Orthopaedic Clinical Questions Flashcards
(204 cards)
1
Q
What muscles attach to the coracoid process?
A
- Short head of biceps
- Pec minor
- Coracobrachialis
2
Q
Attachment and insertion of Biceps brachii
A
- LH = supraglenoid tubercle
- SH = coracoid process
- Insertion = radial tuberosity
3
Q
Boundaries of the lateral triangular space (triangular interval)
A
- Medial = long head triceps
- Lateral = humerus
- Superior = teres major
4
Q
What ways can the shoulder dislocate out of joint?
A
- Anterior = forced abduction and ER
- Posterior = forced adduction and IR
- Inferior = abduction of humeral head onto acromion
5
Q
List the methods of shoulder reduction that you know
A
- Kocher
- Hippocratic
- Milch
- Stimson
6
Q
What are two categories of shoulder dislocation?
A
- TUBS
- AMBRI/MDI
7
Q
XR view for shoulder dislocation
A
- AP
- Y-view
- Axillary
8
Q
List injuries associated with shoulder dislocation
A
- Bankart
- Bony Bankart
- Hill-Sachs
- Rotator cuff tear
- Axillary nerve injury
9
Q
What is a Bankart lesion
A
Avulsion of the anterior labrum and anterior band of IGHL
10
Q
XR sign of posterior dislocation
A
Lightbulb sign
11
Q
Indications for deltopectoral approach
A
- Proximal humerus ORIF
- Septic joint
- Shoulder arthroplasty
12
Q
Deltopectoral approach internervous plane
A
- Deltoid (axillary nerve)
- Pec major (medial and lateral pectoral nerve)
13
Q
Describe the deltopectoral approach
A
- Incision = 10-15cm down deltopectoral groove from coracoid
- Sup. dissection = blunt dissect through deltopectoral fascia, retract cephalic vein, retract deltoid laterally and pec major medially
- Deep dissection = retract conjoined tendon medially, incise fascia to reveal subscapularis, detach subscapularis from lesser tub, incise joint capsule
14
Q
Deltopectoral approach dangers
A
- Cephalic vein
- Musculocutaneous nerve (be wary when retracting conjoint tendon)
- Axillary nerve
- Anterior circumflex humeral artery
15
Q
Simple classification system for clavicle fractures
A
Allman classification:
- Middle 1/3rd
- Lateral 1/3rd
- Medial 1/3rd
16
Q
Describe the ligamentous anatomy around the clavicle
A
Medial:
- Costoclavicular (anterior and posterior)
- Interclavicular
Lateral:
- Coracoclavicular (Trapezoid is lateral, conoid is medial)
- Acromioclavicular
17
Q
Describe the deforming forces of the clavicle
A
- Medial superior force = sternocleidomastoid
- Lateral inferomedial force = pec major
- Lateral inferior force = weight of the arm through the coracoclavicular ligaments
18
Q
Clavicle fracture associated injuries
A
- Ipsilateral scapula fracture
- Scapulothoracic dislocation
- Floating shoulder
- Rib fracture
- Pneumothorax
- NV injury
19
Q
Clavicle fracture XR views
A
- AP
- 15 degree cephalic tilt (zanca view)
20
Q
Absolute indications for clavicular fracture operative management
A
- Skin tenting
- NV deficit
- Open fracture
- Floating shoulder
- Symptomatic nonunion
- Posteriorly displaced group 3 fractures
- Middle 1/3rd fractures with >2cm shortening
- Unstable group 2 fractures
21
Q
What is a floating shoulder?
A
Ipsilateral fractures of the clavicle and neck of the glenoid
22
Q
Should a figure of eight bandage be used?
A
Figure of eight bandages have been shown to give no benefit over conventional sling with respect to healing time/rates/alignment
23
Q
Complications of clavicle ORIF
A
- Hardware irritation
- Subclavian vessel injury
- Adhesive capsulitis
- Non-union
- Malunion
- Infection
24
Q
How would you test branches of the radial nerve?
A
- PIN = Wrist and MCP extension
- Superficial radial = dorsal 1st webscape
- Radial nerve proper = supination
25
What does the radial nerve supply before dividing at the elbow
- Triceps
- Anconeus
- ECRL
- Brachioradialis
(Three sensory branches - posterior cutaneous branch of the arm and forearm, lateral cutaneous nerve of the arm)
26
Common causes of radial nerve injury
- Midshaft humerus fracture
- Radial head fractures
- Crutch palsy
- PIN compression between supinator head
27
What muscles attach to the medial epicondyle
Superficial Forearm flexors:
- Pronator teres
- FCR
- Palmaris longus
- FDS
- FCU
28
What are the deep flexors of the forearm
- FDP
- FPL
- Pronator quadratus
29
Which nerves supply sensation to the skin of the forearm
- Dorsal = posterior cutaneous nerve (branch of radial)
- Medial = medial cutaneous nerve
- Lateral = lateral cutaneous nerve
30
How would you assess the median nerve?
