Flashcards in MSK Deck (78):
What score is used for growth plate #?
What score system is used for open #?
What score is used for hip SA in a child?
What score is used for ACJ joint disruption?
What score is used for ankle #?
What score is used to predict the need to amputate an open fracture?
What score is used to indicate the need to fix a pathological #?
Give three indications for surgery in a #
• Failed non-op management
• Unstable # that cannot be maintained in reduced position
• Displaced intra-articular #
• # known to heal poorly without op
• Large avulsion # that disrupts muscles, tendons or ligaments functioning
• Impending pathological #
• Multiple traumatic # including pelvis, femur and vertebrae
• Unstable open #, type ii or type iii #
• # in patients who would poorly tolerate prolonged immobilisation
• # in growth areas in skeletally immature individuals that risk growth stopping
• Non or mal union in non-surgical treatment
• Polytrauma to one side of the body
What are the different implants that can be used for fracture fixation?
- IM nails
What is the function of screws in fracture fixation?
transform rotational force into compression between 2 or more surfaces
what is the function of plates in the healing of fractures?
stabilize the bone fragments to allow early movement
what is the function of IM nails?
prevent rotational deformity and shortening of long bones
What are the indications for external fixation?
Temporary until the patient is able to have surgery
What are some of the contraindications for surgical fixation of fractures?
Active infection or osteomyelitis
soft tissue that compromises overlying # or surgical approach
Medical conditions that contraindicate anesthesia
What are the complications of EF?
Apart from surgery and more traditional methods what other methods can be tried for bone healing
- Bone morphogenic proteins – promote differentiation of fibroblast like cells into pre-osteoblasts into osteoblasts which form new bone
- USS- low intensity pulsed US to speed up # by stimulating bone cells to grow and repair- best used in delayed healing and non union
What class of analgesia shouldnt be prescribed in a fracture and why?
NSAIDs due to their anti inflammatory nature which would hinder healing
Explain direct healing of fractures and when is this needed
Direct healing doesnt involved a cutting cone or a haematoma
Needed in intra-articular fractures to prevent too much joint desruption.
Explain the traditional healing of bones
2) soft callus formation
3) hard callus formation
4) bony remodelling
`Through what law does bony remodelling occur and what does it state
Form follows function
What displacement can we not accept and why?
Rotational as remodelling doesnt counteract this
( as compared to malalignment which is corrected automatically)
Explain what physical features about bones affects the healing and how this affects our treatment
Bones heal better where there are large muscle bulks due to larger blood supply and supporting tissues
Metaphysis heals better than a shaft due to increased SA and increased cancerous bone which heals better.
- Lower shaft of tibia fracture heals very badly due to no muscle belly and this has implications of treatment. They are usually treated with a nail rather than a plate.
Explain the fractures seen in immature bones
Salter Harris fracture - fracture involving the epiphyseal growth plate
1) Transverse through growth plate - SLIPPED
2) Fracture through growth plate and metaphysis ABOVE
3) Fracture through growth plate and epiphysis LOWER
4) Fracture through all 3 physes EVERYTHING
5) Compression fracture at growth plate THROUGH EVERYTHING
6) Onwards are rare. RAMMED
Axial loading on a long bone leads to a buckle and a characteristic bulge in the cortex.
Typically occur in 5-10 year olds- typically self limiting and do not usually require ops
One side of the bone is broken and the other side is only bent - occurs more in children as bones are softer and more flexible.
Give some feature that may make you consider if an injury is non accidental
delayed presentation, delayed milestones, lack of concordance between injury and mechanism of injury, multiple injuries and injuries not at usual sites
What is a periosteal reaction?
Non specific change to bone seen on XR where the periosteum has been irritated
What types of periosteal reaction are there?
Benign - low grade inflammation allows bone to form a near normal cortex
Aggressive -acute and rapid irritation doesnt allow for the formation of a normal cortex
What is the most common cause of death after a orthopaedic operation?
Name some complications after an othorpaedic operation?
local neurovascular complications
chronic regional pain
What are contraindications for a joint aspiration?
overlying cellulitis or psoriasis
What can a joint aspiration be tested for?
appearance, viscosity, WBCs, neutrophils, gram staining, polarised light microscopy and culture.
How do we measure leg length?
True - ASIS to medial mallelous
Apparent - umbilicus to medial mallelous
Explain the pathophysiology behind Dupuytren's contractures
Fibromatosis of the palmar fascia
typically over the ulnar aspect that results in fixed flexion deformity
Who are dupuytren's contractures most common in?
Males, alcoholics, smokers, diabetics, epileptics and FH
Explain the management of dupuytrens contractures
Normally painless so can be managed conservatively until they become problematic
What is the test that indicates when a duputyrens contracture may need fixing?
Huestons Tabletop test
What surgical management can be done for dupuytrens?
Fasciotomy of there is isolated pretendionous cords and if not then a fasiectomy can be used
What is the problem with treatment in duputyrens contractures?
What is trigger finger?
nodular thickening of the flexor tendon and A I pulley
How can trigger finger be treated?
Conservatively with night splintage in extension, waiting for spontaneous resolution or steroid injections
surgically can release the pulley
What is De quervains synovitis ?
painful disorder of 1st dorsal compartment of the wrist as a result of inflammation
Explain the clinical findings of someone with De Quervains syndrome?
pain over the tendons
worse on thumb movement especially against resistance and pain is elicited on ulnar deviation with the thumb in the palm.
