Orthopaedics

Question 1

How do you manage an open fracture?

Answer 1

6 A’s:

• Analgesia
• Assess: NV status, soft tissues, photograph
• Antisepsis: wound swab, copious irrigation, cover with betadine soaked dressing
• Alignment (and splint)
• Anti-tetanus: check status (booster lasts 10 years)
• Antibiotics
  
  • Fluclox 500mg IV/IM + benpen 600mg IV/IM
  • Or augmentin 1.2g IV

Question 2

How do you classify open fractures?

Answer 2

Gustillo:

1. Wound <1cm in length
2. Wound ≥1cm with minimal soft tissue damage
3. Extensive soft tissue damage

Question 3

Which organism causes gas gangrene?

Answer 3

Clostridium perfringens

Question 4

How do you manage gas gangrene?

Answer 4

Debride, ben pen, clindamycin

Question 5

What are the indications for open reduction of fractures?

Answer 5

• Intra articular fractures
• Open fractures
• 2 fractures in one limb
• Failed conservative treatment
• Bilateral identical fractures

Question 6

What are the complications of fractures?

Answer 6

• Immediate
  
  • Neurovascular damage
  • Visceral damage
• Early
  
  • Compartment syndrome
  • Infection (worse if associated with metalwork)
  • Fat embolism -> ARDS
• Late
  
  • Problems with union
  • AVN
  • Growth disturbance
  • Post traumatic osteoarthritis
  • Complex regional pain syndromes
  • Myositis ossificans

Question 7

How do you classify neurological complications of fractures?

Answer 7

Seddon classification:

• Neuropraxia = temporary interruption of conduction without loss of axonal continuity
• Axonotmesis = disruption of nerve axon with distal Wallerian degeneration
  
  • Connective tissue framework of nerve preserved
  • Regeneration occurs and recovery is possible
• Neurotmesis = disruption of entire nerve fibre
  
  • Surgery usually required and recovery not usually complete

Question 8

What are the causative factors of problems with union?

Answer 8

5 I’s:

• Ischaemia: poor blood supply or AVN
• Infection
• Increased interfragmentary strain
• Interposition of tissue between fragments
• Intercurrent disease: e.g. malignancy or malnutrition

Question 9

What is Pellegrini-Stieda disease?

Answer 9

Form of myositis ossificans where there is calcification of the superior attachment of MCL at the knee following traumatic injury

Question 10

How do you classify intracapsular #NOFs?

Answer 10

Garden Classification:

1. Incomplete #, undisplaced
2. Complete #, undisplaced
3. Complete #, partially displaced
4. Complete #, completely displaced

Question 11

How do you manage an intracapsular #NOF?

Answer 11

• Garden 1, 2: ORIF with cancellous screws
• Garden 3, 4:
  
  • <55: ORIF with screws, follow up in OPD and arthroplasty if AVN develops (30%)
  • 55-75: total hip replacement
  • >75: hemiarthroplasty
    
    • Mobilises: cemented Thompsons
    • Non mobiliser: uncemented Austin Moore

Question 12

What is a Colles’ fracture?

Answer 12

Extra articular fracture of the distal radius with dorsal displacement and angulation of the distal fragment

Question 13

What are the complications of a Colles’ fracture?

Answer 13

• Median nerve injury
• Frozen shoulder/adhesive capsulitis
• Tendon rupture especially EPL
• Carpal tunnel syndrome
• Mal-/non-union
• Sudek’s atrophy/CRPS

Question 14

What is a Smith’s fracture?

Answer 14

Fracture of the distal radius with volar displacement and angulation of the distal fragment (fall onto back of flexed wrist)

Question 15

What is a Barton’s fracture?

Answer 15

Oblique intra-articular fracture involving the dorsal aspect of distal radius and dislocation of the radio-carpal joint

Question 16

What is a Monteggia fracture?

Answer 16

proximal 3rd of ulna shaft with anterior dislocation of radial head at the capitellum

Question 17

What is a Galeazzi fracture?

Answer 17

radial shaft between the mid and distal 3rds with dislocation of the distal radio-ulnar joint

Question 18

How do you classify extension supracondylar fractures of the humerus?

Answer 18

Gartland:

1. Nondisplaced
2. Angulated with intact posterior cortex
3. Displaced with no cortical contact

Question 19

What are the Ottawa Ankle rules?

