as? [1]
A
Dinner fork deformity
9
Q
Classical Colles’ fracture features [3]
A
- Transverse fracture of the radius
- 1 inch proximal to the radio-carpal joint
- Dorsal displacement and angulation
10
Q
What happens in a Smith’s fracture? [1]
A
Volar angulation of distal radius fragment [Garden spade deformity]
11
Q
Cause of Smith fracture [1]
A
Falling backwards onto palm of outstretch hand, or falling with wrists fixed
12
Q
What’s a Bennett’s fracture and when does it occur? Bonus: appearance on XR [3]
A
Intra-articular fracture at the base of the thumb metacarpal
Impact on flexed metacarpal, caused by fist fights
X-ray: triangular fragment at the base of metacarpal
13
Q
When do Monteggias’s fractures occur? [3]
A
Dislocation of the proximal radioulnar joint in association with an ulna fracture
Fall on outstretched hand with forced pronation
Needs prompt diagnosis to avoid disability
14
Q
When do Galleazzi fractures occur? [4]
A
Radial shaft fracture with associated dislocation of the distal radioulnar joint
Occur after a fall on the hand with a rotational force superimposed on it.
On examination, there is bruising, swelling and tenderness over the lower end of the forearm.
X Rays reveal the displaced fracture of the radius and a prominent ulnar head due to dislocation of the inferior radio-ulnar joint.
15
Q
When do Barton’s fractures occur? [2]
A
Distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation
Fall onto extended and pronated wrist
16
Q
When do Scaphoid fractures occur? [7]
A
Scaphoid fractures are the commonest carpal fractures.
Surface of scaphoid is covered by articular cartilage with small area available for blood vessels (fracture risks blood supply)
Forms floor of anatomical snuffbox
Risk of fracture associated with fall onto outstretched hand (tubercle, waist, or proximal 1/3)
The main physical signs are swelling and tenderness in the anatomical snuff box, and pain on wrist movements and on longitudinal compression of the thumb.
Ulnar deviation AP needed for visualization of scaphoid
Immobilization of scaphoid fractures difficult
17
Q
When do radial head fractures occur? [3]
A
Fracture of the radial head is common in young adults.
It is usually caused by a fall on the outstretched hand.
On examination, there is marked local tenderness over the head of the radius, impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination).
18
Q
Which condition has a strong association with temporal arteritis? [1]
A
PMR
19
Q
Histology for temporal arteritis [1]
A
Histology shows changes that characteristically ‘skips’ certain sections of the affected artery whilst damaging others.
20
Q
Features of temporal arteritis[8]
A
- typically patient > 60 years old
- usually rapid onset (e.g. < 1 month)
- headache (found in 85%)
- jaw claudication (65%)
- visual disturbances
amaurosis fugax
blurring
double vision
vision testing is a key investigation in patients with suspected temporal arteritis
secondary to anterior ischemic optic neuropathy - tender, palpable temporal artery
- around 50% have features of PMR: aching, morning stiffness in proximal limb muscles (not weakness)
- also lethargy, depression, low-grade fever, anorexia, night sweats
21
Q
Ix for TA [3]
A
raised inflammatory markers
ESR > 50 mm/hr (note ESR < 30 in 10% of patients)
CRP may also be elevated
temporal artery biopsy
skip lesions may be present
note creatine kinase and EMG normal
22
Q
When does the Tx differ in temporal arteritis? [2]
A
urgent high-dose glucocorticoids should be given as soon as the diagnosis is suspected and before the temporal artery biopsy
if there is no visual loss then high-dose prednisolone is used
if there is evolving visual loss IV methylprednisolone is usually given prior to starting high-dose prednisolone
there should be a dramatic response, if not the diagnosis should be reconsidered
23
Q
Other Tx for TA [3]
A
- urgent ophthalmology review
patients with visual symptoms should be seen the same-day by an ophthalmologist
visual damage is often irreversible - bone protection with bisphosphonates is required as long, tapering course of steroids is required
- low-dose aspirin is sometimes given to patients as well, although the evidence base supporting this is weak
24
Q
Aspirate of painful knee in septic arthritis vs reactive vs gout[2]
A
Septic
- white cells
Reactive
- clear fluid
Gout
- crystals
25
Features of reactive arthritis [6]
- time course
typically develops within 4 weeks of initial infection - symptoms generally last around 4-6 months
around 25% of patients have recurrent episodes whilst 10% of patients develop chronic disease [caused by an STI or food poisoning]
- arthritis is typically an asymmetrical oligoarthritis of lower limbs
- dactylitis
- symptoms of urethritis
- eye
conjunctivitis (seen in 10-30%)
anterior uveitis
- skin conditions
26
Skin conditions associated with reactive arthritis [2]
- circinate balanitis (painless vesicles on the coronal margin of the prepuce)
- keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)
27
What is cubital tunnel syndrome caused by? [1]
Cubital tunnel syndrome is caused by ulnar nerve entrapment at the elbow.