```
Look:
- Thenar muscle wasting
- Ulnar deviation
Sensation:
- Thenar eminence (superficial branch)
- Volar aspect of index finger (true median)
Motor:
- AIN = 'OK' sign for FPL and FDP
- Median proper = thumb to ceiling to test APB
Special:
- Tinel's
- Phalen's
```
31
What does the median nerve supply in the hand
- L = 1st and 2nd lumbricals
- O = opponens pollicis
- A = abductor pollicis brevis
- F = flexor pollicis brevis
32
Median nerve root
- Medial cord (C6/7)
| - Lateral cord (C8/T1)
33
What does the recurrent motor branch of the median nerve supply
- O = opponens pollicis
- A = abductor pollicis brevis
- F = flexor pollicis brevis
34
What is the normal alignment of the wrist
- Radial inclination = 23 degs
- Radial height = 12mm
- Volar tilt = 12 degs
35
What alignment is considered acceptable in distal radius fractures
- <3mm loss in radial height
- <10 degree loss of volar tilt
- <5 degree change in radial inclination
36
Describe the FCR approach to the wrist
- Incision = along palpable FCR tendon 8 cm to wrist crease
- Sup. dissection = incise FCR sheath and retract tendon ulnarly to protect median nerve
- Deep dissection = retract FPL ulnarly, incise radial and distal borders of PQ and elevate from radius
37
Internervous plane for FCR approach to wrist
- FCR = median nerve
| - FPL = AIN
38
What are the borders of the anatomical snuffbox
- Radial border = APL tendon
- Ulnar border = EPL tendon
- Floor = radial styloid, scaphoid, trapezium, base of 1st met
- Roof = deep fascia
39
What are the contents of the anatomical snuffbox
- Radial artery
- Dorsal cutaneous branch of the radial nerve
- (Cephalic vein runs superiorly to deep fascia)
40
What is the blood supply to the scaphoid
- Dorsal carpal branch or radial
| - Superficial palmar branch of radial
41
Indications for Scaphoid ORIF
- Proximal pole fractures
- Displacement >1mm
- 15 degree humpback deformity
- Radiolunate angle >15 degs
- Intrascaphoid angle >35 degs
- Comminuted fractures
- Unstable vertical or oblique fractures
42
What did the SWIFFT trial show
Scaphoid waist fractures with <2mm displacement can be initially managed non-operatively
43
Complications of volar plating in distal radius fractures
- FPL tendon rupture
| - Screw penetration into radiocarpal joint or DRUJ
44
What did the UKDRAFFT trial show
Patient outcomes using PRWE questionnaire showed no difference in QALY gain between CRPP and volar plating
45
Examination findings associated with scaphoid fractures
- Snuffbox tendernes
- Scaphoid tubercle tenderness
- Pain on 1st metacarpal compression
- Pain on radial/ulnar deviation
- Wrist effusion
46
What features increase the risk of AVN in scaphoid fractures
- Displacement
- Comminution
- More proximal fractures
47
How long should scaphoid fractures be immobilised for?
At least 8 weeks or until evidence of bone healing
48
Complications of scaphoid fracture
- Scaphoid malunion
- Osteonecrosis
- Malunion
- Sunchondral bone penetration due to prominent hardware
- SNAC wrist
49
What injuries are associated with supracondylar fractures
- AIN = most common in extension-type
- Radial n. = most common in flexion type
- Ulnar n. = seen in flexion type
- Brachial artery injury/spasm
50
How do you calculate Baumann angle
Draw a line parallel to the longitudinal axis of the humeral shaft and a line along the lateral condylar physis as viewed on an AP image
51
What is the normal Baumann angle
70-75 degrees
52
How would you approach a pale and pulseless hand following supracondylar fracture
- Contact consultant, anaesthetist, CEPOD theatre
- Emergent reduction and CRPP is indicated
- If delay, perform reduction and splint in 40 degrees flexion in ED
(Omid et al)
53
How would you approach the pink and pulseless hand following supracondylar fracture
This requires urgent but not emergent surgery as the collateral circulation is supplying the hand.
54
What is the caveat to the approach to the pink and pulseless hand following supracondylar fracture
If there is concomitant AIN deficit then literature advocates emergent surgery (Mangat et al)
55
Would you request arterial studies such as angiogram in supracondylar fracture
No - no proven benefit
56
What are the complications of CRPP in supracondylar fracture
- Pin migration
- Infection
- Cubitus valgus/varus
- Recurvatum (over extendable elbow)
- Nerve palsy
- Vascular injury
- Volkmann ischaemic contracture
- Postoperative stiffness
57
How would you reduce a supracondylar fracture in theatre
Under image intensifier I would:
1. Correct deformity in the coronal plane by reducing valgus/varus deformity
2. Correct sagittal plane deformity by placing thumb on olecranon and fully flexing forearm
3. Rotational deformity
58
What size k-wires would you use for supracondylar CRPP
2mm
59
Ulnar nerve root origin
C8-T1 (medial cord)
60
What is the 'Ulnar paradox'?
