Orthopaedics Flashcards
(53 cards)
Clavicle fractures - types, incidence and referral criteria
Class A - middle third - 85%
Class B - lateral third - 12%
Class C - medial third - 3%
Non-union 10-15%
Refer if:
-open or tented skin
-NV compromise
-lateral third fracture with displacement
-any fracture with significant displacement eg 100% displacement or 2cm shortening
ACJ injury assessment, Rockwood classification and management
Get bilateral zanca views
Type I - no separation
Type II - clavicle elevated but not superior to acromion
Type III - clavicle elevated above acromion border up to 100% displacement. Surgical treatment if labourer, athlete, cosmetic requirement or not healing
Type IV - posterior displacement to trapezius. surgical fix
Type V - >100% superior displacement. surgical fix
Type VI - rare. Inferior displacement. Surgical fix
SCJ dislocation
If anterior will be pain and swelling. Treat with NSAIDs, ice, rest, physio, sling
If posterior can lead to dysphagia, limb paraesthesia, SOB and stridor/tachypnoea - worse when lying flat. Refer immediately for this
Rotator cuff exam
Supraspinatus - Jobe’s test - empty can position then raise arm against resistance
Infraspinatus - external rotation
Subscapularis - lift-off
Teres minor - stop/hornblowers sign
Test impingement with Hawkins test - internal rotation of shoulder after flexion of shoulder and elbow to 90’
Biceps rupture signs and treatment
Proximal rupture - Popeye sign
Usually not repaired as short head remains intact but refer if young, active.
Distal rupture - impalpable tendon in ACF. Positive squeeze test. Often repaired.
Nerve injury in supracondylar fracture and how to assess
Anterior interosseous branch of median nerve most common. Check OK sign, sensation in palmar first 3.5 digits
Radial nerve. Thumbs up
Ulnar nerve association with flexion injury (less common). Cross fingers.
Complications of supracondylar fracture
Vascular injury - brachial artery
Nerve injury - medial most likley
Volkman’s contracture
Non-union
Chronic deformity
Myositis ossificans
Compartment syndrome
Most common adult elbow fracture?
Radial head
Radial head fracture management
Joint aspiration + LA injection
Sling immobilisation for 3-7/7 then early ROM for low grade injuries
What is the terrible triad of elbow injuries?
Dislocation
Radial head/neck fracture
Coronoid fracture
What is a Monteggia fracture
Proximal 1/3 ulna fracture with radial head dislocation at elbow
Check for posterior interosseous neuropathy by assessing wrist and digit extension
May be associated with “terrible triad” of elbow
Galeazzi fracture
Distal 1/3 radial fracture with ulnar dislocation (anterior/posterior) or DRUJ injury at wrist (best seen on lateral), can be seen as shortening of the radius cf the ulna
Can also see ulnar styloid fracture and widening of DRUJ
Indication for manipulation of Colles
> 5mm shortening
20’ dorsal angulation
Displacement >2/3 of radius width
Carpal tunnel risk factors, signs and referral
Flick test most sensitive and specific (waking in night and shaking hands to restore feeling)
Median nerve compression (hold for 30s)
Phalen’s (flexion)
Tinel’s (tapping)
Hypoalgesia - decreased pain palmar index cf little
Square wrist
Hypothyroid, DM, obesity, repetitive strain, pregnancy, RA
Refer if:
sensory loss
muscle wasting
no improvement after 6/12 conservative tx
De Quervain’s tenosynovitis
Stenosing tenosynovitis of canal which houses Abductor Pollicus Longus and EPB in lateral distal radius
Due to repetitive strain, commonly from lifting babies
Tender here, also hitchhikers sign and Finkelstein’s sign - pain with enclosing thumb in fist + ulnar deviation
Tx with rest, NSAIDs, splinting, hand therapy
TFCC tear
(Triangular fibro-cartilage complex of the wrist)
FOOSH
Pain in wrist esp ulnar/pisiform area
Difficulties with ADLs
Tender ulnar/pisiform area
Decreased wrist power
Pain and weakness with lifting in supination
MRI diagnostic
Splint, rest, hand therapy
Why are scaphoid fractures prone to avascular necrosis in the proximal portion?
Blood supply runs distal to proximal by radial artery branch
Scaphoid fracture exam and management
65% waist
25% prox pole
10% distal pole
Tenderness at ASB/scaphoid tuberble
Pain on resisted pronation
Pain on axial loading
FU in 2/52
If displaced or proximal pole FU in 1/52 with ortho
Canadian CT C-spine criteria
Age >65
Extremity paraesthesias
Dangerous mechanism:
Fall >3 feet/5 stairs
High speed MVA/rollover/ejection
Axial load
Bicycle collision
Motorised RV
Low risk factors:
Simple rear-end MVC
Ambulatory at any time
Sitting in ED
No midline tenderness
Delayed neck pain
Able to actively rotate 45’ L+R
What % of sacral fractures are seen on XR?
30%
SUFE
Posterior and inferior displacement
Obesity #1 risk factor
M>F
L>R, 25% bilateral
Also: endocrine disorders (esp hypothyroid), trisomy 21, renal disorders, prior radiation
Age 10-16
O/E:
Groin/hip/thigh/knee pain. Limp
Pain and reduced ROM on internal rotation
Loss of abduction and flexion
Trendelenburg (drop of contralateral hip on standing phase of gait cycle) or waddling gait
Obligatory external rotation with passive hip flexion
Thigh weakness and atrophy
Grade 1 = 0-33’ slippage “mild”
Grade 2 = 34-50’ slippage “moderate”
Grade 3 = >50’ slippage “severe”
Trendelenburg gait
Drop of contralateral hip on standing on affected side or during standing phase of gait cycle
Due to weak hip aBductors eg gluteus maximus and medius
Can be due to affected superior gluteal nerve esp after hip replacement
Compensation may occur where the individual leans to the affected side to balance hips
Waddling gait is a bilateral weakness of hip aBductors causing bilateral trendelenburg gait and therefore a waddling appearance
Knee dislocation
50% self-reduce
High energy (low energy + obesity also possible)
Dashboard injury is classic
Anterior most common (hyperextension) - 30-50%
Posterior (dashboard) 30-40%
Lateral 13% Medial 3% Rotational 4% - usually irreducible
0.02% Ortho presentations
Neurovascular injuries common. Popliteal artery, vein and perineal nerve (25%) (esp with anterior) are common injuries. Tibial nerve less common
Check ABPI - if <0.9 needs angiography
Needs immediate surgical exploration if pulses remain absent/diminished after reduction. Imaging contraindicated if will result in surgical delay
Femoral fracture
Blood loss if closed can be up to 1500ml, double that if open
Check lower limb pulses, consider ABPI
Possible popliteal injury if distal fracture
