Orthopaedics Flashcards
(22 cards)
Describe the anatomy surrounding the bone physis (growth plate).
- physis: growth plate
- epiphysis: distal to physis
- metaphysis: proximal to the physis
- diaphysis: the long shaft beyond the physis
Name the nerves of the upper limb and their nerve roots.
3 Musketeers Assassinated 5 Rats, 5 Mice, and 2 Unicorns
- Musculocutaneous (C5-8)
- Axillary (C5-6)
- Median (C5-T1)
- Radial (C5-T1)
- Ulnar (C8-T1)
Describe the sensory distribution of the median, ulnar, and radial nerves.
- median: lateral 3.5 fingers (including the thumb) and lateral palm; only tips of these fingers posteriorly
- ulnar: medial 1.5 fingers both anterior and posterior
- radial: posterior arm and posterolateral aspect of hand
Describe the motor actions of the median, ulnar, and radial nerves.
- median: pronation and flexion of the wrist and digits + movements of the thumbs, index and middle fingers (supplies the LOAF muscles; same fingers as sensory distribution!)
- ulnar: flexion and adduction of the medial two fingers
- radial: extension of the wrist and fingers
Give the eponymous names and describe fractures of the distal radius.
- Colles’ fracture: 5D’s (Dorsally Displaced Distal radius leads to a Dinner fork Deformity)
- Smith’s fracture: reverse Colles’ (a fall backwards FOOSH), causing a garden spade deformity and volar angulation
Give the eponymous names and describe fractures of the radius and ulna.
GRUesome MURder
- Galeazzi: Radial fracture with Ulnar displacement
- Monteggia: Ulnar fracture with Radial displacement
Describe the clinical signs (4), investigation (2) and management (2) of a scaphoid fracture.
- clinical signs
– hyperextended wrist with radial deviation
– maximal tenderness over the anatomical snuffbox
– pain on longitudinal compression (telescoping)
– loss of grip/pinch strength - investigation
– x-ray in 4 views (PA, PA in ulnar deviation, lateral, oblique)
– if inconclusive, re-image in 7-10 days - Management
– Futuro splint/below-elbow backslab
– may require surgical fixation
Name the thumb metacarpal fracture commonly caused by fist-fights.
Bennet’s (‘Ben hit’)
Describe adhesive capsulitis (‘frozen shoulder’).
- epidemiology: most common in middle-aged women, and associated with diabetics
- external rotation affected more than internal rotation or abduction, with both active and passive movement affected
- features develop over days and last 6 months - 2 years, with episodes of ‘freezing’ and ‘thawing’
- diagnosis is clinical and management includes NSAIDs, physiotherapy, and/or oral/intraarticular steroids
Describe shoulder dislocation.
- the humeral head dislodges from the glenoid cavity of the shoulder
- anterior dislocation is far more common than posterior (~95%)
- posterior dislocation is associated with tonic-clonic seizures, electric shocks, and dashboard injuries
- a dislocated shoulder requires prompt closed reduction (often in A&E); analgesia and/or sedation may be required
- complications include tears of the glenoid labrum, axillary nerve damage, and rotator cuff tears
Describe carpal tunnel syndrome.
- compression of the median nerve in the carpal tunnel
- associations include pregnancy, oedema (e.g., CHF), lunate fractures, and RA (bilateral carpal tunnel)
- symptoms include weakness of thumb abduction, wasting of the thenar eminence, and paraesthesia in the median nerve distribution (lateral 3.5 fingers)
- clinical signs include
- Tinel’s: tapping causes paraesthesia
- Phalen’s: flexion of the wrist causes symptoms
- conservative management is with a 6 week trial of steroid injection +/- wrist splints at night
- surgical management is with decompression of the flexor retinaculum
Describe what is meant by a positive Tinel’s and Phalen’s sign.
- Tinel’s: tapping over the wrist causes paraesthesia
- Phalen’s: flexion of the wrist causes paraesthesia/pain etc.
Name and describe the two main types of nodes within the hand.
- Bouchard’s nodes: affects PIPJs
- Heberden’s nodes: affects DIPJs (‘Hebrides islands’)
Name and describe the nerves of the lumbar plexus.