An injury of the ulnar nerve at the elbow removes flexion produced by FDP therefore lessening the clawed appearance
61
What is the affect of ulnar nerve palsy at the wrist?
Claw hand - MCP joints are held in extension and the PIP and DIP joints are flexed due to loss of interossei
62
What are the common causes of ulnar nerve injury?
- Medial epicondyle injuries
- Wrist lacerations
- Cubital tunnel or Guyon's canal compression
63
Supracondylar CRPP follow-up plan
- Keep child in hospital until any NV symptoms show signs of resolving
- Bring back to clinic at 7 days for check XR and pin-site check
- Remove wires at 4 weeks
64
What are Kanavel's cardinal signs
- Fusiform swelling
- Tender flexor tendon distribution
- Pain on passive extension
- Finger held in flexion
65
Describe how FDS and FDP insert into the fingers
- The FDS tendon enters the flexor sheath and divides in half passing on either side of the FDP tendon to insert onto the anterior aspect of the middle phalanx
- The FDP tendon enters the flexor sheath and passes from deep to superficial through the two halves of FDS to insert onto the base of the distal phalanx
66
Why is flexor tendon sheath infection an emergency?
The flexor tendon sheath is an enclosed space that communicates with the palmar fascia. Infection can lead to tendon scarring or necrosis and loss of finger function.
67
Describe flexor tendon washout procedure
1. Ensure patient is appropriately marked and consented
2. Carry out the sign in the WHO checklist and position the patient supine with arm board
3. WHO time out
4. Prep and drape
5. Transverse incision over A1 and A5 pulleys
6. Send frank pus for MC&S
7. Irrigate flexor sheath with wide bore cannula with needle removed
8. Leave wounds open and apply non-adhesive dressing and splint hand
9. Post-operative I would keep them in a Bradford sling with broad antibiotic cover
10. Plan for wound check at 24 and 48 hours
68
What imaging is required for both bone paediatric forearm fracture?
- AP
- Lateral
- Orthogonal views of elbow and wrist
69
Describe the deforming forces present in mid-shaft forearm fractures
- Biceps and supinator flex and supinate proximal fragment
- Pronator teres and pronator quadratus pronate the distal fragment
- Brachioradialis dorsiflexes and radially deviates the distal fragment
70
Which muscles insert into the olecranon
- Triceps
| - Anconeus
71
Elbow injury 'terrible triad'
1. Elbow dislocation
2. Radial head fracture
3. Coronoid fracture
72
What are the static stabilisers of the elbow
- Ulnohumeral joint
- Anterior MCL bundle
- LCL complex
73
What are the dynamic stabilisers of the elbow
- Anconeus
- Brachialis
- Triceps
74
How would you approach a high energy trauma scenario
1. I would be concerned for significant intra-cranial/thoracic/abdominal/pelvic and long bone injury
2. The patient should be assessed in a resus bay by the trauma team
3. ATLS protocols should be adhered to - the patients c-spine should be immobilised. Airway, breathing, circulation and neurological status should be assessed and any life-threatening issues corrected
4. Following the primary survey I would take and AMPLES history and administer analgesia as required
5. The C-spine can be cleared as per BOAST guidelines and the patient log-rolled
6. I would perform a focused examination of the area of injury
75
How would you approach the 'C' part of the primary survey in a hypotensive trauma patient
1. Inspect for signs of blood loss
2. Measure CR, Pulse, BP
3. Large bore IV access
4. Warmed IV fluids
5. Major heamorrhage protocol if needed
6. FAST USS scan
76
How would you manage a dislocated native hip?
1. Inform registrar
2. Document clearly pre-reduction NV status
3. Consent patient for closed reduction of the hip
4. Ensure ED staff able to administer and monitor sedation
5. 3rd member required for counter-traction
6. Attempt Allis method of closed reduction (traction counter-traction with IR)
7. Post-reduction XR
8. Arrange post-reduction CT
9. Cricket pad splint and skin traction
77
How are native hip dislocations classified?
- Posterior (90%)
- Anterior (10%): two sub-types
a) superior (pubic)
b) inferior (obturator)
78
What other injuries are associated with posterior hip dislocation?
- Osteonecrosis
- Posterior acetabular wall fractures
- Femoral head fractures
- Sciatic nerve injuries
- Ipsilateral knee injuries
79
What imaging is required post-reduction?
CT - to look for femoral head fractures, loose bodies, acetabular fractures
80
What approach is used in open reduction of native hip dislocation?
