Orthopaedics (+ trauma) Flashcards
(108 cards)
1
Q
4 principles of fracture management
A
- Resuscitation 2. Reduction 3. Restriction 4. Rehabilitation
2
Q
What type of fracture has more than 2 fragments?
A
communited
3
Q
bony fragment torn off by a tendon or ligament. What type of fracture?
A
Avulsion
4
Q
Type of fracture more commonly seen in children
A
Greenstick (bones are softer and more pliable and tend to bend rather than break)
5
Q
What is a dislocation?
A
complete loss of congruity between articular surfaces of a joint
6
Q
What is a subluxation?
A
partial loss of contact between 2 joint surfaces
7
Q
5 stages to the healing of a fracture?
A
- bleeding
- inflammation
- cells proliferate and early bone and cartilage is formed
- new bone consolidates (as woven boen is transfomred into stronger lamellar bone)
- bone remodels
8
Q
Length of time (in general) for long bones of upper limb in healthy adult to begin to consolidate?
A
6 weeks
9
Q
Length of time (in general) for long bones of lower limb (tibia/femur) in healthy adult to begin to consolidate?
A
12 weeks
10
Q
How long are ankle fractures involving the malleoli in plaster for?
A
6 weeks
11
Q
4 complications of any tissue damage?
A
haemorrhage and shock
fat embolism and respiratory distress syndrome
infection
muscle damage and rhabdomyolysis
12
Q
3 complications of prolonged bed rest?
A
chest infection and UTI
pressure sores and msucle wasting
DVT/PE
13
Q
3 complications of anaesthesia?
A
anaphylaxis
damage to teeth
aspiration
14
Q
complications specific to fracture?
A
- IMMEDIATE - haemorrhage; neurovascular and visceral damage
- EARLY - compartment syndrome; infection (worse if associated with metalwork)
- LATE - delayed union, non- and malunion; avascular necrosis; Sudek’s atrophy; myositis ossificans; joint stiffness; growth disturbance
15
Q
“temporary loss of motor and sensory function due to blockage of nerve conduction, usually lasting an average of six to eight weeks before full recovery” (Seddon classification of peripheral nerve injury)
a. neuropraxia
b. axonotmesis
c. neurotmesis
A
a. neuropraxia
16
Q
“disruption of nerve cell axon where axons and their myelin sheath are damaged, but Schwann cells, the endoneurium, perineurium and epineurium remain intact” (Seddon classification of peripheral nerve injury)
a. neuropraxia
b. axonotmesis
c. neurotmesis
A
b. axonotmesis
17
Q
“both the nerve and the nerve sheath are disrupted. While partial recovery may occur, complete recovery is impossible.” (Seddon classification of peripheral nerve injury)
a. neuropraxia
b. axonotmesis
c. neurotmesis
A
c. neurotmesis
18
Q
What nerve plasy may occur with a dislocated shoulder?
A
axillary nerve palsy
19
Q
What nerve plasy may occur with a fracture of the shaft of the humerus?
A
radial nerve palsy
20
Q
What nerve plasy may occur with an elbow dislocation?
A
ulnar nerve palsy
21
Q
What nerve plasy may occur with a dislocated hip?
A
sciatic nerve palsy
22
Q
What nerve plasy may occur with a fracture of the neck of the fibula or knee dislocation?
A
common peroneal nerve palsy
23
Q
What classification system is used for fractures of the hip?
A
Garden classification
24
Q
What classification system is used for fractures of the ankle
A
Weber classification
25
What classification is used for epiphyseal plate fractures (hence typically occur in children)?
Salter-Harris Classification
26
examination findings of a leg with a fractured neck of femur
leg lying externally rotated and shortened (iliopsoas attaches to lesser trochanter of femur)
27
Why are fractures of the neck of the femur classified as extracapsular or intracapsular? What is the complication?
determined by the blood supply to head of femur. intracapsular fractures more likely to disrupt blood supply, leading to avascular necrosis
28
management of hip fracture
1. history and social staus of patient
2. insert cannulae and send off bloods for U&Es, FBS and group and save
3. get ECG and CXR and x-ray of pelvis and affected limb
4. mark the affected limb in prep for surgery
5. ensure surgeon obtains consent
6. if necessary, correct any medical problems optimising them for theatre
7. if patient is in severe discomfort, skin traction can be applied to reduce the pain
29
The saying for surgical fixation of intracapsular fractures as classified by Garden
One, two, screw, three, four, Austin-Moore
(only paplies to patients over 65)
30
fracture of ulna shaft with dislocation of radial head
a. Monteggia fracture
b. Galleazzi fracture
c. Colles fracture
d. Smith's fracture
e. Barton's fracture
a. monteggia fracture
31
fracture of the radial shaft with a dislocation of the distal radioulnar joint
a. Monteggia fracture
b. Galleazzi fracture
c. Colles fracture
d. Smith's fracture
e. Barton's fracture
b. Galleazzi fracture
32
extra-articular fracture of the distal radius with dorsal displacement and radial shift of the distal fragment with radial shortening. in addition, in rotational injuries the ulna styloid may get pulled off its attachment to the triangular fibrocartilaginous disc.
