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SpC O&T + A&E > O&T: 10 Common Ortho Problems > Flashcards

O&T: 10 Common Ortho Problems Flashcards

1
Q
  1. De Quervain’s disease
A

See JC Surgery O&T: Upper Limb Painful Conditions

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2
Q
  1. Trigger finger
A

See JC Surgery O&T: Upper Limb Painful Conditions

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3
Q
  1. Mallet finger
A

Pathophysiology:
Commonly caused by sudden + acute forceful flexion of extended digit
—> Rupture of extensor tendon / Avulsion of the tendon +/- a small bony fragment
—> Loss of continuity of the extensor tendon over the distal finger joints
—> Hyperextension of the middle joint is due to unopposed central slip tension at PIP joint and joint laxity

Classification:
1. Close / Open
2. Bony / Tendinous

Clinical features:
1. Loss of active extension of DIP
2. Passive extension full
3. Mild hyper-extension of PIP

Investigations:
1. X-ray
- differentiate between bone or tendon
—> Avulsion fracture
—> Volar subluxation of distal phalanx (if present then stronger indication for surgery)

Management:
1. Conservative
- ***Mallet splint (6-8 weeks —> night splint)
2. Surgery
Indications:
- Open injury
- Cannot wear splint
- Bony mallet - avulsion fragment
—> Splinting (if <50%)
—> OR + Fixation (if >50% (volar subluxation of DP))
- Chronic injury (e.g. swan-neck deformity)
—> needs complex reconstruction
—> Reconstruction with tendon graft (tendon already contracted so cannot suture together)

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4
Q
  1. Ankylosing spondylitis
A

Investigations:
1. HLA B27
- AS: 90% +ve
- Normal population: 8% +ve

  1. X-ray
    SI joint:
    - Erosion (osteopenia, fuzziness)
    - Subchondral sclerosis
    - Fusion

Spine:
- Squaring of vertebra
- Marginal syndesmophytes
- Bamboo spine

Treatment:
- Refer to Rheumatology for medication
- Orthopedic surgeon for advanced disease

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5
Q
  1. Septic arthritis
A

See JC Surgery O&T: A 6 Month Old Child With Bone Pain And Fever

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6
Q
  1. Dry gangrene due to DM
A

P/E:
1. Wound
- discharge / pus
2. Extent of involvement
- Swelling
- Local tenderness
- Tenosynovitis
3. Peripheral vascular examination
4. Sensory examination

Treatment:
1. Admit the patient!!!
2. X-ray
3. Not just antibiotic
4. Need surgical debridement

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7
Q
  1. Ankle inversion injury
A

Potential injury:
Ligament:
1. **ATFL
2. **CFL (underneath peroneal tendon)
3. PTFL
4. Medial ligament injury
5. Syndesmosis (AITFL) sprain

Bone:
1. **Malleoli (lateral/ medial/ posterior)
2. **Base of 5th metatarsal
3. Tibial plafond (axial loading)
4. Anterior process of calcaneum
5. Lateral process of talus
6. Os trigonum

Tendon:
1. Superficial peroneal retinaculum (peroneal tendon dislocation)
2. Tendon rupture (peroneal tendon, tibialis posterior)

Others:
1. Dislocated ankle (fracture / dislocation)

P/E:
1. Bruising / Swelling

  1. Local tenderness (ligament / bone)
    - Feel distal fibula tip: go anterior: ATFL
    - Distal and posterior to fibula tip = CFL
    - Back of fibula tip = PTFL (rarely injured)
    - Identify the 5th metatarsal base (prominence at lateral foot): palpate for local tenderness
    - Syndesmosis: go a few cm above fibula tip between it and tibia
  2. Ankle laxity
    - **Anterior drawer test (for ATFL) —> Stabilize tibia, use hand to cup the heel and draw it forward
    - **    Talar tilt test (CFL) —> If CFL torn —> can open up lateral side
    - Grading: Sprain, Partial tear, Complete tear
    - Tear will produce bruising

Investigations:
1. X-ray
- Ankle AP + Mortise (internal rotation view of ankle to better see the syndesmosis) + Lateral view
- Foot AP + Oblique view to pick up common foot fractures
- Stress views (after acute phase)

Treatment:
1. Conservative
- RICE (Rest, ice, compression, elevation)
- Brace (inversion-control ankle brace)
- Analgesics
- Physiotherapy

