Ortho Flashcards
Fracture Healing phases?
- Reactive Phases (injury - 48hr). Can be a haematoma from bleeding into the site, or from inflammation via cytokines and GF, vasoactive mediator release.
- Reparative Phase (2 days-2 weeks)
- Proliferation of osteoblasts + fibroblasts –> Cartilage + woven bone –> Callus
- Consolidation (endochondral ossification) of woven bone –> Lamellar bone. - Remodelling Phase (1 week-7yrs)
- Remodelling of lamellar bone to cope with mechanical forces applied to it (Wolff’s law: form follows function).
Which fractures heal in 3 weeks?
Closed, Paediatric, metaphyseal, upper limb: 3 weeks.
Which fracture heals in 6 weeks
- Adult
- Lower limb
- Diaphyseal
- Open
- Smoking slows healing time.
Types of a traumatic fracture?
Traumatic fracture
- Direct
- Indirect e.g FOOSH –> Clavicle fracture (fall on outstretched hand)
- Avulsion
What is a stress fracture?
- Bone fatigue due to repetitive strain
- E.g foot fractures in marathon runners
Can get it in in tibia.
Would be unwise to discharge therefore need an X-ray initially.
What is a pathological fracture?
Normal forces but diseased bone
- Local: tumours
- General: osteoporosis, Cushing’s, Paget’s.
Classifications of fractures?
Stress
Pathological
Traumatic
How does one describe a fracture?
Radiographs must be orthogonal: request AP and lat. films.
Need images of joints above and below fracture.
PAIDSS
- Demographic
= Pt details, date radiograph was taken
= Orientation and content of image - Pattern
- transverse
- Oblique = fracture lies obliquely to long axis of bone.
- Spiral = severe oblique fracture with rotation along long axis of bone.
- Multifragmentary
- Crush
- Greenstick - young, soft bone breaks (one cortex is ok, the other isn’t as it is more bendy)
- Avulsion - occurs when a fragment of bone tears away from the main mass of bone as a result of physical trauma.
Plastic deformity - stres on bone resulting in deformity without cortical disruption
Buckle Fracture - incomplete cortical disruption leading to bulging of the cortex.
- Anatomical location
- Diaphyseal, metaphyseal, epiphyseal - Intra/extra-articular
- Dislocation or subluxation (incomplete or partial dislocation) - Deformity (distal relative to proximal)
- Translation
- Angulation or tilt (normal axis of the bone is different) (dorsal, palmar). Distal portion of bone points off in a different direction.
- Rotation - Rotation of distal fracture fragment in relation to proximal part.
- Impaction (–> shortening) - Soft tissue
- Open or closed
- Neurovascular status
- Compartment syndrome - Specific classification type
- Salter Harris
- Garden
- Colles’, Smith’s, Monteggia
What are the 4 Rs for Fracture Management?
- Resuscitation
- Reduction
- Restriction
- Rehabilitation
What are the principles of Resuscitation?
ATLS Guidelines
- Trauma in primary survey: C-spine, chest and pelvis
- # usually assessed in 2dry survey
- Assess neurovascular sttus and look for dislocations
- Consider reduction and splinting before imaging
(decreased pain, bleeding, risk of neurovascular injury)
- X-ray once stable.
Urgent management of an open fracture (once which breaks the skin)?
- Analgesia: M+M (morphine)
- Assess: NV status, soft tissues, photograph
- Antisepsis: wound swab, copious irrigation, cover with betadine-soaked dressing
- Alignment: align fracture and splint
- Anti-tetanus: check status (booster lasts 10yrs)
- Antibiotics: co-amoxiclav or cefuroxime
Fracture is stabilised and an external fixator is often used in the first instance.
Management: Debridement and fixation in theatre and should be delayed until soft tissues have recovered. Should be done within 6hr of injury.
Long-term = Definitive skeletal and soft tissue reconstruction. Avoid internal fixation until thoroughly debrided.
Remember: Vascular impairment requires immediate surgery and restoration of circulation, ideally within 3-4 hrs. FOllow the sequence of shunting, temporary skeletal stabilisation and then vascular reconstruction.
Classification of open fractures?
Gustillo's 1. Wound <1cm in length 2. Wound >1cm with minimal soft tissue damage 3. Extensive soft tissue damage a - adequate soft tissue coverage b - inadequate soft tissue coverag c(implies vascular compromise) fos
Most dangerous complication of open #?
Clostridium perfringes
- Wound infection + gas gangrene
- ± shock and renal failure
- Management: debride, benpen + clindamycin
Principles of Reduction?