a. Monteggia fracture
b. Galleazzi fracture
c. Colles fracture
d. Smith's fracture
e. Barton's fracture
c. Colles fracture
33
6 complications of Colles fracture?
1. malunion
2. median nerve problems
3. a stiff 'frozen' shoulder (due to immobilisation)
4. tendon rupture (tendon of extensor pollicis longus rubs along distal radial fragment and can rupture several weeks later)
5. Sudek's atrophy
6. carpal tunnel syndrome
34
Casued by a fall onto the back of a flexed wrist, distal radial fragment is not only displaced anteriorly (in a volar/towards the palm direction) but also the volar tilt may be greater than the normal 11 degres
## Footnote
a. Monteggia fracture
b. Galleazzi fracture
c. Colles fracture
d. Smith's fracture
e. Barton's fracture
d. Smith's fracture (reverese Colles)
35
The distal radial fracture is oblique and extends into the wrist joint
a. Monteggia fracture
b. Galleazzi fracture
c. Colles fracture
d. Smith's fracture
e. Barton's fracture
e. barton's fracture
36
Bankart lesion?
glenoid labrum is pulled off anteriorly in an anterior shoulder dislocation (95% of shoulder dislocations are anterior)
37
the line formed by the medial edge of the femoral neck and the inferior surface of the pubic ramus (in normal x-ray)
Shenton's line
38
Lesion formed on the superior surface of the humeral head if the humeral head impacts against the relatively hard anterior glenoid. significance?
Hill-Sachs lesion (35-40% of anterior dilocations). may destabilise the glenohumeral joint and predispose to further dislocation
39
Recovery time in sling for anterior shoulder dislocation. Movements to avoid?
3-4 weeks. abduction adn external rotation
40
TUBS? treatment?
| (clue: shoulder dislocation)
Traumatic Unilateral dislocations with a Bankhart lesion often require Surgery.
surgery with bankhart repair
41
AMBRI?
| (clue: shoulder dislocation)
Atraumatic Multidirectional Bilateral shoulder dislocation (or subluxation) and is best treated by Rehabilitation but occasionally should be considered for an Inferior capsular shift.
42
who gets a posterior dislocation of the shoulder?
epileptic or electricuted
43
What is Bohler's angle?
On a lateral view this angle is formed by the intersection of two lines. The first line is drawn from (1) - the upper edge of the calcaneal body posteriorly to (2) - the upper edge of the posterior articular facet of the calcaneus at the subtalar joint. From this point another line is drawn to (3) - the upper edge of the anterior process of the calcaneus.
Bohler's angle is normally between 28-40 degrees.
44
Where is the Lisfranc ligament?
The 'Lisfranc' ligament stabilises the mid-forefoot junction. Loss of alignment of the 2nd metatarsal base with the intermediate cuneiform indicates injury to this important ligament.
ie lies between 2nd metatarsal base and intermediate cuneiform
45
An open fracture presents to A&E and you are the surgical on-call/first doctor to see the patient. How would you manage this?
1. Resuscitation. Follow the ATLS guidelines to deal with any life-threatening injuries (airway, breathing, circulation
2. assess the neurovascular status + condition of skin and soft tissue surrounding fracture
3. need to be booked into theatre as an emergency (within 6 hours/on the next surgical list
4. x-ray the fracture
5. remove any gross contaminants
6. start broad spectrum antibiotics (augmentin or clindomycin if allergic)
7. tetanus booster, if necessary
8. photoraph the wound
9. dress with a sterile dressing soaked in saline
"In open fractures -- save life, save limb and stabilise fracture"
46
What is osteoarthritis?
