What are the causes of a scaphoid fracture?
FOOSH + sports + car accident
- FOOSH: fall onto an outstretched hand (axial compression of scaphoid w/ Wrist hyperextended & radially deviated)
- Contact sports: football
- Road traffic accidents: holding steering wheel
what are the symptoms & clinical exam presentations of a scaphoid fracture?
- Pain: radial aspect, base of thumb, anatomical snuffbox (between extensor pollicis longus & extensor pollicis brevis tendons)
- Clinical exam: tenderness at anatomical snuffbox, pain when telescoping/ longitudinal compression of thumb, loss grip & pinch strength of thumb
How is scaphoid fracture investigated & diagnosed?
- Clinical exams: longitudinal compression, loss of grip & strength at the thumb
- Plain film X-ray: anterior-posterior view, lateral views
- MRI: diagnosis but not used commonly in the UK
What is the initial & orthopedics management for scaphoid fractures?
- Futuro splint or standard below elbow backslab Refer to orthopedic
- Undisplaced fracture of scaphoid waist : cast for 6-8 weeks
- Displaced fracture of scaphoid waist: surgical fixation
- Proximal scaphoid pole fracture: surgical fixation
What are the 2 main complications of scaphoid fracture?
- Avascular necrosis of scaphoid due to blood supply interruption of dorsal carpal branch of radial artery
- Non-union: bone fails to heal-> pain & early osteoarthritis
where does carpal tunnel syndrome occur? (what other structure does the carpal tunnel contain)
- median nerve inside the carpal tunnel surrounded by carpal bones & flexor retinaculum
- tunnel also contain flexor pollicis longus (pollicis= thumb), the four flexor digitorum superficialis and the four flexor digitorum profundus
What are the causes of carpal tunnel syndrome?
- Compression of the median nerve in the carpal tunnel
- Pregnancy, oedema from HF, Rheumatoid arthritis can lead to bilateral carpal tunnel due to expansion of interstitial space with soft tissue growth or fluid (acromegaly due to bone growth as well but after age 50)
- Lunate fracture
What are the symptoms of carpal tunnel syndrome?
- Pain, tingling, pins and needle in thumb, index, middle finger
- Symptoms worse at night, patient wake up to “ shake their hand”
What are the examination findings of carpal tunnel? What clinical exam test is used?
- Wasting of thenar eminence (3 muscles supplied by median nerve)
- Tinel’s sign: tapping cause paraesthesia
What are the treatment options for carpal tunnel?
- 6 week conservative treatment for mild-moderate symptoms (ie, Corticosteroid injection, Wrist splints at night)
- Severe symptoms-> surgical decompression through flexor retinaculum division
What does the extensor mechanism of the knee consist of ? What injuries can occur?
quadriceps tendon-> patella-> patellar tendon-> tibial tuberosity
Patellar tendon and quadricep tendon can rupture
Patella can fracture and dislocate
What are the causes, age group, and symptoms of extensor mechanism rupture?
- Rapid Contractile force, trauma, heavy weight lifting
- Patellar in 40-, quadriceps in 40+
- can’t do straight leg raise w/ knee pain + effusion & palpable gap in extensor mechanism
What are the investigation & management for extensor mechanism rupture?
- X-ray showing patella sitting high in patella rupture & low in quadricep rupture
- Urgent surgery, physio to increase range of motion
What are the causes, target group for patella dislocation?
- high force impact or direct twist causing lateral dislocation
- Teenage females w/ high riding patella
(High chance of recurrence)
what are the symptoms and clinical exams for patella dislocation
- medial pain and haemarthrosis/ effusion
- lateral patella apprehension test is positive
What is the investigation & treatment for patella dislocation?
- X ray: lipo-haemathrosis
- Self-relocating when knee straightened or manually put it back
- splintage, aspirate for severe pain & swollen
What is the cause & symptom of dupuytren’s contracture
- Inherited (autosomal dominant)
- Secondary to cirrhosis, SE of phenytoin treatment
- Hyperplasia of palmar fascia forming nodules and cords progressing to contractures at the MCP and PIP joints (pinky & ring finger bend towards you)
How is Dupuytren’s contracture treated? (under what condition)
- if MCP cannot be straightened when they place palm flat on surface
- Surgery: removal of disease tissue or division of chords
What is the cause and presentation of ACL rupture?
- twisting/ internal rotation of tibia or Awkward landing
- Popping sound
- Knee pain w/ swelling from haemoarthrosis or effusion
What is the clinical diagnosis of ACL rupture? How is it done
- Anterior draw test: knee bent at 90, hands around tibia and pull it forward, check for anterior/ forward translation
- Lachman’s test: knee bent at 20-30, one hand hold femur, one hand hold tibia, check is there is anterior/ forward translation
(uninjured ACL should hold femur and tibia intact and NOT allow forward translation)
What is the treatment for ACL rupture?