Displaced #s should be reduced
- Unless no effect on outcome (ribs)
- Aim for anatomical reduction (if articular surfaces involved - correct alignment)
What are the methods of reduction?
Manipulation/Closed reduction
- Under Local, regional or general anaesthetic
- Traction to disimpact
- Manipulation to align
Traction (generally pulling)
- Not typically used now
- Employed to overcome contration of large muscles e.g femorals #s
- Skeletal traction vs skin traction
Open reduction (and internal fixation)
- Accurate reduction vs risk of surgery
- Intra-articular #s
- open #s
- 2# in 1 limb
- Failed conservative management
- Bilateral identical fractures
Principle of restriction?
- Interfragmentary strain hypothesis dictates that tissue formed @ #site depends on strain it experiences
- Fixation –> decreased strain –> Bone formation
- Fixation also –> Decreased pain, increased stability, increased ability to function
Methods of restriction?
Non-rigid
- Slings
- Elastic supports
Plaster
- POP
- In first 24-48hrs use back-slab or split case due to risk of compartment syndrome
Functional bracing
- Joints free to move but bone shafts supported in cast segments
Continuous traction
- E.g collar-and-cuff
Ex-Fix
- Fragments held in position by pins/wires which are then connected to an external frame
- Intervention is away from field of injury.
- Useful in open fractures, burns, tissue loss to allow wound access and decrease infection risk
- Risk of pin-site infection
Internal fixation
- Pins, plates, screws, IM Nails
- Usually perfect anatomical alignment
- Increased stability
- Aid early mobilisation
Principles of Rehabilitation?
Immobility –> decreased muscle and bone mass, joint stiffness
- Need to maximise mobility of uninjured limbs
- Quick return to function decrease later morbidity
Methods of Rehabilitation?
Physiotherapy: Exercises to improve mobility
OT: Splints, mobility aids, home modification
Social services: meals on wheels, home help.
General complications of fractures?
- Tissue Damage
- Anaesthesia
- Prolonged Best Rest
Problems with tissue damage?
- Haemorrhage and shock
- Infection
- Muscle damage –> Rhabdomyolysis
Problems with anaesthesia?
- Anaphylaxis
- Damage to teeth
- Aspiration
Problems with bed rest?
- Chest infection
- UTI
- Bed sore and pressure sores
- DVT
- Decreased bone mineral density
Specific complications for fractures?
- Immediate
- Early
- Late
Immediate complications of fractures?
- Neurovascular damage
- Visceral damage
Early complications of fractures?
- Compartment syndrome
- Infection (worse if associated with metalwork)
- Fat embolism –> ARDS
Recent injury and physical signs that would be concordant with fat embolism syndrome. Normally within 3 days.
Triad = Hypoxaemia, neurological abnormalities, petechial rash.
Resp = Early persistent tachycardia, tachypnoea, dyspnoea hypoxia, pyrexia.
Derm: red/brown impalpable petechial rash. Subconjunctival and oral haemorrhage.
CNS - confusion + agitation. Retinal haemorrhage and intra-arterial fat globules on fundoscopy.
Management
- Prompt fixation of long bone fracutre
- Some debate vs medullary reaming in femoral shaft.
- DVT prophylaxis
- General supportive care.
Late complications with fractures?
- Problems with union
- AVN
- Growth disturbance
- Post-traumatic osteoarthritis
- Complex regional pain syndromes
- Myositis ossificans
Neurological complications of fractures?
- Severance is rare, stretching over bone edge commoner
- Seddon classification describes three types of injury?
Seddon classification of 3 neurological complications?
Neuropraxia - Temporary interruption of conduction w/o loss of axonal continuity
Axonotmesis
- Disruption of nerve axon -> distal Wallerian degeneration.
- Connective tissue framework of nerve preserved
- Regeneration occurs and recovery is possible
Neurotmesis
- Disruption of entire nerve fibre
- Surgery required and recovery not usually complete
Palsy as a result of anterior shoulder dislocation or humeral surgical neck?
Axillary Nerve damage –> Numb chevron and weak abduction
Check pulses and nerves.
Always do X-ray.
Palsy as a result of #humeral shaft?
Radial nerve –> Waiter’s tip (Erb’s Palsy)
Palsy as a result of elbow dislocation?
Ulnar nerve –> Claw Hand (Klumpke’s Palsy)
Palsy as a result of hip dislocation?
Sciatic Nerve –> Foot drop
Palsy as a result of #neck of fibula or knee dislocation?
Fibular Nerve –> Foot drop
Compartment syndrome pathophysiology?
- Osteofacial membranes divide limbs into separate compartments of muscle.