- Posterior dislocation = posterior approach
| - Anterior dislocation = anterior (smith peterson approach)
81
Anterior (Smith-Peterson) approach internervous plane
- Sartorius (femoral nerve)
| - TFL (superior gluteal nerve)
82
Anterior approach dangers
- Lateral femoral cutaneous nerve
| - Femoral nerve
83
Anterolateral approach (Watson-Jones) internervous plane
- TFL (superior gluteal)
| - Gluteus medius (superior gluteal)
84
Dangers of anterolateral approach
- Femoral nerve (retractors)
| - Femoral artery (retractors)
85
Lateral (Hardinge) approach internervous plane
- Gluteus medius (superior gluteal)
| - Vastus lateralis (femoral)
86
Dangers of lateral approach
- Superior gluteal nerve
| - Femoral nerve
87
Dangers of posterior approach
- Sciatic nerve
| - Inferior gluteal artery
88
Nerve roots of the sciatic nerve
L4-S3
89
Describe the course of the sciatic nerve
1. L4-S3 root
2. Leaves pelvis via greater sciatic foramen below piriformis
3. Runs down back of ischium under gluteus maximus
4. Passes down posterior compartment on the posterior surface of adductor magnus to the popliteal fossa
5. Divides into tibial and common peroneal nerves in upper 1/3rd of popliteal fossa
90
Sciatic nerve sensory distribution
Posterior thigh and lateral aspect of lower leg
91
Clinical findings of complete sciatic nerve lesion
- Loss of all motor function in the leg except adduction, hip flexion, knee extension
- Loss of sensation over posterior thigh and lateral aspect of lower leg and sole and dorsum of foot
92
Clinical findings of common peroneal nerve lesion
- Loss of dorsiflexion (foot drop)
| - Loss of sensation over lateral aspect and dorsum of foot
93
Classification system of pelvic fractures
Young-Burgess:
- AP compression
- Lateral compression
- Vertical shear
94
How should you examine a suspected pelvic fracture
1. Inspect for:
- Limb shortening and ER
- Scrotal, labial, or perineal haematoma
Flank haematoma
- Perineal laceration
- Degloving injuries
2. Neurological:
- Rule out lumbosacral plexus injuries
- DRE
3. Urogenital exam
- Blood at urethral meatus
- High riding prostate
4. DRE and PV exam to rule out open fracture
95
How should you investigate suspected urological trauma in pelvic fractures?
- Catheter passes = the finding of blood-stain urine necessitates RETROGRADE CYSTOGRAM
- Catheter passage fails = remove catheter and perform RETROGRADE URETHROGRAM
96
How should open pelvic fractures be managed
1. Involve general surgeons and urologists
| 2. Treat as per open long bone fracture
97
How should a patient be managed post pelvic fixation
1. VTE prophylaxis
2. NWB to PWB at 6/52
3. Peri and post-op Abx
4. Repeat XR to check posterior complex
98
What XR views are helpful for imaging acetabular fractures
- Judet views
- Obturator views
- Iliac views
99
What is the lethal triad in trauma?
- Hypothermia
- Metabolic acidosis
- Coagulopathy
100
What are the indicators of occult hypoperfusion
- Lactate >2.5
- Temp <35
- pH <7.24
101
How would you classify open fractures
Gustillo-Anderson Classification:
1. Clean wound <1cm
2. 1-10cm without extensive tissue loss
3a. wound >10cm, extensive soft tissue damage, adequate tissue for coverage
3b. extensive periosteal stripping, wound requires soft tissue coverage
3c. vascular injury requiring vascular repair
102
How would you examine and initially manage an open fracture?
- Control active haemorrhage with direct pressure
- Assess neurovascular status and clearly document this. If concern over vascular injury then perform ABPI
- Handle wound only to remove gross contamination
- Photograph wound
- Cover wound with saline soaked gauze and occlusive film
- Commence IV antibiotics and tetanus prophylaxis
- Realign and splint the limb under conscious sedation and request orthogonal XRs
- Reassess NV status
103
Outline the timing of surgery in open fractures
- Immediately for highly contaminated wounds or when there is associated vascular compromise (compartment syndrome or arterial disruption)
- Within 12 hours of injury for other solitary high energy open fractures
- Within 24 hours for all other low energy open fractures
104
What are the complications of open fractures?