It is a degenerative joint disorder in which there is progressive loss of articular cartilage
47
3 symptoms of osteoarthritis
1. pain - aggravated by exercise and relieved by rest. progressive over time. often periods of remission and flare-ups
2. stifness. patient very stiff in the morning but tends to improve during day
3. deformity. muscular spasms, capsular and ligamentous contracture and distortion of joint surfaces (fixed flexion deformity later on)
48
6 X-ray changes in osteoarthritis?
1. narrowing of joint space
2. osteophytes - bits of bone overgrowth, usually near joint edge
3. subchondral sclerosis
4. subchondral bone cysts
5. may be evidence of old fractures, rheumatoid or congential defects
6. structural damage - bony destruction and deformity is a late sign
49
What is the Injury Severity Score (ISS)?
When is it used?
Assess trauma severity. correlates to mortality, morbidity and hospitalisation time after trauma
A major trauma (polytrauma) is defined as ISS greater than 15.
6 point ordinal scale:
1. Minor
2. Moderate
3. Serious
4. Severe
5. Critical
6. Maximal (currently untreatable).
9 regions top-to-toe
Head
Face
Neck
Thorax
Abdomen
Spine
Upper Extremity
Lower Extremity
External and other.
50
What is the Gustilo Anderson Scale used for?
Classification of OPEN fracture severity.
(Correlates with infection risk and thus risk of nonunion (ie morbidity))
51
What are the grades of Gustilo Anderson Classification?
(Classifies open fracture severity)
1. wound 1cm in length
2. wound between 1-10cm in length; no soft tissue damage
3A. wound with extensive soft tissue damage
3B. extensive soft tissue damage and periosteal stripping. usually with massive contamination
3C. neurovascular compromise
52
What is a fragility fracture?
A fracture which occurs from a fall from standing height or less( this is a pathological fracture)
53
Mortality associated with fracture NOF in 1 month?
10%
54
What are the 4 classifications in the Garden classification?
I. incomplete, impaction in valgus (stable)
II. complete, undisplaced (stable)
III. complete, incompletely displaced (unstable)
IV. complete fracture, complete displacement (unstable)
I&II = stable --\> head- preserving internal fixation
III&IV = unstable --\> hemiarthroplasty
55
Pauwel's classification. what is it based on and give the types.
* based on vertical orientation of fracture line*
1. \<30 degree from horizontal
2. 30-50 degree from horizontal
3. \>50 degree from horizontal
56
typical presentation of NOF fracture?
external rotation and shortening of leg (due to unopposed iliopsoas action on lesser trochanter attachment)
57
AO principles of fracture management (v similar to general priniciples of fracture management)
1. respect the soft tissues
2. anatomic reduction
3. stable fracture fixation
4. early mobilisation
58
Management of osteoarthritis? (start with conservative to most invasive)
1. conservative (alagesics, weight loss, advice on altering load-bearing activities (eg using walking aids and avoiding activities which exacerbate), physiotherapy, injection of steroids and local anaesthetic, intraarticular hyaluronic acid abd dietary supplements
2. arthroscopic washout joint of debris (cartilage/broken-off osteophytes)
3. osteotomy. bone divided and left to unite (with fixation)
4. arthrodesis. joint is fused (used as last resort where loss of joint movement is not too disabling)
5. arthroplasty, either replacement or excision
59
5 complications of total hip replacement?
1. dislocation (about 3% of primary THRs)
2. DVT (up to 50% of THRs, risk is halved with prophylaxis; early mobilisation to prevent)
3. infection (1-2%). metalwork removed in Girdlestone procedure (hip excision)
4. nerve damage. sciatic nerve posteriorly (=foot drop); superior gluteal nerve anterolaterally (=weakness of abductors and Trendelenburg gait)
5. leg length discrepancy. balacning the neck length with tightness of soft tissues. correct with shoe insole
60
Blood supply to neck of femur?
medial circumflex artery, lateral circumflex artery, artery of ligamentum teres
61
Which direction is valgus?
a deformity involving oblique displacement of part of a limb AWAY FROM the midline.
(varus=a deformity involving oblique displacement of part of a limb TOWARDS the midline)
(German sheepdog test)
62
Which direction os varus?
varus=a deformity involving oblique displacement of part of a limb TOWARDS the midline
(a deformity involving oblique displacement of part of a limb AWAY FROM the midline)
(German sheepdog test)
63
What is damaged in the unhappy triad of O'Donoghue? How does this triad occur?
anterior cruciate, medial meniscus and medial collateral.
Following severe rotational injury.
64
4 cardinal knee symptoms?
1. pain
2. locking - cannot fully extend due to mechanical obstruction, eg meniscal tear
3. giving way - sign of instability (eg ACL torn) or pain
4. swelling
65
types of knee swelling?