- Oedema following # –> increased the compartment pressure –> decreases venous drainage –> increased compartment pressure
- If compartment pressure > capillary pressure –> Ischaemia.
- Muscle infarction –>
- Rhabdomyolysis and ATN
- Fibrosis –> Volkman’s ischaemic contracture
Presentation of compartment syndrome?
Due to supracondylar fracture and tibial shaft fracture.
- Pain > clinical findings
- Pain on passive muscle stretching - passive ankle dorsiflexion
- Warm, erythematous, swollen limb
- Increased CRT and weak/absent peripheral pulses
- Remember presence of pulse does not rule out compartment syndrome.
Diagnosis
- Intracompartmental pressure measurement - Pressure excess of 20mmHG are abnormal and >40mmHG is diagnostic.
- Compartment syndrome will show nothing on x-ray
Management of compartment syndrome?
- Elevate limb
- Remove all bandages and split/remove cast
- Fasciotomy
Complications of fractures: problems with union?
Delayed union: union takes longer than expected?
Non-union: # fails to unite
Causative factors of malunion: 5 Is
Ischaemia: poor blood supply or AVN
Infection
Increased interfragmentary strain
Interposition of tissues between fragments
Intercurrent disease: e.g malignancy or malnutrition
Non-union classification?
- Hypertrophic: bone end is rounded, dense and sclerotic
- Atrophic: Bone looks osteopenic
Management for non-union?
Management
- optimise biology: infection, blood supply, bone graft, BMPs
- Optimise mechanics: ORIF
What is malunion?
healed in imperfect position
- Poor appearance and/or function
- Gunstock deformity (varus)
What is avascular necrosis?
- Death of bone due to deficient blood supply
- Sites: femoral head, scaphoid, talus
- Consequences = Soft + deformed bone –> pain, stiffness and OA
- X-ray shows sclerosis and deformity.
What is Myositis ossificans?
- Heterotopic ossification of muscles @ site of haematoma formation.
- Leads to restricted, painful movement
- Commonly affects the elbow and quadriceps
- Can be excised surgically
What is Pellegrini-Stieda disease?
- Form of MO
- Calcification of the superior attachment of MCL @ knee following traumatic injury
Complex Regional Pain Syndrome Type 1 (Reflex Sympathetic Dystrophy, Sudek’s Atrophy)
- Complex disorder of pain, sensory abnormalities, abnormal blood flow, sweating and trophic changes in superficial or deep tissues.
- No evidence of nerve injury
Causes of complex regional pain syndrome type 1?
- Injury: #s, carpal tunnel release, ops for Dupuytren’s contracture
- Zoster, MI, Idiopathic
Presentation of CRPS T1
- Wks - months after injury
- Not traumatised area that is affected: affects a neighbouring area
- Lancing pain hyeralgesia or allodynia
- Vasomotor: hot and sweaty or cold and cyanosed
- Skin: swollen or atrophic and shiny
- NM: weakness, hyper-reflexia, dystonia, contractures.
Management of CRPS
- Usually self-limiting
- Refer to pain team
- Amitryptilline, gabapentin
- Sympathetic nerve blocks can be tried.
CRPS Type II?
Causalgia
- Persistent pain following injury caused by nerve lesions.
Growth disturbances classification?
Salter-Harris Classification for growth plate injuries - In children
- S = Straight across (type 1) = physis (can be completely slipped.
- A = Above + across (type 2) = metaphysis and physis
- L = Lower (type 3) include joint. = physis and epiphysis
- T = Through (Type 4 )
- CRUSH = Type 5
Examples of a Salter Harris Type 1?
SUFE. Normal growth with good reduction (re duce = Bring back to normal).
Through physis
Examples of a Salter Harris Type 4?
Union across physis may interfere with bone growth
Examples of a Salter Harris Type 5?
Crush –> Physis injury –> Growth arrest
Epidemiology of hip fractures?
- 80/100,000
- 50% in >80 yrs old - It is a disease of old age
- F>M = 3:1
Pathophysiology of hip fracture?
Old = Osteoporosis with minor trauma (e.g fall) Young = Major trauma
Osteoporosis risk factors: age + SHATTERED..
- Steroids
- Hyper-parathyroidism
- Alcohol and Cigarettes
- Thin (BMI <22)
- Testosterone low
- Early Menopause
- Renal/Liver failure
- Erosive/inflammatory bone disease (RA, myeloma)
- Dietary Ca low/malabsorption
Presentation of hip fracture?
Anterior O/E: shortened leg and externally rotated
If internally rotated = posterior hip dislocation.
Key questions in a hip fracture history?