- Surgical site infection
- Osteomyelitis
- Neurovascular injury
- Compartment syndrome
105
What are the risks associated with carpal tunnel decompression
- Wound infection
- Metalwork infection
- Painful scar
- Damage to palmar cutaneous nerve
- Damage to median nerve
- Ongoing lack of function
- Ongoing symptoms
- Chronic pain
- Altered sensation over palm
- Bleeding
- Recurrence
106
Boundaries of the carpal tunnel
- Medial = pisiform, hamate
- Lateral = scaphoid, trapezium
- Roof = TCL
- Floor = proximal carpal row
107
Describe Gilula's arcs
Used to assess for the normal alignment of the carpus on PA film:
1st - smooth curve outlining the proximal convexities of the scaphoid, lunate and triquetrum
2nd - traces the distal concave surfaces of the same bones
3rd - follows the main proximal curvatures of the capitate and hamate
108
What is the follow up plan for a child who as undergone CRPP for supracondylar fracture
- Fracture clinic in 1 week for XR and pin site check
- Wire removal at 4 weeks
- Mobilisation
109
Describe the blood supply to the femoral head
- Medial circumflex artery (branch of profunda femoris) gives rise to retinacular vessels
- Artery of ligamentum teres from obturator artery
110
Describe the attachment of the capsule to the femur
- Anterior = intertrochanteric line
| - Posterior = femoral neck
111
What stabilises the hip joint?
- Bone
- Labrum
- Ligaments (iliofemoral, pubofemoral, ischiofemoral)
- Muscles
112
What score can be used to predict mortality in hip fracture patients?
Nottingham hip fracture score
113
What is the tip-apex distance?
Relates to the lag screw in the femoral head, it is the summation of the distance between the end of the screw and the apex of the femoral head on the AP and lateral radiographs
114
What are the diameters of a generic DHS guide wire and lag screw
- Guide wire = 2.5mm
| - Lag screw = 12.5mm
115
Name the flexors of the hip joint
- Iliopsoas
- Pectineus
- Sartorius
- Rectus femoris
116
What muscles abduct the hip
- TFL
- Gluteus medius
- Gluteus minimus
117
Approach to a wound ooze
- I would review the wound myself and ascertain the blood loss
- If day 1 post-op a compression bandage could be used
- If the ooze continues the worry is haematoma and deep infection
- I would discuss anticoagulation with the medical doctors and weight up the risks and benefits
118
Who should be offered total hip replacement in NOF fracture
According to NICE - displaced fracture in those who:
- Able to mobilise independently outdoors with one stick or less AND
- Are not cognitively impaired AND
- Are medically fit for anaesthesia and the procedure
119
What approach should be used for hemiarthroplasty and why
Anterolateral - less risk of instability compared to posterior
120
What are the 4 main AO principles for fracture treatment?
1. Anatomic reduction
2. Stable fixation
3. Preservation of blood supply
4. Early, active mobilisation
121
When does primary bone healing occur?
When there is absolute stability achieved through anatomical reduction and stable fixation
122
Describe primary bone healing
1. New vessels cross the fracture gap
2. Bone remodelling occurs with no callus formation
3. Cutting cones create cavities for new bone to fill
123
What are the phases of secondary bone healing
1. Inflammatory phase
2. Reparative phase
3. Remodelling phase
124
Describe the inflammatory phase of secondary bone healing
- Bleeding
- Clot
- Cytokines recruit inflammatory cells
- Cell proliferation peaks at day 7
125
Describe the reparative phase of secondary bone healing
- Fibroblasts lay down disordered matrix of type 2 collagen
- Chondrocytes mature
- Soft callus is formed
- Callus is mineralised by day 14
- Neovascularisation occurs
126
Describe the remodelling phase of secondary bone healing
- Can take 1-4 years
| - Converts woven bone to lamellar bone which has an internal structure ordered in response to load across it
127
What factors delay bone healing
```
Systemic:
- DM
- Vascular insufficiency
- Malnutrition
- Disorders of vitamin D, calcium or phosphate metabolism
- NSAIDs, steroids
Local:
- Infection
- Inadequate immobilisation
- Loss of local blood supply
```
128
How can you achieve absolute stability?
1. Lag screw with neutralisation plate
2. Buttress plate
3. Compression plate
4. Tension band plate
129
What is Perren's strain theory
Strain affects the type of tissue laid down vs non-union
- <2% = lamellar bone
- 2-5% = hard callus
- 5-10% = cartilage
- 10-100% = granulation tissue
- >100% = non-union
130
What is Wolf's law?
Bone will remodel according to the loads under which it is placed. Site of bone loading (compression) will lay down additional bone and sites of decreased loading (tension) will become less dense
131
What is the lead of a screw
The length travelled by the screw for each 360 degree turn
132
What is the pitch of a screw
The axial distance between adjacent threads
133
What is the effective thread depth of a screw
The difference between the core and thread diameter
134
What is cancellous bone
Spongy trabeculae network found typically in the axial skeleton
135
What is cortical bone
Dense outer layer of bone
136
What is the difference between cortical and cancellous screws
- Cortical = finer pitch and thread diameter, larger core diameter, high surface area
- Cancellous = coarser pitch and thread diameter, smaller core diameter
137
What is the purpose of a locking screw
Locks into the plate to create a fixed angle construct
138
What is the benefit of countersinking
- Increases the surface area of the screw head in contact with the near cortex - dissipate stress
- Less soft tissue irritation
139
What is the working length of a plate
- The distance between the 2 fixation points closest to the fracture on each end of the fracture
- Decreasing the working distance increases the stiffness of the construct
140
What is the difference between load-bearing and load-sharing plates
- Load-bearing = no force goes through the bone
| - Load-sharing = force is shared between plate and bone
141
How do you increase the stability of an ex-fix?