Answer 19

X ray ankle if pain is in the malleolar zone + if any of:

• Tenderness along distal 6cm of posterior tib/fib including posterior tip of the malleoli
• Inability to bear weight both immediately and in ED

Question 20

What is the Weber classification?

Answer 20

Ankle fractures: relation of fibula # to joint line:

• A: below joint line
• B: at joint line
• C: above joint line
• Weber’s B and C represent possible injury ot the syndesmotic ligaments between tib and fib -> instability

Question 21

Causes of avascular necrosis

Answer 21

• # or dislocation
• SCD, thalassaemia
• SLE
• Gaucher’s
• Drugs: steroids, NSAIDs

Question 22

What are buckle fractures?

Answer 22

incomplete fractures of the shaft of a long bone that is characterised by bulging of the cortex. They typically occur in children aged 5-10 years.

Question 23

Features of chondromalacia patellae

Answer 23

• Softening of the cartilage of the patella
• Common in teenage girls
• Characteristically anterior knee pain on walking up and down stairs and rising from prolonged sitting
• Usually responds to physiotherapy

Question 24

Features of common peroneal nerve lesion

Answer 24

The most characteristic feature of a common peroneal nerve lesion is foot drop

Other features include:

• weakness of foot dorsiflexion
• weakness of foot eversion
• weakness of extensor hallucis longus
• sensory loss over the dorsum of the foot and the lower lateral part of the leg
• wasting of the anterior tibial and peroneal muscles

Question 25

Which nerve is saturday night palsy

Answer 25

Radial

Question 26

Features of De Quervain's tenosynovitis

Answer 26

* pain on the radial side of the wrist * tenderness over the radial styloid process * abduction of the thumb against resistance is painful * Finkelstein's test: with the thumb is flexed across the palm of the hand, pain is reproduced by movement of the wrist into flexion and ulnar deviation

Question 27

Features of trochanteric bursitis

Answer 27

Due to repeated movement of the fibroelastic iliotibial band Pain and tenderness over the lateral side of thigh Most common in women aged 50-70 years

Question 28

What are the features of osteochondritis dissecans

Answer 28

Pain after exercise Intermittent swelling and locking

Question 29

Features of L3 nerve root compression

Answer 29

Sensory loss over anterior thigh Weak quadriceps Reduced knee reflex Positive femoral stretch test

Question 30

Features of L4 nerve root compression

Answer 30

Sensory loss anterior aspect of knee Weak quadriceps Reduced knee reflex Positive femoral stretch test

Question 31

Features of L5 nerve root compression

Answer 31

Sensory loss dorsum of foot Weakness in foot and big toe dorsiflexion Reflexes intact Positive sciatic nerve stretch test

Question 32

Features of S1 nerve root compression

Answer 32

Sensory loss posterolateral aspect of leg and lateral aspect of foot Weakness in plantar flexion of foot Reduced ankle reflex Positive sciatic nerve stretch test

Question 33

Features of cubital tunnel syndrome?

Answer 33

initially intermittent tingling in the 4th and 5th finger may be worse when the elbow is resting on a firm surface or flexed for extended periods later numbness in the 4th and 5th finger with associated weakness Ulnar nerve compression

Question 34

Features of frozen shoulder

Answer 34

external rotation is affected more than internal rotation or abduction both active and passive movement are affected patients typically have a painful freezing phase, an adhesive phase and a recovery phase bilateral in up to 20% of patients the episode typically lasts between 6 months and 2 years

Question 35

Features of meralgia paraesthetica

Answer 35

Caused by compression of lateral cutaneous nerve of thigh Typically burning sensation over antero-lateral aspect of thigh

Question 36

features of referred lumbar spine pain

Answer 36

Femoral nerve compression may cause referred pain in the hip Femoral nerve stretch test may be positive - lie the patient prone. Extend the hip joint with a straight leg then bend the knee. This stretches the femoral nerve and will cause pain if it is trapped

Question 37

Features of morton's neuroma

Answer 37

forefoot pain, most commonly in the third inter-metatarsophalangeal space worse on walking. May be described as a shooting or burning pain. Patients may feel they have a pebble in their shoe Mulder's click: one hand tries to hold the neuroma between the finger and thumb. The other hand squeezes the metatarsals together. A click may be heard as the neuroma moves between the metatarsal heads there may be loss of sensation distally in the toes

Question 38

How do you interpret a DEXA?

Answer 38

\<-1 is normal 1. 0-2.5 is osteopaenia 2. 5 and up is osteoporosis