- Mechanism of injury
- Risk factors for osteoporosis/pathological fractures
- Premorbid mobility
- Premorbid independence
- Comorbid independence
- Comorbidities
- MMSE
Initial Management for hip fracture?
- Resuscitate: dehydration, hypothermia
- Analgesia: M+M (morphine/iliofascial block recommended and midazolam)
- Assess neurovascular status of limb
- Imaging: AP and lateral films
- Prep for theatre
If patient has clinical signs of hip fracture, do further imaging. MRI is first line recommended.
What does prepping for theatre entail?
ABCDEFG
- Inform Anaesthetist and book theatre
- Bloods: FBC, U+E, Clotting, X-mathc (2U)
- CXR
- DVT (prophylaxis: TEDS, LMWH)
- ECG
- Films: orthogonal X-rays
- Get Consent
Imaging for hip fracture?
- Ask for AP and lateral films
- Look @ Shenton’s lines
- Intra- and extra-capsular
- Displaced or non-displaced
- Osteopaenic
What are Shenton’s lines
- Imaginary curved line drawn along inferior border of superior pubic ramus and along inferomedial border of neck of femur.
- In the joint capsule (up to the neck) or outside. (extracapsular)
Key anatomy of the hip?
- Capsule attaches proximally to acetabular margin and distally to intertrochanteric line.
Blood supply to the femoral head?
- Retinacular vessels, in capsule, distal –> Proximal
- Intramedullary vessels
- Artery of ligamentum teres
What happens if the retinacular vessels are damaged?
Risk of AVN at the femoral head –> leads to pain, stiffness and OA.
Classification of a hip fracture?
- Intracapsular: Subcapital (junction of head and neck), transcervical, basicervical (base of femoral neck)
- Extracapsular: Intertrochanteric, subtronchanteric
Garden Classification of INTRACAPSULAR FRACTURES?
- Incomplete #, undisplaced
- Complete #, undisplaced
- Complete #, partially displaced
- Complete #, completely displaced
Surgical management of intracapsular Garden 1,2 #?
Painkillers - Iliofascial nerve block - reduced need for morphine or opioids.
ORIF with multiple cannulated screws.
Undisplaced fracture = internal fixation or hemiarthroplasty if unfit/major illness.
Surgical management intracapsular Garden 3, 4#?
<70: ORIF with screws. Follow- up in OPD and do arthroplasty if AVN develops (in 30%).
(young people need hip for long time - therefore hip prosthesis require one or more revisions). Follow up for AVN.
Independently mobile, does not use more than a stick.
>70: Total hip replacement
If major/immobile.
>70: Hemiarthroplasty (can be total too):
- Mobilises: cemented Thompson’s - mainly cemented.
- Non-mobiliser: non-cemented Austin Moore.
Consider Bipolar vs Unipolar (swivelling of head in bipolar).
Post surgery
- Full weight bearing immediately post-op. This reduces length of stay and complications associated with prolonged immobility.
What is a hemiarthroplasty?
Placing half the joint, not the internal capsule.
Management of extracapsular hip fracture?
If intertrochanteric
- ORIF with Dynamic Hip Screws
- For unstable inter-trochanteric fracture can use intra-medullary nails (cephalomedullary).
Subtronchanteric = Intramedullary nail.
What is a dynamic hip screw?
- Large cancellous lag screw that glides freely in a metal sleeve.
- Sleeve attached to a plate which is fixed to the lateral femoral cortex.
Discharge of hip fracture patients?
- Involves OT and physios
- Discharge when mobilisation and social circumstances permit
Specific complications with hip fracture?
- AVN of femoral head in displaced #s due to damage to the retinacular vessels.
- Non/mal-union (10-30%)
- Infection
- Osteoarthritis
Prognosis of a hip fracture?
30% mortality @ 1 yr
50% never regain pre-morbid functioning
>10% unable to return to premorbid residence
- Majority will have some residual pain or disability
Distal Forearm fracture examples?
- Colles’ Fracture
- Smith’s
- Barton’s Fracture
Clinical features of Colles’ fracture?
- Fall onto an outstretched hand
- Most common in elderly females with osteoporosis
- Dinner fork deformity
Radiographic features of a Colles’ Fracture?
- Extra-articular # of distal radius (w/i 1.5 inches of joint)
- Dorsal displacement of distal fragment
- Dorsal angulation of distal fracture 11 degrees volar tilt
- Decreased radial height (norm = 11mm )
- Decreased radial inclination (norm = 22 deg)
= ± avulsion of ulnar styloid
± impaction
Specific management of a Colles’ Fracture?