- Larger diameter pins (most important)
- Contact of ends of fracture
- Additional pins
- Decreased bone-to-rod distance
- Increase size or stacking of rods
- Pins in different planes
- Rods in different planes
142
What points should you include in the history for a potential pathological fracture
- B-symptoms
- Night pain
- Chest/prostate/breast/kidney/thyroid symptoms
143
What are the five most common primaries for bony mets?
- Renal
- Lung
- Prostate
- Thyroid
- Breast
144
What primaries produce sclerotic bony mets?
- Prostate
| - Breast
145
What is the commonest site of bony metastases?
- Spine
- Femur
- Humerus
146
How can you reduce the risk of fat embolism in prophylactic IM nailing of femoral mets?
Venting
147
How would you manage a patient in septic shock from prosthesis infection?
1. Abx and IVF immediately
2. Blood culture
3. Aspirate joint in theatre and washout
4. Chase sensitivities
148
How would you manage a septic patient from prosthesis infection?
1. Aspirate joint in theatre and washout
2. Abx and IVF
3. Chase sensitivities
149
How would you manage a stable patient with prosthesis infection?
1. Aspirate joint in theatre
2. Chase MC&S
3. DAIR Vs Revision Vs Abs
150
How do you manage acute vs. chronic arthroplasty infection
- Acute (<6 weeks) = no biofilm -> DAIR
| - Chronic = biofilm -> revision (1 or 2 stage)
151
How can the risk of prosthetic joint infection be reduced?
```
Patient Factors:
- Optimise medically e.g. DM
- Stop smoking
- Stop steroids
Operative Factors:
- ABx at induction
- MRSA swabs pre-op
- Laminar flow
- Sound wound closure
- Occlusive dressing for 14 days
- Shorter theatre and tourniquet time
- ABx loaded cement
- GIRFT
```
152
Who is most at risk of compartment syndrome?
- Young males (large muscle volume with unchanged fascia)
- 69% fractures (50% tibia)
- Bleeding disorders/anticoagulation
153
Causes of compartment syndrome
- Fractures
- Crush injuries
- Contusions
- Gunshot wounds
- Tight casts
- Burns
- Reperfusion
154
Signs of compartment syndrome
- Pain with passive stretch
- Paraesthesia and hypoaesthesia
- Paralysis
- Palpable swelling
- Absent peripheral pulses
155
Compartment syndrome differentials
- DVT
- Post-operative swelling/haematoma
- Cellulitis
- Oedema (more likely bilateral)
156
How would you perform compartment pressure testing?
- Within 5cm of fracture site
- Anterior = 1cm lateral to anterior border of tibia
- Lateral = anterior to posterior border of fibula
- Deep posterior = enter posterior to medial border of tibia
- Superficial posterior = mid-calf
157
How would you assess suspected compartment syndrome?
1. CCrISP
2. Focused history - PMH, blood thinners, last meal etc.
3. Focused examination - distal NV status
4. Assess response to passive stretch
5. If suspected I would remove all circumferential dressings and elevate limb
6. I would re-assess the patient in 30 minutes as per BOAST guidelines
7. I would inform my senior in the meantime
8. If any ambiguity I would check compartment pressures
158
Describe the incisions of a two-incision four-compartment fasciotomy
- Anterolateral = midway between fibula and crest of tibia over anterolateral muscular septum
- Medial = 2cm behind palpable posteromedial edge of tibia
159
What must you be wary of when making fasciotomy incisions?
- Anterolateral = superficial peroneal nerve
| - Medial = saphenous vein and nerve
160
Describe the compartments of the forearm
1. Volar:
- FCR
- Pronator teres
- FPL
- FDS
- FDP
- FCU
- Pronator quadratus
2. Mobile wad:
- Brachioradialis
- ECRL
- ECRB
3. Dorsal
- ECU
- Extensor digitorum
- Supinator
- EDM
161
How are knee dislocations classified following post-reduction vascular assessment?