28
Clinical features of cubital tunnel syndrome [4]
- Tingling and numbness of the 4th and 5th finger which starts off intermittent and then becomes constant.
- Over time patients may also develop weakness and muscle wasting
- Pain worse on leaning on the affected elbow
- Often a history of osteoarthritis or prior trauma to the area.
29
Ix for cubital tunnel syndrome [2]
the diagnosis is usually clinical
however, in selected cases nerve conduction studies may be used
30
Mx cubital tunnel syndrome [4]
Avoid aggravating activity
Physiotherapy
Steroid injections
Surgery in resistant cases
31
What is the most common cause of OM? [1]
Staph aureus [except in pts with sickle-cell anaemia where salmonella species predominate]
32
Ix for OM [1]
MRI with a sensitivity of 90-100%
33
Mx of OM [2]
- flucloxacillin for 6 weeks
- clindamycin if penicillin-allergic
34
2 types of OM [1]
haematogenous OM and non-haematenous OM
35
Features of haematogenous OM [5]
results from bacteraemia
is usually monomicrobial
most common form in children
vertebral osteomyelitis is the most common form of haematogenous osteomyelitis in adults
risk factors include: sickle cell anaemia, intravenous drug user, immunosuppression due to either medication or HIV, infective endocarditis
36
Features of non-haematongenous OM [4]
results from the contiguous spread of infection from adjacent soft tissues to the bone or from direct injury/trauma to bone
is often polymicrobial
most common form in adults
risk factors include: diabetic foot ulcers/pressure sores, diabetes mellitus, peripheral arterial disease
37
Adverse effects of azathioprine [4]
- bone marrow depression [especially as it interacts with allopurinol, both inhibitors of xanthine oxidase]
- nausea/vomiting
- pancreatitis
- increased risk of non-melanoma skin cancer
38
Features of drug-induced lupus [6]
arthralgia
myalgia
skin (e.g. malar rash) and pulmonary involvement (e.g. pleurisy) are common
ANA positive in 100%, dsDNA negative
anti-histone antibodies are found in 80-90%
anti-Ro, anti-Smith positive in around 5%
39
Most common causes of drug-induced lupus [2]
Bonus: least common causes of drug-induced lupus
Most common causes
procainamide
hydralazine
Less common causes
isoniazid
minocycline
phenytoin
40
What is a iliopsoas abscess? [1]
An iliopsoas abscess describes a collection of pus in iliopsoas compartment (iliopsoas and iliacus).
41
Primary vs secondary causes of iliopsoas abscess [7]
Primary
Haematogenous spread of bacteria
Staphylococcus aureus: most common
Secondary
Crohn's (commonest cause in this category)
Diverticulitis, colorectal cancer
UTI, GU cancers
Vertebral osteomyelitis
Femoral catheter, lithotripsy
Endocarditis
intravenous drug use
42
Clinical features of iliopsoas abscess [4]
Clinical features
Fever
Back/flank pain
Limp
Weight loss
43
Clinical examination for iliopsoas abscess [2]
Patient in the supine position with the knee flexed and the hip mildly externally rotated
Specific tests to diagnose iliopsoas inflammation:
Place hand proximal to the patient's ipsilateral knee and ask patient to lift thigh against your hand. This will cause pain due to contraction of the psoas muscle.