- Examine for neurovascular injuries as median and radial artery lie close
- if much displacement –> reduction
(under haematoma block, IV regional anaesthesia (Bier’s block) or GA. Disimpact and correct angulation. Position: ulnar deviation + some wrist flexion - Apply dorsal backslab: provide 3-point pressure. When you want to prevent flexion or extension.
- Repeat X-ray
- If comminuted, intra-articular or re-displaced: Surgical fixation with ex-fix, Kirschner-wires or ORIF and plates.
This is a significant fracture at high velocity therefore will need ORIF.
Colles Fracture - Re X-ray - Satisfactory position?
No: Ortho review and consider MUA ± K wires
Yes: home with # f/up within 48hr for completion of POP.
Specific complications with Colles Fracture?
- Median N.injury
- Frozen Shoulder/adhesive capsulitis
- Tendon Rupture: Esp EPL (extensor pollux longus)
- Carpal Tunnel Syndrome
- Mal/non-union
- Complex regional pain atrophy
Anatomy of the hand nerves
- Median Nerve THUMB
- Ulnar Nerve (Little finger)
What is a Smith’s Fracture?
- Fall on back of flexed wrist
- Fracture of distal radium with volar displacement and angulation of distal fragent
- Reduce to restore anatomy and POP for 6 weeks
What is a Barton’s Fracture?
- Oblique intra-articular # involving the dorsal aspect of the distal radius and dislocation of radio-carpal joint. Smiths/Colles with radiocarpal.
- Reverse Barton’s Involves the volar aspect of the radius
Clinical features of a scaphoid fracture?
- FOOSH
- Pain in anatomical snuffbox
- Pain on telescoping the thumb
Specific management of a scaphoid fracture?
- Request scaphoid X-ray view
- If clinical history and exam suggest a scaphoid #, it should initially be treated even if the x-ray is normal
- # may become apparent after 10 days due to localised decalcification
- Therefore immobilise straight away.
- Place wrist in scaphoid plaster (beer glass position)
- Can use futura splint.
- If initial x-ray is negative, pt return to # clinic after 1- days for re-xray.
- # visible –> Plaster for 6 weeks
- No visible # but clinically tender –> plaster for 2 weeks.
- # not visible and not clinically tender –> no plaster
Specific complications of scaphoid fracture?
- Main risk of AVN of the scaphoid as blood supply runs distal to proximal. Dorsal carpal branch of the radial artery is the main neurovascular structure that is compromised in a scaphoid fracture.
- -> Stiffness and pain at the wrist.
Bones of the hand distal to proximal
Distal Phalanx Middle Phalanx Proximal Phalanx Metacarpal Carpal bones
Mnemonic for carpal bones?
Some - Scaphoid Lovers - Lunate Try - Triquetrum Positions - Pisiform That - Trapezium They - Trapezoid Can't - Capitate Handle - Hamate
Radial and Ulna Shaft Fractures Classification?
Monteggia
- # of proximal 3rd of ulnar shaft. (ulnar
- Anterior dislocation of radial head at capitellum
- May lead to a palsy of deep branch of radial nerve - weak finger extension but no sensory loss.
Galleazzi
- Fracture of radial shaft between mid and dital 3rd.
- Dislocation of distal radio-ulnar joint.
GRUsome MURder
G-aleazzi R-adius fracture, ULnar radial dislocation
Monteggia Ulnar fracture, radial dislocation
Normal radial head fracture - usually caused by fal on outstretched hand. Marked local tenderness over head of radius, impaired movement at the elbow, sharp pain at the lateral side of the elbow and sharp pain at the lateral side of the elbows on pronation and supination.
Radial head subluxation
- during pulling injuries.
- Signs are limited supination and extension of elbow.
- Managed with reduction of radial head into position by passive supination of the elbow joint at 90 degrees.
Management of Radial and ulnar shaft fractures?
- Unstable fractures
Adults: ORIF
Children: MUA + above elbow plaster - Fractures of forearm should be plastered in most stable position
Proximal #: Supination (S for Sky)
Distal #: pronation
Mid-shaft: Neutral
Classification of a shoulder dislocation?
Anterior
Posterior
What is an anterior shoulder dislocation?
- 95% of shoulder dislocation
- Direct trauma of falling on hand
- Humeral head dislocated anterio-inferiorly.
What is a posterior shoulder dislocation?
- Caused by direct trauma or muscle contraction (seen in epileptics)
Associated lesions with shoulder dislocation?
Bankart lesion
- Damage to anteroinferior glenoid labrum . Leads to a glenohumeral dislocation.
- See on x-ray displacement of the glenoid labrum
- Usually due to recurrent dislocation and may need to be surgically repaired.
Hill-Sach’s Lesion at top cos hill.