- Those with definitive vascular deficit who need to go to theatre for exploration
- Those that definitely do not have a vascular deficit and need to be admitted for observation
- Those who might have a vascular deficit with either weak pulses or ABPI <0.9 who need to have an angiogram
162
How would you approach the management of a knee dislocation
1. ATLS - high energy trauma
2. Assuming this is an isolated injury I would take an AMPLES history and administer analgesia
3. I would perform a focused examination of the limb paying attention to skin integrity and NV status (I would make sure this is clearly documented)
4. I would update my registrar and request assistance with reduction
5. I would request a member of the ED staff assist with sedation
6. I would reduce the knee
7. Following reduction the knee should be splinted in 20 degrees of flexion and repeat XRs requested. I would reassess the NV status:
- Pulses
- Doppler
- ABPI
8. An MRI would need to be ordered prior to discharge
163
Potential nerve lesions in knee dislocation
- Tibial nerve
| - Common peroneal nerve (most common)
164
Effect of a tibial nerve lesion at the knee
- Loss of plantarflexion and inversion
| - Loss of sensation over sole of foot
165
Effect of common peroneal nerve lesion
- Loss of dorsiflexion and eversion
| - Loss of sensation over dorsum of foot and lateral leg
166
Outline the medial parapatellar approach to the knee
1. Intermuscular plane = rectus femoris (femoral nerve), vastus medialis (femoral nerve)
2. Midline incision from tibial tubercle to 5cm above superior pole of patellar
3. Sup. dissection = divide subcutaneous tissues and deepen dissection between vastus and quads tendon. Perform medial parapatellar arthrotomy
4. Dislocate the patellar and flip laterally. Flex to 90 degrees for full exposure
167
What are the dangers of the medial parapatellar approach to the knee
- Infrapatellar branch of the saphenous nerve
| - Skin necrosis
168
Differences between lunate and peri-lunate dislocation
- Lunate dislocation = lunate forced volar or dorsal while carpus remains aligned
- Peri-lunate dislocation = lunate stays in position while carpus dissociates
169
Describe Gilula's carpal arcs
```
1st = smooth curve outlining the proximal convexities of the scaphoid, lunate, triquetrum
2nd = traces the distal concave surfaces of the scaphoid, lunate, triquetrum
3rd = follows the main proximal curvatures of the capitate and hamate
```
170
What is the spilled teacup sign?
Abnormal volar displacement and tilt of a dislocated lunate on lateral XR. The convexity of the lunate is no longer in articulation with the distal radius while the concavity is no longer in articulation with the capitate.
171
What is the significance of the spilled teacup sign?
Helps differentiate between lunate dislocation and peri-lunate dislocation. In peri-lunate dislocation the cup does not spill forward.
172
How would you reduce a lunate dislocation?
1. Finger traps with elbow at 90 degrees of flexion and 10lbs of traction for 15 minutes
2. Apply in-line traction and manipulate lunate back into carpal row
173
Complications of lunate/peri-lunate dislocation
- Acute carpal tunnel syndrome
| - Transient ischaemia of the lunate
174
How do you definitively manage peri-lunate dislocation
Emergent closed reduction followed by open reduction, ligament repair, fixation, and possible carpal tunnel release
175
What are the risk factors for carpal tunnel syndrome
- Female sex
- Obesity
- Pregnancy
- Hypothyroidism
- Rheumatoid arthritis
- CKD
- Smoking and alcoholism
- Repetitive motion activities
176
Describe the variations in the recurrent motor branch of the median nerve
- 50% extraligamentous
- 30% subligamentous
- 20% transligamentous
177
Signs and symptoms of carpal tunnel syndrome
- Numbness and tingling in radial 3.5 digits
- Clumsiness
- Pain and paraesthesia at night
- Thenar atrophy
- Phallen test +ve
- Tinel test +ve
178
Carpal tunnel syndrome differential diagnosis
- AIN compressive neuropathy
- Pronator syndrome
- Ulnar tunnel syndrome
- Cervical radiculopathy
179
Outline the management of carpal tunnel syndrome
1. Non-operative:
- NSAIDs
- Night splint
- Activity modification
- Steroid injection
2. Operative:
- Carpal tunnel release
180
Describe how you would mark your incision for carpal tunnel release
1. Kaplan's cardinal line = hook of hamate to apex of 1st interdigital fold (demarcates superficial palmar arch)
2. Radial border of 4th digit
3. Distal wrist crease
181
Outline the procedure for carpal tunnel release
1. WHO sign in and position supine with hand table
2. Time out and prep and drape
3. Inject LA at the proximal wrist crease
4. Mark incision
5. Make incision to visualise proximal and distal ends to TCL
6. Expose TCL - be wary of the palmar cutaneous nerve. Palmaris brevis may need to be incised
7. Release TCL at the most ulnar aspect to avoid median nerve
8. Confirm release proximally and distally
9. Expose the median nerve to ensure decompression and check tunnel for masses