Lie the patient on the normal side and hyperextend the affected hip. This should elicit pain as the psoas muscle is stretched.
44
Ix for iliopsoas abscess [1]
CT abdomen
45
Mx for iliopsoas abscess
Antibiotics
Percutaneous drainage is the initial approach and successful in around 90% of cases
Surgery is indicated if:
1. Failure of percutaneous drainage
2. Presence of an another intra-abdominal pathology which requires surgery
46
features of seronegative sponyxarhtopathies [5]
associated with HLA-B27
rheumatoid factor negative - hence 'seronegative'
peripheral arthritis, usually asymmetrical
sacroiliitis
enthesopathy: e.g. Achilles tendonitis, plantar fasciitis
extra-articular manifestations: uveitis, pulmonary fibrosis (upper zone), amyloidosis, aortic regurgitation
47
Examples of spondyloarthropathies [4]
ankylosing spondylitis
psoriatic arthritis
reactive arthritis
enteropathic arthritis (associated with IBD)
48
Which Ix should be done with all pts presenting with suspected RA? [1]
XR of hands and feet
49
Which blood test should be performed on a pt with suspected RA? [2]
Other tests that should be performed in this patient include rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (anti-CCP).
50
S and S for ACCPA [2]
Anti-cyclic citrullinated peptide antibody may be detectable up to 10 years before the development of rheumatoid arthritis. It has a key role in the diagnosis of rheumatoid arthritis, allowing early detection of patients suitable for aggressive anti-TNF therapy. It has a sensitivity similar to rheumatoid factor (around 70%) with a much higher specificity of 90-95%.
51
What is dermatomyositis? [3]
- an inflammatory disorder causing symmetrical, proximal muscle weakness and characteristic skin lesions
- may be idiopathic or associated with connective tissue disorders or underlying malignancy (typically ovarian, breast and lung cancer, found in 20-25% - more if patient older). Screening for an underlying malignancy is usually performed following a diagnosis of dermatomyositis
- polymyositis is a variant of the disease where skin manifestations are not prominent
52
Skin features of dermatomyositis [6]
photosensitive
macular rash over back and shoulder
heliotrope rash in the periorbital region
Gottron's papules - roughened red papules over extensor surfaces of fingers
'mechanic's hands': extremely dry and scaly hands with linear 'cracks' on the palmar and lateral aspects of the fingers
nail fold capillary dilatation
53
Other features of dermatomyositis [5]
proximal muscle weakness +/- tenderness
Raynaud's
respiratory muscle weakness
interstitial lung disease: e.g. Fibrosing alveolitis or organising pneumonia
dysphagia, dysphonia
54
Ix for dermatomyositis [2]
the majority of patients (around 80%) are ANA positive
around 30% of patients have antibodies to aminoacyl-tRNA synthetases (anti-synthetase antibodies), including:
antibodies against histidine-tRNA ligase (also called Jo-1)
antibodies to signal recognition particle (SRP)
anti-Mi-2 antibodies
55
What is the Ottawa ankle rules? [1]
A way of trying to minimise the use of unnecessary XR
These state that XR are only necessary if there's pain in the malleolar zone and:
1. inability to weigh tear for 4 steps
2. Tenderness over the distal tibia
3. Bone tenderness over the distal fibula
56
Go through the Weber classification in relation to a fibular fracture [3]
Related to the level of the fibular fracture.