- Cortical depression in the posterolateral part of the humeral head following impaction against the fleniod rim during anterior dislocation.
- When the humerus is driven from the glenoid cavity, its relatively soft head impacts against the anterior edge of the glenoid. The result is a divot or flattening in the posterolateral aspect of the humeral head, usually opposite the coracoid process.
What is the presentation of shoulder dislocation?
- Shoulder contour lost :appears square
- Bulge in infraclavicular fossa: humeral head
- Deltoid is flat.
- Arm supported in opposite hand
- Severe pain
Specific management of a shoulder dislocation?
- Assess for neurovascular deficit: do this by assessing the ‘chevron’ area of the shoulder for axillary nerve damage.
- DO an X-ray: AP and transcapular.
- Reduction under sedation (e.g propafol)
1) Hippocratic: longitudinal traction with arm in 30 degrees abduction and counter traction at the axilla.
2) Kocher’s: External rotation of adducted arm, anterior movement, internal rotation. - Rest arm in sling for 3-4 weeks
- Physio
Posterior dislocation
- Rare, caused by seizure or electrocution
- Lightbulb sign on X-ray
- Refer to orthopaedic surgeons.
Why is an Transcapular X-ray good?
It is a pertinent projection to assess suspected dislocations, scapula fractures, and degenerative changes.
Complications of shoulder dislocations?
- Recurrent Dislocation - 90% have traumatic dislocations in less than 20 yrs.
- Axillary N.injury.
Recurrent Shoulder Instability management?
TUBS: Traumatic Unilateral dislocations with a Bankart Lesion often require surgery.
- Surgery involves a Bankart Repair.
AMBRI: Atraumatic Multidirectional Bilateral shoulder dislocation is treated with Rehabilitation, but may require inferior capsular shift.
What is painful arc/Impingement syndrome?
- Entrapment of supraspinatus tendon and subacromial bursa between acromion and greater tuberosity of humerus
–> Subacromial bursitits and or supraspinatous tendonitis.
Anatomy of the shoulder posterior muscles?
- Supraspinatus
- Infraspinatus
- Teres Minor
Anatomy of shoulder anterior
- Supraspinatus
- Subscapularis
- Infraspinatus
Rotator cuff muscles?
- Supraspinatus - Abducts to humerus. On top of your shoulder and runs parallel to your deltoid.
- Subscapularis - Internally rotates the humerus. Medially.
- Infraspinatus - Externally rotates the shoulder joint.Rotates arm laterally.
- Teres Minor - External Rotation. Adducts and rotates laterally.
Function of the rotator cuff?
Maintaining stability of the glenohumeral joint. Hold the cuff in the glenoid fossa of the scapula.
Presentation of impingement syndrome?
Painful arc: 60-120
Weakness and decreased ROM
+ve Hawkin’s Test
Investigations for impingement syndrome?
- Plain X-ray: Bony spurs?
- US
- MRI arthrogram
Management for impingement syndrome?
- Conservatively: Rest and Physiotherapy
- Medical: NSAIDS/Steroid injections
- Surgical: Acrthroscopic acromioplasty.
Differentials for painful arc?
- Impingement
- Supraspinatous tear or partial tear
- AC joint OA.
Frozen shoulder presentation?
- Progressive decreased active and passive ROM (range of movement)
- Decreased external rotation <30
- Decreased abduction <90
- Shoulder pain especially at night (unable to lie on painful side)
Tendonitis?
- Inflammation as muscles pass through the subacromial space
- Symptoms: pain decreased ROM, weakness
Diagnosis: clinical
Treatment :rest, physiotherapy, steroids, surgery
Causes of frozen shoulder presentation?
- May be due to trauma in the elderly
- Associated with T2DM
Management of a frozen shoulder?
- Conservative: rest, physio
- Medical: NSAIDS, Subacromial bursa steroid ± LA injection.
What is a rotator cuff tear?
- 2ndry to degen or sudden jolt or impingement syndrome.
- A partial tear presents with painful arc
- Complete tear
: Passive movement full range
Shoulder tip pain
Cannot abduct the arm
After passive motion may be able to abduct to 90, then drop, drop arm sign.
Supracondylar Fractures of the Humerus presentation?
Common in children after FOOSH
Elbow very swollen and held semi-flexed.
Sharp edge of proximal humerus may injure brachial artery which lies anterior to it.
Classification of supracondylar fracture of the humerus?
Extension
- Distal fragment displaces posteriorly
Type 1: non-displaced
Type 2: anglated with intact posterior cortex
Type 3: Displaced with no cortical contact.