What tests are used for DDH?
Ortolani test - abduction and gentle elevation will create a clunk of reduction if there is a dislocated hip
Barlow test - gentle depression of adducted hip will cause dislocation
What are the risk factors for DDH?
High birth weight
What is the manaagement of DDH?
Pavlick harness if present before 3y/o
Delayed presentation often requires surgical intervention
What is osteochondritis dissecans?
AVN of the subchondral bone and dissection of the overlying cartilage
Commonly affects the knee and often presents in adolescence
How does osteochondritis dissecans present?
Poorly localised pain
swelling and knocking the knee
What is the management of osteochondritis dissecans?
Skeletally immature - conservative
Once mature - surgical options such as debribement or grafts/fixation
What causes the displacement of a NOF#?
What specific pain relief should be done in a NOF#?
Fascia ilaca block
What si greater trochanteric pain syndrome?
Degenerative damage to the ITB leading to inflamation of the trochanteric bursa
How is GTPS managed?
Physio to stretch ITB
What are the Ottowa rules at the knee?
Tender over the head of fibula
Isolated tenderness over the patella
Inability to flex the knee to 90 degrees
Inability to weight bear
What is the difference between true and pseudolocking of the knee?
True locking - where the knee is actually stuck in a position of flexion and needs wiggling side to side to get it moving again
Psuedolocking - limited by the pain and consequential muscle contraction
what is a morton neuroma?
Benign neuroma of the intermetatarsal plantar nerve
causes pain and numbnesss
Outline the antibacterial prophylaxis for limb surgery
- Co Amox 1.2 Iv at induction followed by 2 further doses 600mg at 8 hourly intervals
- If MRSA positive or previously positive then add 400mg IV tecoplanin
> Pen allergy give 400mg Teicoplanin and 120 mg IV gentamicin at induction
What is the protocol for open fractures and antibiotics?
Antibiotics should be given ASAP and within 3 hours of injury
- Co amox (or mero if pen allergy)
Photograph, initial debridement if large foreign materials, cover in warm saline gauze, reduce and splint if possible, pressure on circulation, tetanus booster (revaxis), involve specialist senior teams
what is osteomyletis?
Infection of the bone
How may osteomyelitis present?
Continuous throbbing pain in affected area
Often worse at night
swelling of surrounding soft tissue
Ehen does osteomyeltiis become chronic?
Present for greater than 4 weeks
What changes are present in chronci osteomyelitis?
Outline the management of osteomyelitis
If a collection, sequestrum (walling off of bone) or involucrum (new bone formation) is present it may not respond entirely to IV abx and may require surgical intervention – debridement, excision, irrigation, stabilisation and sometimes the dead space will need to be filled (blood acts as a perfect culture)
What are the types of cancer that most commonly metastasize to bone?
What is different about prostatic mets rather than the other types of cancer?
Prostate are often sclerotic whereas the others are lytic
What is the pathophysiology behind multiple myeloma?
B cell lymphoproliferative disorder of the bone marrow affecting plasma cells
How does multiple myeloma present?
- high Calcuim - increased bone turnover leads to increased Ca
- Renal failure - proliferation of plasma cells leads to increased levels of proteins, mainly immunoglobulins in the blood which increases viscosity of the blood and damages the kidney
- Anaemia - inhibition of erythropoesis in the bone marrow
- Bone pain - increased osteoclastic activity causing lytic lesions of the bone and pathological fractures
--> tends to affect the spine and ribs the most
What ccan be detected in the urine for multiple myeloma?
Bence jones proteins
How is the radial nerve tested?
Sensory - dorsal aspect of the thumb and index finger webspace
motor - wrist and finger extension
how is the median nerve tested?
Sensory - radial aspect of the index finger
Motor - thumb abduction against resistance with palm flat on the table
How do you test the ulna nerve? What is meant by Froment's test?
Sensory - ulnar aspect of tip of little finger
Motor function - Froment’s test (+ve for damage if thumb bends as unable to use adductor pollicis) or pushing the little fingers against each other testing the dorsal interossei
What is meralgia paraesthetica?
compression of the lateral cutaneous nerve causing burning pain in this region
can often result from weight gain
What is Charcot Marie Tooth disease?
Hereditary motor and sensory neuropathy characterised by motor and sensory loss
What are the signs and symptoms of Charcot Marie Tooth?
High arch of the foot and clawing of the toes
Muscle weakness in the feet, ankles , hands and legs
Lack of sensation in the arms and feet
Poor peripheral circulation
Muscle wasting in the lower legs - upside down champagne bottle appearance
What is Gullain Barre Syndrome?
autoimmune destruction of the peripheral nervous system typically causing muscle weakness accompanied by pain or sensory changes developing distally and spreading proximal over hours to weeks
Can compromise respiratory muscles requiring intubation and ventilation
What is a terrible traid at the elbow?
elbow dislocation, radial head fracture and coronoid fracture
What score is used to check for hypermobility?
What sites are most common for disk herniation?
L4/L5 or L5/S1
What is radiculopathy?
Dermatomal pain, weakness, loss of sensation and reduced reflexes