Type A is below the syndesmosis
Type B fractures start at the level of the tibial plafond and may extend proximally to involve the syndesmosis
Type C is above the syndesmosis which may itself be damaged
57
Whta is the Maisonneuve fracture? [1]
A subtype known as a Maisonneuve fracture may occur with spiral fibular fracture that leads to disruption of the syndesmosis with widening of the ankle joint, surgery is required.
58
Mx of ankle fractures [3]
All ankle fractures should be promptly reduced to remove pressure on the overlying skin and subsequent necrosis
Young patients, with unstable, high velocity or proximal injuries will usually require surgical repair. Often using a compression plate.
Elderly patients, even with potentially unstable injuries usually fare better with attempts at conservative management as their thin bone does not hold metalwork well.
59
Mx of Weber A fractures
Patient with minimally displaced, stable fractures may weight weight bear as tolerated in a CAM boot [controleld ankle motion boot]
60
Mechanism for a ruptured ACL injury, how it presents and Mx [5]
Sport injury
Mechanism: high twisting force applied to a bent knee
Typically presents with: loud crack, pain and RAPID joint swelling (haemoarthrosis)
Poor healing
Management: intense physiotherapy or surgery
61
Mechanism for a ruptured PCL injury, how it presents and Mx [3]
Mechanism: hyperextension injuries
Tibia lies back on the femur
Paradoxical anterior draw test
62
Mechanism for a ruptured MCL injury, how it presents and Mx [2]
Mechanism: leg forced into valgus via force outside the leg
Knee unstable when put into valgus position
63
Mechanism for a meniscal tear, how it presents and Mx [4]
Rotational sporting injuries
Delayed knee swelling
Joint locking (Patient may develop skills to 'unlock' the knee
Recurrent episodes of pain and effusions are common, often following minor trauma
64
Mechanism for chondromalacia patellae and how it presents [3]
Teenage girls, following an injury to knee e.g. Dislocation patella
Typical history of pain on going downstairs or at rest
Tenderness, quadriceps wasting
65
Mechanism for discoloation of the patella and how it presents [5]
Most commonly occurs as a traumatic primary event, either through direct trauma or through severe contraction of quadriceps with knee stretched in valgus and external rotation
Genu valgum, tibial torsion and high riding patella are risk factors
Skyline x-ray views of patella are required, although displaced patella may be clinically obvious
An osteochondral fracture is present in 5%
The condition has a 20% recurrence rate
66
Types of fractured patellar
i. Direct blow to patella causing undisplaced fragments
ii. Avulsion fracture
67
What is a tibial plateau fracture? [4]
Occur in the elderly (or following significant trauma in young)
Mechanism: knee forced into valgus or varus, but the knee fractures before the ligaments rupture
Varus injury affects medial plateau and if valgus injury, lateral plateau depressed fracture occurs
Classified using the Schatzker system (see below)
68
What should be undertaken before Tx with hydroxychloroquine? [1]
bull's eye retinopathy - may result in severe and permanent visual loss
recent data suggest that retinopathy caused by hydroxychloroquine is more common than previously thought and the most recent RCOphth guidelines (March 2018) suggest colour retinal photography and spectral domain optical coherence tomography scanning of the macula
baseline ophthalmological examination and annual screening is generally recommened
69
Which antibodies most associated with drug-induced lupus? [1]
Antihistone antibodies are associated with drug-induced lupus
70
Blood work for osteoporosis [1]
OP commonly associated with normal blood values [ALP, calcium, phosphate and PTH]
71
When is T recommended for OP? [2]
To assess the actual bone mineral density a dual-energy X-ray absorptiometry (DEXA) scan is used. The DEXA scan looks at the hip and lumbar spine. If either have a T score of \< -2.5 then treatment is recommended.
72
First-line Mx for OP [2]
The first-line treatment for osteoporosis is an oral bisphosphonate such as alendronate. Other treatments are available but the vast majority of patients are managed with this therapy.