1. immediate
2. delayed until next day
1. haemarthrosis - fractures or torn cruciates
2. (overnight swelling) effusion - meniscal tear or annother ligamentous injury
66
management of acutely swollen knee with no fractues?
RICE
Rest
Ice
Compress or splintage
Elevation
Re-assess after sweling subsides for meniscal, ligamentous or chondral damage
67
scaphoid fracture main complication?
Avascular necrosis. blood supply to scaphoid is via small vessels that enter the bone distally and hence the proximal fragment is at risk of becoming avascular, leaving the patient with pain and stiffness in the wrist
68
What direction is volar?
Anatmoical term meaning on the plam side of the hand (ie palmar/plantar)
69
6 causes of avascular necrosis?
1. fracture/dislocation
2. sickle cell disease - climping of RBCs leads to diminshed capillary flow
3. decompression sickness (caisson disease)
4. Gaucher's disease - rare familial disorder of lipid metabolism
5. drug-induced (especially corticosteroids)
6. idiopathic (osteochondritides)
70
Give a surgical sieve
V vascular
I infection
T trauma
A autoimmune
M metabolic
I inherited
N neoplastic
D drugs
71
AVN of the second metatarsal head
1. Freiberg's disease
2. Kohler's disease
3. Keinboch's disease
4. Panner's disease
1. Freiberg's disease
72
AVN of the navicular
1. Freiberg's disease
2. Kohler's disease
3. Keinboch's disease
4. Panner's disease
2. Kohler's disease
73
AVN of the lunate
1. Freiberg's disease
2. Kohler's disease
3. Keinboch's disease
4. Panner's disease
3. Keinboch's disease
74
AVN of the capitulum of the humerus
1. Freiberg's disease
2. Kohler's disease
3. Keinboch's disease
4. Panner's disease
Panner's disease
75
Do you know what parts of the long bones these terms relate to?
1. diaphysis
2. physis
3. epiphysis
4. metaphysis
1. centre of the shaft (ie in between the physes)
2. growth plate from which longitudinal growth of bone occurs
3. outer ends of the bone (ie on top of the physes)
4. area in which new bone is laid down towards the diaphysis (ie next to the physes)
76
Name benign primary bone tumours
ABC FFG OO
## Footnote
Aneurysmal bone cysts (ABCs)
Bone cysts
Chondroma
Fibrous cortical defect
Fibrous dysplasia
Osteochondromas
Osteoid osteoma
77
Common sources of bone metastasis
* breast
* bronchus
* bhyroid (thyroid)
* benal (renal)
* brostate (prostate)
(The 5 'B's - no apologies for the awful mnemonic)
78
What is osteomyelitis?
Inflammation of the bone or bone marrow, usually due to infection.
79
What is Erbs palsy?
'Waiter's tip' position - adducted, internally rotated, loss of snesation C5/6
lesion of upper brachial plexus (C5/C6)
can occur at birth
abductors and external rotators paralysed
80
What is klumpke's paralysis?
claw hand with loss of sensation in C8/T1
lesions of lower brachial plexus (C8/T1)
loss of intrinsic muscles of hand
81
Loss seen in radial nerve palsy?
loss of extension of carpophalangeal joint
wrist drop
loss of sensation along radial nerve distribution
82
Saturday night palsy - what is the cause and what is paralysed?
pressure in the axilla on the very proximal radial nerve
due to incorrect use of crutches or arm hung over chair when drunk
paralysis of triceps as well as loss of wrist extensors
83
loss seen in ulnar nerve palsy?
'claw-like hand'
loss of all interossei, half of flexor digitorum profundus and lumbricals to ring and little fingers, causing them to claw (if lesion at elbow)
lesion at wrist - unopposed action of extensors and FDP
lesion s at elbow - have less clawing as ulnar half of FDP is now paralysed so fingers are straighter
loss of sensation in ulnar distribution of hand, wasting of interossei on the dorsum of the hand
84
5 clinical signs of a fracture
1. pain
2. swelling
3. crepitus
4. deformity
5. adjacent soft tissue damage (nerves/vessels/ligaments/tendons)
85
Describe the Slater-Harris classification and its importance
(SALTR)
Type I: Slipped - fracture plane passes all the way through the growth plate
Type II: Above - fracture passes through growth plate and metaphysis
Type III: Lower - fracture passes through growth plate and epiphysis
Type IV: Through/Transverse/Together - fracture passess through growth plate, epiphysis and metaphysis
Type V: Ruined/Rammed - growth plate damaged by direct compression
Type I+II have better prognosis; II, IV + V have poorer prognosis (limb shortening and abnormal growth)
86
describe an antalgic gait
* pain
* not fully weight bearing on affected side
* thus stance phase reduced
87
Ewing's sarcoma
tumour of diaphysis
88
osteogenic sarcoma
tumour originiating from metaphysis
89
giant cell tumour
tumour originating in epiphysis, occurs in mature bone only (ie physis has fused)
90
What orthopaedic conditions are associated with diabetes?