What are the causes of medial and lateral collateral ligament rupture?
Medial: valgus stress and medial blow to the knee (close)-> Skiing
Lateral: varus/ lateral blow to knee (open), isolated LCL injury is uncommon
What is the treatment for medial and lateral collateral ligament rupture?
Medial: brace and physio
Lateral: reconstruction surgery
What are the 2 types of hip dislocation? What are the diff causes?
- Congenital: DDH (developmental dysplasia of the hip) due to shallow acetabulum from failure to develop
- Acquired dislocation: 90% is posterior dislocation, caused by trauma (car accident or fall from height), complication of total hip replacement or hemiarthroplasty
What is the DDH? what are the risk factors
- Dislocation of femoral head at rest or easily done with movement during prenatal period due to shallow acetabulum which affects the development of hip joint
- Female babies with breech presentation (feet and butt at the canal), and family history
What are the presentations of DDH
- Shorter limb on affected side causing unilateral limp
- Wobbling gait if both hip joints are affected
- Limited abduction at the hip
- Asymmetrical gluteal or thigh muscles
What are the clinical exams and investigations for DDH
- Clinical exams: barlow test (attempt to dislocate an articulated femoral head)
- Ultrasound of pelvis at 6 weeks if infants have breech presentation-> use X-ray for 4.5 months older for first-line
What is the treatment for DDH?
- Pavlik harness (dynamic flexion-abduction orthosis) in children 4-5 month
- Surgery in older children
What is the presentation of acquired hip dislocation?
- Posterior dislocation: leg is shortened, adducted, internally rotated
- Anterior dislocation: leg is abducted, externally rotated (no shortening)
What is the management for acquired hip dislocation?
- Reduction w/ in 4 hours to reduce risk of avascular necrosis
- Physiotherapy for long term
What are the complications of acquired hip dislocation?
- Sciatic nerve injury (reduced sensation in posterior thigh, leg and foot with impaired dorsiflexion of the foot/ foot drop)
- Femoral nerve injury
- Avascular necrosis
- Osteoarthritis and recurrent dislocation
What is the cause and typical patient profile of hip fractures?
- Low impact fall in elderly female with osteoporosis
- If young is due to high energy trauma
What are the symptoms and signs of hip fracture?
- Symptoms: hip/ groin pain, cannot weight bear
- Signs: shortened and externally rotated limb on effect side
What are the 2 locations where hip fracture can occur? What is the main difference
- Intracapsular: proximal to intertrochanteric line, involve femoral head and neck, may disrupt blood supply to the femoral head
- Extracapsular: distal to intertrochanteric, blood supply to the head of femur is intact
what is the main complication of intracapsular hip fracture
lost of blood supply to head of femoral head causing avascular necrosis by damaging medial femoral circumflex artery
What is the system used to classify hip fracture (mostly intracapsular type)?
- Type 1: stable fracture with impaction in valgus
- Type 2: complete fracture, undisplaced
- Type 3: displaced fracture with bony contact
- Type 4: complete bony disruption
(blood supply to femoral head usually lost in type 3 and 4)
What are the different types of extracapsular fracture of the hip? describe the locations
What is the investigation for hip fracture?
- X-ray: loss of shenton’s line might be present (difficult to see in femoral neck fracture)
- MRI or repeated X-ray in 10 days if not clear in original X-ray
How is intracapsular hip fracture treated?
- Undisplaced: internal fixation or hemiarthroplasty
- Displaced: total hip replacement (high functioning patient) or hemiarthroplasty (low functioning patient)
How is an extracapsular hip fracture treated?
Intertrochanteric/ non special type: dynamic hip screw/ DHS
Subtrochanteric, reverse oblique, transverse: IM nail
What is avascular necrosis of the hip? What are the causes
- Death of bone tissue secondary to loss of blood supply
- Long term oral steroid use, chemotherapy, trauma (fracture and dislocation), excess alcohol
What are the symptoms of avascular necrosis of the hip?
- Initially asymptomatic then causes pain in the affected join
- Groin pain, pain on weight bearing and movement
What is the investigation and results of avascular necrosis of the hip?
- X-ray: osteonecrosis
- MRI of the hip is diagnostic and can see changes in early stages
What are the X-ray results for avascular necrosis of the hip
- Osteonecrosis: crescent sign (subchondral fracture), sclerosis
- Osteopenia and microfractures are early signs
- Osteoarthritis will also develop in osteonecrosis (LOSS on X-ray)
How is avascular necrosis of the hip treated?
Reversible: no articular surface collapse (ie, no crescent sign on X-ray, early sings) treat with bisphosphate or core decompression
Irreversible: articular surface collapse present treat with joint replacement