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Flashcards in Radiology & Trauma Deck (34):
1

What are the seven steps of reporting X-rays?

1. View e.g. AP, lateral
2. Anatomy visible (right or left)
3. Name and age
4. Date and time (most recent radiograph?)
5. Most obvious abnormality
6. Describe deformities

2

How should the obvious deformity on an X-ray be described?

Location: diaphyseal, metaphyseal, epiphyseal, articular surfaces, junctional/combination

Displaced or undisplaced
- obvious indicates displaced
- difficult to tell indicates "relatively undisplaced"

3

Differentiate how well tolerated different types of fracture are.

Deformity in plane of movement is well tolerated

Rotational/angular deformity is not well tolerated

Children: the younger the child the greater the tolerance for deformity due to the propensity for ongoing growth

4

How should X-ray deformities be described?

Angle of displacement = angle of midpoint of cortices of proximal and distal fragments OR describe where apex of fracture is pointing in space e.g. posterolateral, medial (greater than 7 degees more likely to require fixation)

Change in length = shortening (proximal fragment translated past distal fragment) or lengthening (weight of limb, muscle palsy; periosteum, muscle, blood vessels, and nerves may become trapped between fragments)

Translation = movement of bone fragments across from each other in terms of %

Apposition = do fragments appear to fit together

Rotation = mismatch in width of bone cortices, pattern of fracture, different views above and below joint

Intra-articular?

Loss of congruity = subluxation or dislocation

5

Name some different types of fracture.

Comminuted - reserve for multiple small fragments that could not be fixed by screws

Transverse - direct high energy

Oblique - indirect low energy

Butterfly - direct high energy

Spiral - indirect low energy

Greenstick/buckle

Segmental

Linear

6

What are the different types of bone lesion?

Sclerotic = more bone (tumours activate osteoblasts and inhibit osteoclasts)

Lytic = less bone (tumours activate osteoclasts and inhibit osteoblasts)

Mixed

7

What is the zone of transition referring to in bone lesions?

Margin around bone elsion

Discrete margin indicates less aggressive, slower growing tmour

Ill defined margin indicates more aggressive, faster growing lesion

note: may have marginal sclerosis around a lytic lesion

8

What are the features of Paget's disease on an X-ray?

Visible trabeculae

Asymmetrical rotation

9

What are the MSK indications for USS?

Shoulder:
- rotator cuff tears
- rotator cuff tendinopathy
- impingement

Carpal tunnel syndrome

Tenosynovitis

10

What are the MSK indications for CT?

Occult bone pathology

MRI contraindicated

11

What is scintigraphy?

Technetium radioisotope injected IV causes body to emit gamma rays.

Osteoblastic activity highlighted as bright spots (+ bladder)

Random distribution of bright spots indicates metastases, ordered indicates OA

note: myeloma/TB gives "cold scan"
note: superscan when too much Tch given (bladder empty)

12

What is the Gustillo classification of open fractures?

Type I = clean wound <1cm long

Type II = wound >1cm without extreme soft tissue damage

Type III = wound usually >5cm with associated extensive soft tissue damage OR contaminated wound irrespective of size e.g. farm, river, marine

- a = adequate periosteal cover (wound can be covered by existing tissue)
- b = significant periosteal stripping (req. soft tissue cover)
- c = vascular repair req. to revascularise leg

13

Outline the assessment of the limb in an open fracture.

ATLS: Airway & cervical spine control, Breathing, Circulation, Cannulation, Crossmatch, Catheterisatio, Dysfunction (nerves), Examine Everything

- pulses: dorsalis pedis, pos. tibial
- temperature
- sensation: distal to wound, in same compartment as injury, peripheral nerve territories
- movements
- visible bones +/- periosteum
- wound debris
- soft tissue envelope
- colour
- size of wound
- obvious deformities (length, rotation)
- photograph fracture before moving on

14

What are the investigations and management of an open fracture?

1. Take blood (group and save, Hb, glucose, U&Es, LFTs) and cannulate
2. Anti-emetic (before analgesia) e.g. cyclizine
3. Analgesia e.g. IV morphine 10mg
4. Fluids e.g. bolus of Hartmann's, then as maintenance
5. Abx e.g. 1.2g IV co-amoxiclav
6. ?tetanus jab req.
7. Limited washout and removal of obvious debris OR dress without touching (see BAPRAS)
8. Reduce fracture (realign limb) and backslab (splint and plaster)
9. Reassess neurovascular status
10. Organise X-ray
11. Contact: anaesthetist, orthopaedic reg., plastics, ward/bed coordinator, theatres
12. Prepare for theatre/ward
- theatre within 24hrs UNLESS there is vascular injury or contamination
- NICE: consultant has to debride within 12hrs (?plastics req. to do this)

15

What is compartment syndrome?

Raised pressure within an enclosed fascial space leasing to localised tissue ischaemia

Increased pressure within body compartment which contains muscles or nerves

- due to change in pressure-volume relationship within a tight fascial compartment
- normal pressure ~10mmHg
- increase in pressure > 40mHg ---> veins compressed ---> blood moves in but not out ---> arteries compressed ---> acute limb ischaemia

16

What are the signs and symptoms of compartment syndrome?