Charcot's disease
frozen shoulder
plantar fascitis
Dupetryen's contracture
91
Where is Gerdy's tubercle? What is the significance?
Lateral lubercle of of tibia. Insertion of iliotibial tract.
92
What is a fracture?
soft tissue injury which happens to have a bone in it
93
What is the syndesmosis?
3 ligaments:
anterior and posterior tibiofibula ligaments plus interosseous membrane
(begins at level of tibial plafond up to where tibia and fibula lose contact)
94
What is an alternative name for AP view of an ankle radiograph?
Mortis view (like a mortis lock) - internally rotated 20degrees
95
If the syndesmosis is torn, what can we conclude about the deltoid ligament?
it is also torn
96
what side is the deltoid ligament of the ankle on?
medial aspect
97
What is the index used for identifying whether an ankle injury should be x-rayed for fracture?
What are the criteria?
What must you always document on examination?
The Ottawa index
1. Bone tenderness along distal 6cm posterior edge of tibia or tip of medial malleolus
2. Bone tenderness along distal 6cm posterior edge of fibula or tip of lateral malleolus
3. inability to bear weight both immediately or for more than 4 steps in A&E
Foot x-ray if:
* bone tenderness at base of 5th metatarsal
* bone tenderness at navicular bone
* inability to weight bear immediately and for more than 4 steps in A&E
Suitable for use in children over 6
ALWAYS DOCUMENT NEUROVASCUALR STATUS
98
What ligaments should be palpated and may be tender in ankle sprain?
1. anterior talofibular ligament
2. calcaneofibular ligament
3. posterior talofibular ligament
Rembember to ALWAYS ASSESS NEUROVASCUALR STATUS OF FOOT
99
How to treat stable ankle fracture?
analgesia, RICE plus walking boot
| (rest, ice, compression, elevation)
100
key x-ray finding of unstable ankle fractures?
how to treat unstable ankle fracture?
talar shift (always lateral shift)
joint line not symetrical, even and intact all the way along tibial plafond
treat: below knee backslab (below knee to ball of foot) with ankle in dorsiflexion at 90 degrees to lock the ankle joint (talus is wider at front)
101
How do you assess the neurovascular status of an ankle injury?
vascular:
* dorsalis pedis (base of 1st and 2nd metatarsal joint)
* posterior tibial artery (posterior to medial malleolus)
neuro (always motor and sesnory component) - 3 main nerves (1 for each compartment of lower leg/foot)
* anterior compartment = deep peroneal nerve
* sensory - 1st dorsal web space
* motor - dorsiflexion of big toe
* lateral compartment = superficial peroneal nerve
* sensory - over 4th metatarsal dorsal surface
* motor - eversion of toes and ankle
* posterior compartment = tibial nerve
* sensory - sole of foot
* motor - flexion of toe
102
How do you reduce an ankle fracture?
What must you always do?
ALWAYS DOCUMENT NEUROVASCUALR STATUS OF AFFECTED LIMB BOTH BEFORE AND AFTER
apply traction anteriorly, medially (to correct talar shift) and internally rotate -- need to check this one!
Be sure to bend knee slightly to unlock Achilles' tendon
103
What is a fracture blister?
What are the consequences?
blister formation secondary to fracture not reduced properly
1. Can't operate due to weak skin over incision site --\> wound cannot be closed after open surgery
2. increases risk of infection of metalwork
104
What is a maisonneuve fracture?
Fracture of proximal fibula, ripping interosseous membrane all the way down and then across the tibial plafond to rip deltoid.
Sustained by going over ankle and twisting
105
What is a Brostrom procedure?
Repair of ligaments on lateral side of ankle
106
management of ankle sprain?
RICE then MICE (move after a few days)
107
What is the Lauge Hansen classification used for?
system for catgorising ankle fractures based on foot position and force applied
108
Clinically, how could you assess if an ankle fracture is stable or unstable?
"finger of God"
1. use the xray to assess uniformity of joint space
2. poke the deltoid ligament (below medial malleolus)