Mnemonic: I (twice) Get Laid On Fridays
- iliohypogastric: (S) posterolateral gluteal skin, (M) abdominal muscles (IO, TA)
- ilioinguinal: (S) superomedial gluteal skin, penis + scrotum/mons pubis + labia majora
- Genitofemoral (S, genital) scrotum / mons pubis + labia majora (S, femoral) skin of upper anterior thigh, (M) cremasteric muscle
- lateral cutaneous nerve of the thigh (S) anterior and lateral thigh down to the level of the knee
- obturator: (S) medial thigh, (M) medial thigh compartment [thigh adduction]
- femoral: (S) anterior thigh and medial leg (M) anterior thigh compartment [extends leg at knee]
Name and describe the nerves of the sacral plexus.
Mnemonic: SLIP, DSP (if you SLIP you’ll need the Disability Support Pension)
- superior gluteal: (M) gluteus medius, minimus, and tensor fascia lata
- lumbosacral trunk
- inferior gluteal: (M) gluteus maximus
- posterior femoral cutaneous: (S) skin on posterior thigh and leg, perineum
- direct branches: nerve to piriformis, obturator internus, quadratus femoris
- sciatic [formed of the tibial and common peroneal/fibular]:
— tibial (S) posterolateral leg, lateral and plantar foot (M) posterior thigh and leg compartments
— common fibular (S) lateral leg and dorsal foot (M) anterior and lateral leg compartments
- pudendal (S) penis, clitoris, perineal skin (M) perineal muscles, external sphincters (urethral, anal), levator ani
Describe the presentation, investigations, and management of a hip fracture.
- presentation: classically a painful, shortened and externally rotated leg
- investigation: first line is x-ray to guide management
- management: depends on the anatomical location of the fracture
— intracapsular, non-displaced: ORIF (fit), hemiarthroplasty (comorbid)
— intracapsular, displaced: THR (fit), hemiarthroplasty (comorbid)
— intertrochanteric: dynamic hip screw
— subtrochanteric: intramedullary nail
Describe hip dislocation.
- presentation: extremely painful, most often caused by direct trauma such as RTAs or fall from height
— posterior (90%): shortened, adducted, internally rotated
— anterior (10%): no shortening, abducted, externally rotated - management: ABCDE, analgesia, and reduction under GA within 4 hours. Long term management is with physiotherapy.
- complications: nerve injury (sciatic, femoral), AVN, OA, recurrent dislocation
Give the two main differentials for pain over the superolateral thigh.
- trochanteric bursitis (‘greater trochanteric pain syndrome’): women 50-70, repeated movement of the fibroelastic iliotibial band
- meralgia paraesthetica: compression of the lateral cutaneous nerve of the thigh. As pain is neurogenic it is often described as ‘burning’.
When would you expect a positive anterior drawer, Steinmann, and Lachman test?
- anterior drawer, Lachman; knee ACL injury
- Steinmann: meniscal injury
Describe Achilles tendon rupture.
- presentation: audible ‘pop’, sudden pain, sudden onset significant pain, inability to walk following sporting injury
- patient is examined using Simmonds triad:
— angle of declination (greater angle of dorsiflexion in affected leg)
— palpation (gap in the tendon)
— Thompsons calf squeeze test (with the patient prone, squeezing the calf does not result in foot movement) - ultrasound is the imaging modality of choice (rather than MRI)
- refer acutely to orthopaedics with a suspected tendon rupture
Name and describe the criteria guiding use of x-ray, and classification, of ankle fracture.
-
Ottawa criteria guide need for x-ray in A&E with a suspected ankle #. They state x-ray is required only if there is pain in the malleolar zone plus one of
— tenderness of the medial malleolus (distal tibia)
— tenderness of the lateral malleolus (distal fibula)
— inability to weight bear for 4 steps - there are many ankle fracture classification types but the Weber system is the most common.
— Weber A: # below the syndesmosis
— Weber B: # at the level of the tibial plafond, may extend proximally to involve the syndesmosis
— Weber C: above the syndesmosis, which itself may be damaged
Describe the management of ankle fracture.
- all ankle fractures require closed fixation under sedation in A&E to correct the anatomy
- the fracture is then placed in a below-knee back-slab, followed by a repeated neurovascular assessment and repeat imaging to ensure alignment
- this management is sufficient for Weber A and B fractures non-displaced and without talar shift
-
ORIF is required if any of the following features are present:
— Weber C (or Weber B with talar shift)
— open fracture
— displaced bimalleolar or trimalleolar fracture