  1. Surgery
    - Anatomical repair (rarely possible to suture damaged collateral ligament directly because the tendons are retracted)
    - Repair with augmentation with extensor retinaculum
    - Repair with augmentation/ internal brace
    - Tenodesis reconstruction with peroneal brevis
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8
Q
  1. Bone metastasis to hip
A

***Search for primary (PKBTL)

Investigations
X-ray pelvis:
- Radiolucency (i.e. osteolytic)
- Border ill-defined
- Periosteum elevated
- Pathological fracture

Search for primary:
1. X-ray
- local (whole femur to look for skipped lesions)
- CXR
2. Blood test
- Bone profile, infective parameter
3. CT, PET
4. Biopsy

Potential complications:
- Pain
- **Pathological fracture
- **Spinal cord compression
- **Hypercalcemia
(- **Marrow failure)

Treatment:
1. Treat cancer
- Analgesic, RT, Chemo

  1. Treat complications
    - **Pain: Analgesia
    - **    Spinal cord compression: Spine stabilisation + spinal cord decompression
    - **HyperCa: Bisphosphonate
    - **    Pathological fracture: Fixation —> **Mirel’s score >9 —> **Prophylactic fixation (Prophylactic IM nailing with screws)

***Mirel’s scoring system for risk of pathological fracture:
1. Site
2. Radiographic appearance
3. Bone width involved
4. Pain

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9
Q
  1. Necrotising fasciitis
A

Initial Treatment:
1. IV Ampicillin + Cloxacillin 1gm Q6H
2. Marking of erythema area

NF vs Cellulitis:
1. General condition
- NF: Toxic
- Cellulitis: Normal

  1. BP / Pulse
    - NF: Shock
    - Cellulitis: Normal
  2. Tenderness
    - NF: ++++, ***Pain out of proportion to sign
    - Cellulitis: +
  3. External appearance
    - NF: Generalised swelling
    - Cellulitis: Peau d’orange
  4. Subcutaneous aspiration
    - NF: Plenty of organism
    - Cellulitis: Scanty of organism

Investigations:
1. X-ray / USG —> No use
2. MRI
- high intensity T-2 signal at fascia (fascial edema), never been proven to be specific to NF
DO NOT let investigations delay treatment

Diagnosis:
1. **Subcutaneous aspiration
- identify organism but negative cannot R/O NF:
—> **21G needle / angiocath + syringe
—> ***subcutaneous plane
—> cut the cannular of angiocath into sterile bottle
—> rinse the needle with <2 ml NS
—> send to lab STAT x urgent smear

  1. Surgical findings
    - **dishwater pus
    - brownish SC fat
    - whitish fascia
    - **    thrombosis of small vessels
    - ***loss of tissue plane resistance

Treatment:
1. Surgical debridement
- life-saving procedure
- radical debridement within 24 hours of onset of symptom improves survival

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10
Q
  1. Wrist fracture
A

(From SC045)
Evaluation:
- Patient’s functional demand
- ***Neurological exam (median nerve)
- Fluoroscopy
- CT assessment

Classification:
A: Extraarticular (within width of joint) —> **Colles’ / Smith Fracture (Dorsal angulation, Dorsal displacement, Radial angulation, Radial displacement, Radial shortening)
B: “Partial” articular —> **Barton fracture
C: “Complete” articular

Problem:
- Changes in wrist mechanics may lead to arthrosis especially with intraarticular steps

Problems with acute displacement:
- Pain
- Unstable
- Nerve impingement (Median nerve)
- Loss of reduction
- Skin impingement
- **Tendon impingement (*EPL)

P/E:
1. Neurology
- **Carpal tunnel syndrome
- **EPL (due to decreased in nutrient supply after injury)

Investigations:
1. X-ray
Normal alignment:
- Coronal plane: **Radial Angle (RA) (Ulnar slant) 22o
- Sagittal plane: **Palmar Tilt (PT) (Volar inclination) 11o

Look for:
- **Malalignment (Dorsal angulation, Dorsal displacement, Radial angulation, Radial displacement)
- **Radial shortening
- ***Intra-articular fracture: step-off and gap (acceptable < 2mm)

Factors for treatment:
1. Fracture characteristics
2. Age

Treatment:
1. ***CR + POP
- if alignment not acceptable + immobilisation
—> Intra-articular fracture: long arm POP x3 weeks then short arm x3 weeks
—> Old patient: slab x 4-6 weeks
—> May need change of POP if decrease swelling
—> F/U X-ray

  1. ***OR + IF
    - poor alignment / sign of Intra-articular step/gap
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SpC O&T + A&E (8 decks)

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