10. Close with 3-0 nylon to skin and soft dressing
11. Follow-up in two weeks
182
What are the complications of carpal tunnel release
- Incomplete release
- Progressive thenar atrophy due to injury of unrecognised transligamentous motor branch
- Lumbircal muscle weakness secondary to neuropraxia of proper palmar digital nerve to index finger
183
Outline the Weber classification of ankle fractures
- A = infrasyndesmotic
- B = transsyndesmotic
- C = suprasyndesmotic
184
Outline the Lauge-Hansen classification of ankle fractures
- Supination-Adduction = talofibular sprain/avulsion and vertical medial malleolus fracture
- Supination-ER = ATFL sprain, oblique fibular fracture, PTFL rupture, medial malleolus fracture
- Pronation-Abduction = medial malleolus transverse, ATFL sprain, transverse fib fracture at syndesmosis
- Pronation-ER = medial malleolus transverse fracture, ATFL sprain, spiral fibula above syndesmosis, posterior malleolus avulsion
185
Describe the Ottawa ankle rules
Ankle pain AND (malleolar tenderness OR inability to weight bear) = XR
186
Why might an ankle not reduce
Periosteum, deltoid ligament, soft tissue stuck in joint
187
Outline approach to management of ankle fracture
1. ATLS
2. Focused history - MOI, comorbidity (DM, renal failure), mobility, smoking
3. Focused examination of limb with clear documentation of NV status
4. Mortise and lateral ankle XR (proximal tib/fib view if maissoneuve fracture suspected - transverse malleolus fracture)
5. Reduction and splinting
6. Re-check NV status and check XR
7. Baseline bloods and ECG to assure readiness for theatre
8. VTE prophylaxis
9. Mark and consent
10. Follow up in 6 weeks
188
What is a mortise view of the ankle
20 degrees of IR to give better view of lateral joint space
189
How would you manage Weber A fractures
Moon boot
190
How would you manage Weber B fractures
- Weight bearing views
- Black boot
- Review in clinic in 1 week with XR
191
How would you manage unstable ankle fractures
- <60 = ORIF
| - >60 = if reduction maintained then CCC, if reduction lost then ORIF Vs hindfoot nail
192
Who would you offer a hindfoot nail
Unstable ankle fractures in those who are frail or diabetic. They allow FWB and avoid most wound complications.
193
Outline the lateral approach in ankle ORIF
- Incision = longitudinal along posterior border of fibula
- Sup. dissection = be wary of SSV and sural nerve, identify superficial peroneal nerve
- Deep dissection = incise periosteum over fracture
194
Dangers of lateral approach to ankle ORIF
- Sural nerve = runs posterior to lateral malleolus deep to peroneal tendon sheath
- Short saphenous vein
- Superficial peroneal nerve = crosses from posterior to anterior over the fibular shaft approx 10cm from tip of lateral malleolus
195
Outline the medial approach in ankle ORIF
- Incision = curved over medial malleolus
- Sup. dissection = identify and protect long saphenous vein and saphenous nerve and clear remaining tissue down to periosteum
- Deep dissection = expose fracture site, make small incision in anterior joint capsule, split fibres of deltoid ligament to allow hardware to sit on bone, visualise tib post tendon
196
Dangers of the medial approach to ankle ORIF
- Long saphenous vein
| - Saphenous nerve
197
What are you restoring with ankle ORIF
- Fibula length
- Talar shift
- Joint congruity
198
What are the landmarks for incision in the Henry's approach to the forearm
- Proximal = biceps tendon
| - Distal = radial styloid
199
What is the internervous plane for the Henry's approach
```
Distal:
- Brachioradialis = radial nerve
- FCR = median nerve
Proximal:
- Brachioradialis = radial nerve
- Pronator teres = median nerve
```
200
Describe the superfiicial dissection in Henry's approach
- Incise the deep fascia in line with the skin incision and develop plane between BR and FCR distally
- Move proximal to develop plane between PT and BR
- Identify the superficial radian nerve beneath BR and ligate the branches of the radial artery
201
Describe the deep dissection of the Henry's approach for the proximal 1/3rd
Proximal 1/3rd:
- Follow biceps tendon to its insertion on the bicipital tuberosity and incise the bursa
- BEWARE of the radial artery which runs on the ulna side of biceps tendon
- Fully supinate the forearm to displace the PIN radially to allow incision of the supinator along its broad insertion
202
Describe the deep dissection of the Henry's approach for the middle 1/3rd
Middle 1/3rd:
- Pronate the forearm to bring the insertion of pronator teres, along with the radial aspect of the radius, into view and detach it from the radius
- Retract PT medially
203
Describe the deep dissection of the Henry's approach for the distal 1/3rd
Distal 1/3rd:
- Partially supinate the forearm and dissect the periosteum off the lateral aspect of the distal radius, lateral to PQ and FPL
204
What are the dangers of the Henry's approach
- PIN - enters supinator beneath arcade of Frohse
- Supinator injury
- Superficial radial nerve
- Radial artery