73
2 most common types of psoriatic arthritis [2]
symmetric polyarthritis
very similar to rheumatoid arthritis
30-40% of cases, most common type
asymmetrical oligoarthritis: typically affects hands and feet (20-30%)
until recently it was thought asymmetrical oligoarthritis was the most common type, based on data from the original 1973 Moll and Wright paper. Please see the link for a comparison of more recent studies
74
XR for psoriatic arthritis looks how? [3]
often have the unusual combination of coexistence of erosive changes and new bone formation
periostitis
'pencil-in-cup' appearance
75
1st line Mx for AS [1]
Exercise and NSAIDs
76
What is Felty's syndrome? [1]
Splenomegaly and neutropenia seen in a patient with RA
77
Features of a hip fracture
pain
the classic signs are a shortened and externally rotated leg
patients with non-displaced or incomplete neck of femur fractures may be able to weight bear
78
Classification of hip fractures [2]
intracapsular (subcapital): from the edge of the femoral head to the insertion of the capsule of the hip joint
extracapsular: these can either be trochanteric or subtrochanteric (the lesser trochanter is the dividing line)
79
Way of classifying hip fractures [1]
Garden system
80
go through the garden system [4]
The Garden system is one classification system in common use.
Type I: Stable fracture with impaction in valgus
Type II: Complete fracture but undisplaced
Type III: Displaced fracture, usually rotated and angulated, but still has boney contact
Type IV: Complete boney disruption
81
Which types of hip fractures in the garden classification have blood supply disruption? [2]
Blood supply disruption is most common following Types III and IV.
82
Undisplaced hip fracture Mx [1]
internal fixation, or hemiarthroplasty if unfit.
83
Displaced hip fracture Mx [3]
- NICE recommend replacement arthroplasty (total hip replacement or hemiarthroplasty) to all patients with a displaced intracapsular hip fracture
- total hip replacement is favoured to hemiarthroplasty if patients:
were able to walk independently out of doors with no more than the use of a stick and
are not cognitively impaired and
are medically fit for anaesthesia and the procedure.
84
Mx of extra-capsular hip fracture [2]
Management
stable intertrochanteric fractures: dynamic hip screw
if reverse oblique, transverse or subtrochanteric fractures: intramedullary device
85
most common radiological feature in AS [1]
Syndesmophytes [ossification of outer fibres of annulus fibrosis] are a feature of AS]
86
S1 lesion features [important]
Sensory loss of posterolateral aspect of leg and lateral aspect of foot, weakness in plantar flexion of foot, reduced ankle reflex, positive sciatic nerve stretch test
87
L5 nerve root compression
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
88
L4 nerve root compression
Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
89
L3 nerve root compression
Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
positive femoral stretch test
90
Mx for nerve root compression
Management
similar to that of other musculoskeletal lower back pain: analgesia, physiotherapy, exercises
if symptoms persist 9e.g. after 4-6 weeks) then referral for consideration of MRI is appropriate
91
A patient sustains an injury to one of the nerves of his upper limb. He complains of weak finger abduction and adduction with reduced sensation over the ulnar border of his hand. On examination you note clawing of the 4th and 5th digits. During recovery, the patient notices worsening of this deformity before eventually resolving.
What is the most likely diagnosis?
Damage to the ulnar nerve at the elbow
Ulnar paradox: proximal lesions of the ulnar nerve produce a less prominent deformity than distal lesions.
The ulnar nerve supplies the palmer and dorsal interossei muscles and therefore finger abduction and adduction. Therefore this is an ulnar nerve lesion.
Closer to the paw, the bigger the claw.