Flexion
- Less common
- Distal fragment displaces anteriorly
Specific management of SC # Humerus?
- Ensure there is no neurovascular damage
(if the radial pulse is absent or there is damage to a brachial artery, take to theatre for open reduction + on-table angiogram - Median nerve is also vulnerable
Restore anatomy
- No displacement –> flex the arm as fully as possible and apply a collar and cuff for 3 weeks –> triceps acts as sling to stabilise fragment
- Displacement –> MUA + Fixation with K-wires + collar and cuff with arm flexed for 3 weeks.
Specific complications for supracondylar fractures of the humurus?
Neurovascular injury?
- Brachial artery
- Radial nerve
- Median nerve esp anterior interosseous branch
(Supplies deep forearm flexors (FPL, Lateral half of FDP and pronator quadratus).
Compartment syndrome
- Monitor closely during the first 24hrs
- Pain on passive extension of the fingers (stretches flexor compartment) is earl sign
- Mx: try extension of elbow, surgical management may be needed.
- Volkmann’s ischaemic contracture can result –> fibrosis of flexors –> claw hand.
Gunstock deformity
- Valgus, varus and rotiational deformities in the coronal plane do not remodel and –> cubitus varus.
- Cubitus varus deformity is referred to as a gunstock deformity.
Femoral and Tibial Fractures management?
- Resuscitation and management of life-threatening injuries first.
- X-match
Tibial #: 2 units
Femoral #: 4 units - Assess neurovascular status: esp distal pulses.
- If open
Abx and ATT
Take to theatre urgently for debridement, washout and stabilisation - Fixation methods
Intramedullary nail
Ex-fix
Plates and screws
MUA with fixed traction for 3-4 months.
Specific complications of femoral and tibial fractures?
- Hypovolaemic shock
- Neurovascular
: SFA: swellign and check pulses
Sciatic nerve - Compartment syndrome
- Respiratory complications
Fat Embolism
ARDS
Pneumonia
Ankle Injuries - Ligament strain?
- Typically twisting inversion injury
- Strains anterior talofibular part of lateral collateral ligament
- Medial deltoid ligament strains are rare
- May be associated with malleolar avulsion #s
Management - RICE (Rest, ice, compression, elevation.
NSAIDS
Ankle fracture - Ottawa ankle rules?
X-ray ankle if pain in malleolar zone + in any of:
- Tenderness along distal 6cm of posterior tib/fib including posterior tip of malleoli.
- Medial or Lateral malleolus, Base of the 5th metatarsal, Navicular
- Bony tenderness at the medial malleolar zone
- INability to walk four weight bearing steps immediately after the injury and in an emergency department.
Bones of the ankle?
Below TIbia
- Talus
- Navicular
- Cuneiform Bones
- Metatarsal bones
- Phalanges
Fibula
- Calcaneus
- Cuboid
Weber Classifications for ankle fractures?
- Relation to fibula # to the joint line. Below the level of the tibiofibular syndesmosis.
- A: below the joint line
- B: at the joint line
- C: above the joint line
Weber’s B and C represent possible injury to the syndesmotic ligaments between tibia and fib –> instability.
Modified Weber?
- A = Infra-syndesmotic or below syndesmosis
- B = Trans-syndesmotic or level of syndesmosis
- C = Supra-syndesmotic
Management of Weber A?
All fractures should be promptly reduced to remove pressure on overlying skin + subsequent necrosis. VERY IMPORTANT.
- Boot or below-knee POP. Use an Below knee POP once radiological union is achieved.
Management of non-displaced Weber B/C
- Below-knee POP
Management of displaced Weber B/C?
- Closed reduction and POP if anatomical reduction achieved
- ORIF if closed reduction fails. If these is disruption of the tibio-fibular syndesmosis the surgical repair is warranted.
This is very important initial management. If displaced must reduce. Once reduced it can then be classified.
Diagnostic factors of an ankle fracture?
- Pop heard on fall
- Ankle deformity
- Tenderness of proximal fibula
- Inability to weight-bear
- Medial or lateral malleolus swollen and tender to palpation
Other types of classifications of ankle injuries?
Displaced vs undisplaced Talar shift vs no talar shift Reducible vs non-reducible Open vs closed bimalleolar vs trimalleolar
Knee injury history and presentation?
Knee Swelling
- If immediate = haemarthrosis = # or torn cruciates
- Overnight = effusion = meniscus or other ligaments
Pain/tenderness
- Joint line = meniscal
- Med/lateral margins = collateral ligaments
Locking: meniscal tear –> mechanical obstruction
Giving way: instability following ligament injury.
Anatomy of the knee?