- disproportionate pain to injury/increase in pain following immobilisation on passive movement/stretch of muscles within compartment (therefore can be above injury) due to hypoxia and buildup of toxic metabolites
- swelling/tightness of compartment
- paraesthesia
- dysaesthesia (normal stimulus gives abnormal sensation)
- pallor
- paralysis
- pulseless
- perishingly cold

17

What is the treatment of compartment syndrome?

Dermatofasciotomy of all limb compartments
Debridement of necrotic tissue
Skeletal stabilisation
Treatment of underlying cause
Can do compartment pressure monitoring

18

What are Klein's line and Trethowan's sign?

Klein's line = line drawn parallel to superior femoral neck should intersect the most lateral portion of the capital femoral epiphysis

Trethowan's sign = line of Klein passes above femoral head (sign of SUFE)

19

What is Paget's disease of bone (osteitis deformans)

Idiopathic disorder of bone remodelling causing healthy mature bone to be replaced by thick, vascular, osteoid bone

Hx:
- 50yrs<
- deep-seated aching/gnawing pain
- often asymptomatic (incidental finding)
- headache (incresed vascularity of skull)

O/E:
- skull enlargement
- kyphosis
- deafness
- sabre tibia
- blindness
etc.

Mx: bisphosphonates + analgesia + calcium

20

What is Perkin's classification of fracture healing?

Upper limb:
- spiral: union = 3wks, consolidation = 6wks
- transverse: union = 6wks, consolidation = 12wks

Double for lower limb

21

What components are required for normal fracture healing?

Viability of fractures i.e. intact blood supply

Mechanical rest: not moving, external immbolisation

Absence of infection

22

What are the complications of disturbed fracture healing?

Delayed union

Non-union (pseudoarthritis)

Refracturing

Malunion

23

What are the sesamoid bones of the body?

Bone embedded in tendon or muscle

- patella (quadriceps tendon)
- 2 in distal portions of 1st MCP
- distal portion of 2nd MCP
- pisiform (flexor carpi ulnaris)
- 2 in 1st MTP
- lenticular process of incus

24

What is the Garden classification?

Intracapsular fractures degree of displacement

I = impacted; fracture line through one cortex
II = minimally displaced; fracture through both cortices
III = partially displaced
IV = totally displaced

25

What is the Schatzer classification?

Tibial plateau fractures

I = pure cleavage fracture of lateral tibial plateau ("just split up")
II = type I + depressed component ("split and feeling depressed")
III = pure depression of lateral tibial plateau ("pure depression")
IV = medial tibial plateau fracture ("other side of break up"
V = bicondylar fracture ("see both sides of split")
VI = dissociation of tibial metaphysis and diaphysis ("complete emotional mess")

26

What is a Pilon fracture?

Fracture of distal tibia involving its articular surface at the ankle joint +/- fibular fracture

27

What is the Weber classification?

Ankle fracture

A = below syndesmosis; fibula and tibia still joined ---> cast
B = through syndesomosis; stable or unstable
C = above syndesmosis; unstable

28

What is a Maisonneuve fracture?

Spiral fracture of proximal fibula and ankle injury

29

What is a Lisfranc fracture?

Disruption between the articulation of the medial cuneiform and base of second metatarsal

30

What is an Ilizarov apparatus?

Method of external fixation using anteromedial and perpendicular pins inserted directly into fragments

Used to fix tibial fractures where fracture has extended into the ankle joint (so no support for intramedullary pins)

Also used to lengthen limbs

31

What are the different types of suture?

Monofilament v.s. polyfilament
- monofilament = better passage through tissues, reduced tissue reaction
- polyfilament = better knot securing

Absorbable v.s. Non-asorbable
- absorbable = internal
- non-asorbable = external or in heart, bladder

e.g. monofilament, absorbable = catgut, monocryl
e.g. monofilament, non-absorbable = nylon/ethilon
e.g. polyfilament, absorbable = vicryl
e.g. polyfilament, non-absorbable = silk

32

What are the types of suturing techniques?

Interrupted
- horizontal mattress (6 throws: 2, 1, 1, 1, 1)
- simple (2, 1, 1)
- vertical mattress

Continuous
- simple
- running subcuticular

Buried = distribute wound tension to dermis

33

What materials are used in arthroplasties?

Hybrid = use two different materials e.g. steel acetabulum + cemented femoral head

Polyethylene = strong (cross-linked); release molecules which are engulfed by macrophages ---> inflammatory reaction ---> ?bone destruction

Metal = can cause pseudotumour formation with associated osteolysis and periprosthetic bone loss; ?hypersensitivity to metal

Ceramic

34

What mnemonic can be used in the trauma history?

AMPLE
- Allergies
- Medical Hx
- Past Medical Hx
- Last meal
- Events (mechanism of injury)