Ulnar injury at wrist : marked claw
Ulnar injury at elbow : less claw but get worse before getting better
92
What is antiphospholipid syndrome [2]
Antiphospholipid syndrome is an acquired disorder characterised by a predisposition to both venous and arterial thromboses, recurrent fetal loss and thrombocytopenia. It may occur as a primary disorder or secondary to other conditions, most commonly systemic lupus erythematosus (SLE)
93
Features of APS
venous/arterial thrombosis
recurrent fetal loss
livedo reticularis
thrombocytopenia
prolonged APTT
other features: pre-eclampsia, pulmonary hypertension
94
Mx of APS [3]
primary thromboprophylaxis
low-dose aspirin
secondary thromboprophylaxis
initial venous thromboembolic events: lifelong warfarin with a target INR of 2-3
recurrent venous thromboembolic events: lifelong warfarin; if occurred whilst taking warfarin then consider adding low-dose aspirin, increase target INR to 3-4
arterial thrombosis should be treated with lifelong warfarin with target INR 2-3
95
Important test for those with RA who have tested negative with RF? [1]
The clinical features are suggestive of rheumatoid arthritis (RA). It is important to remember that Anti-CCP (cyclic citrullinated peptide) antibody is positive in approximately 40% of patients who test negative for Rheumatoid Factor. Therefore Anti-CCP is an important diagnostic test for RA.
96
Interactions for MTX? [2]
avoid prescribing trimethoprim or co-trimoxazole concurrently - increases risk of marrow aplasia
high-dose aspirin increases the risk of methotrexate toxicity secondary to reduced excretion
97
What are proximal humerus fractures? [4]
Very common. Usually through the surgical neck. Number of classification systems though for practical purposes describing the number of fracture fragments is probably easier. Some key points:
It is rare to have fractures through the anatomical neck.
Anatomical neck fractures which are displaced by \>1cm carry a risk of avascular necrosis to the humeral head.
In children the commonest injury pattern is a greenstick fracture through the surgical neck.
Impacted fractures of the surgical neck are usually managed with a collar and cuff for 3 weeks followed by physiotherapy.
More significant displaced fractures may require open reduction and fixation or use of an intramedullary device.
98
Types of shoulder disolocation
```
Glenohumeral dislocation (commonest): anterior shoulder dislocation most common
Acromioclavicular dislocation (12%): clavicle loses all attachment with the scapula
Sternoclavicular dislocation (uncommon)
```
99
What is Osteogenesis Imperecta? [2]
Osteogenesis imperfecta (more commonly known as brittle bone disease) is a group of disorders of collagen metabolism resulting in bone fragility and fractures. The most common, and milder, form of osteogenesis imperfecta is type 1.
- autosomal dominant
- abnormality in type 1 collagen due to decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides
100
Features of osteogenesis imperfects
presents in childhood
fractures following minor trauma
blue sclera
deafness secondary to otosclerosis
dental imperfections are common
101
Ix for OI [1]
adjusted calcium, phosphate, parathyroid hormone and ALP results are usually normal in osteogenesis imperfecta
102
How is Sheton's line formed? [1]
Medial edge of the femoral neck and the inferior edge of the superior pubic ramus
103
When may loss of contour of Shenton's line happen? [1]
fractures NoF
- though, fractures of the femoral neck do not always cause loss of Shenton's line
104
What does the capsule envelope in the hip? [1]
The femoral head and neck
105
Types of intracapsular hip injuries [3]
Subcapital, transcervical and basicervical fractures are intracapsular hip injuries
106
Types of extra capsular injuries [2]
Intertrochanteric and subtrochanteric fractures do not involve the neck of femur
107
Go through the Schatzker classification system for tibial plateau fractures
108
Label this diagram
109
lablel this lateral XR view
110
Which type of hip fracture would require a total hip replacement? [2]
111
Which type of hip fracture would require hemiarthroplasty? [2]
112
Which type of hip fracture would require a sliding hip screw or a intramedullary nail? [4]
113
Which type of hip fracture would require a
114
What does this should XR show? [1]
115
go through intra vs extracapsular hip fracture types
116
What is going on in this XR? [1]
117
Go through Garden classification system
118
What fracture is this?
Garden IV fracture
- loss of Shenton's line
complete fracture of the full diameter of the femoral neck
total displacement of the 2 fracture componenets
119
Hip XR
120
XR
Subtrochanteric fracture
121
Go through the brachial plexus
122
rotator cuff muscles