Quadriceps -
- Rectus femoris
- Vastus lateralis
- Vastus medialis
- Vastus Intermedius
Above - Femur with patella. Within the knee - Lateral collateral ligament - Medial collateral ligament - ACL from front (injured in twisting sports) - PCL from back (hyperextension)
Lateral meniscus and medial meniscus
Fibula and tibia.
ACL injury definition
- Occurs as a result of acute non-contact deceleration injury,
- forceful hyperextension,
- excessive rotational forces about knee
ACL history?
- Acute trauma
- Using spikes
- Audible pop
- Rapid knee swelling
- Sensation of knee instability
- Pain
- Most accurate = Positive Lachman’s test - Lifting up.
Management of ACL?
Sedentary patients?
- Protected weight bearing, rest, ice, compression, elevation. medicine (PRICEM)
- Physio to strengthen quads and hamstring
- Moderate intensity demands?
Formal physiotherapy + customised bracing - High intensity
Bone-patellar tendon-bone autograft.
Hamstring tendon grafts (bundling/augmentation and tunnelling approaches).
What is the unhappy triad of O’Donoghue
- An injury of the ACL, PCL and lateral meniscus/medial meniscus.
- Pain in affected knee
- Stiffness + swelling
- Locking of knee
- Instability of knee
= Injury due to lateral force on knee whilst fixed on the ground. - Pivot Shift mechanism
Management of acutely injured knee?
- Full examination of acutely swollen knee after injury is hard
- Take x-ray to ensure no #s
Fluid level indicates a lipohaemarthrosis and indicates either a # or torn cruciate. - If no # –> RICE + later re-exam for pathology
- If meniscal or cruciate injury suspected –> MRI
Knee Arthroscopy?
Direct vision of inside of knee joint by arthroscope.
Can examine knee under anaesthesia (decreased muscle tone)
- Meniscal tears can be trimmed or repaired/suturing
Osteoarthritis definition?
Degenerative joint disorder in which there are progressive loss of hyaline cartilage and new bone formation at the joint surface and its margin
OA Aetiology/Risk Factor?
- Age (80% >75yrs)
- Obesity
- Female gender
- Joint abnormality
Classifications of OA?
Primary: no underlying cause
Secondary: due to obesity, joint abnormality/damage, rheumatoid arthritis, gout.
Symptoms of osteoarthritis?
- Affects: Knees, hips, DIPs, PIPs, thumb CMC. (carpometacarpal). Joint above CMC is the MCP
- Pain: Worse with movement, background rest/night pain, worse at the END of the day.
- Stiffness: especially after rest, lasts around 30 mins (e.g AM)
- Deformity
- Decreased Range of Movement.
Which joint of the hand does osteoarthritis spare?
MCP. Involves the PIP and DIP
OA Signs in the hand?
- B(P)ouchards (prox) and Heberdens (dips) (distal).
- thumb CMC squaring
- Fixed flexion deformity (knee)
History in OA
- Pain severity, night pain
- Walking distance
- Analgesic requirements
- ADLs and social circumstances
- Co-morbidities
- Underlying causes: trauma, infection, congenital.
Pathophysiology of Osteoarthritis?
- Softening of articular cartilage –> Fraying and fissuring of smooth surface –> underlying bone exposure.
- Subchondral bone becomes sclerotic with cysts. (fluid-filled hole).
- Proliferation and ossification of cartilage in unstressed areas –> Osteophytes.
Differential for OA?
- Septic Arthritis
- Crystal Arthropathies
- Trauma
- Rheumatoid arthritis
- Psoriatic Arthritis
X-ray changes of osteoarthritis?
LOSSD
Loss of joint spaces Osteophytes Subchondral sclerosis Subchondral cysts Deformity
Bloods in OA?
- CRP may be mildly elevated
- Ca, Po4 and ALP all normal
Management of OA?
MDT - GP, Physio, OT, Dietician, Orthopod
Conservative:
- Lifestyle: decreased wt, increased exercise
- Physio: muscle strengthening/quads strengthing
- OT: walking aids, supportive footwear, home mods.
Medical
- Analgesia
local topical: Capsaicin topical, methylsalicylate, diclofenac
Then add Paracetamol
NSAIDS: eg arthrotec (diclofenac + misoprostol)
Tramadol
Joint injections: local anaesthetic and steroids
If persistent pain despite multiple treatment modalities or with severe disability
Surgical
- Arthroscopic washout (not recommended)
Mainly knees
trim cartilage
remove loose bodies
- Realignment osteotomy
Small area of bone cut out
useful in younger pts with medial knee OA
High tibilar valgus osteotomy redistributes weight.
- Arthroplasty: replacement
