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Flashcards in sarah gill trying to kill us Deck (114):
1

Fall with shoulder in external rotation?

Anterior dislocation of shoulder

2

What should you check if you have anterior shoulder dislocation?

Axillary badge patch!!

3

Fall with shoulder in internal rotation?

Posterior dislocation

4

Arm held in abduction
Humeral head inferior to the glenoid

Inferior dislocation
-NEEDS PROMPT NEUROVASCULAR ASSESSMENT AND REDUCTION

5

Light bulb sign on x-ray, which type of shoulder dislocation?

Posterior shoulder dislocation

6

Elbow dislocation gives small risk of which two fractures?

Coronoid process and radial head

7

Say you pull a child's arm upwards, what could you dislocate?

Radial head

8

Management of shoulder dislocation?

Closed reduction under sedation
Open reduction
Stabilisation & rehabilitation

9

Management of elbow dislocation?

Closed reduction under sedation
Open reduction rarely required
2 weeks in sling & rehabilitation

10

Hippocratic, Kocher’s, in-line traction used to reduce which type of dislocation?

Shoudler

11

Traction in extension +/- pressure over olecranon used to reduce which type of dislocation?

Elbow dislocation

12

Closed reduction under digital or metacarpal block
Open reduction rarely required
2 weeks in neighbour strapping
Volar slab in Edinburgh position if unstable ++

IPJ dislocation

13

Which way will the patella dislocate?

It will always be a LATERAL dislocation

14

Always a lateral dislocation?

Patella!

15

Who is most likely to sustain a patella knee dislocation?

Teenage girls

16

Associations/causes of patella dislocation?

Hypermobility
Under-developed (hypoplastic) lateral femoral condyle
Increased Q-angle
Genu valgum
Increased femoral neck anteversion
Lateral quads insertions or weak vastus medialis

17

Q angle

Line 1: ASIS to midpoint of patella
Line 2: Tibial tuberosity to midpoint of patella

18

Examination of dislocated knee cap?

Pain medially (from torn medial retinaculum)
Effusion (haemarthrosis)
Patella apprehension test +ve

19

Management of knee dislocation

Reduce with knee extension
Radiographs
Aspiration
Brace
Physiotherapy

20

Surgery for repeat dislocations of the knee

Lateral release with medial reefing
Patellar tendon reallignment

21

Lateral collateral ligament injury and peroneal nerve injury, what have you probably done to your knee?

Dislocated it
-beware of spontaneous relocation, you do not want to miss diagnosis of dislocation!!

22

Knee dislocation and vascular damage, when do you observe and when do you do arteriorgram?

Vascular injuries: Popliteal artery / vein injury
May not be obvious (intimal tear or thrombus

NORMAL EXAM = OBSERVE IN HOSPITAL

CLINICAL CONCERN = ARTERIOGRAM / MRI

23

How would you stabilise a knee after reduction?

Splint or external fixation

24

Time window for vascular repair following knee dislocation?

6 hours

25

Complications of knee dislocation

Arthrofibrosis and stiffness
Ligament laxity
Nerve or arterial injury

26

Fractures associated with hip dislocation?

Posterior acetabular wall
Femoral fractures

27

Flexed, internally rotated and adducted knee

Hip dislocation

28

Complications of hip dislocation

Sciatic nerve palsy
Avascular necrosis of the femoral head
Secondary osteoarthritis of hip
Myositis ossificans

29

General principles for treatment of open fractures?

Antibiotics, tetanus, early debridement and operative stabilisation

30

Approx blood loss in femoral fracture?

1 litre

31

Risks associated with femoral shaft fracture?

Fat embolism, ARDS

32

Analgesia for femoral shaft fracture?

Femoral block

33

Splintage for femoral shaft fracture?

Thomas splint

34

Treatment for unstable femoral shaft fracture?

IM nailing

35

Treatment for distal femur fractures?

Extra-articular
If not too distal, can nail
Distal = plating
Intra-articular:
Anatomical reduction, rigid fixation
Plate and screws

36

Usual fracture of proximal tibia?

High energy young, low energy old

Usually Valgus stress  lateral tibial plateau # with disruption articular surface

37

What investigation should you carry out for proximal tibial fracture?

CT scan!! (to determine personailty of fracture)

38

Internal rotation and tibial shaft fracture?

Internal rotation POORLY toerated
Can tolerate 5 degress angulation any plane, 50% bony contact

39

Pilon fracture?

Intra-articular distal tibial fracture

40

Injuries associated with a distal tibial fracture?

Calcaneous
Pelvis
Spine
(distal tibial fracture is usually high energy)

THIS IS A SIGNIFICANT SOFT INJURY
-external fixation
- +/- limited internal fixation
- CT

41

What happens if you have a distal fibular fracture with deltoid ligament rupture?

Talar shift

42

Often avulsion fracture from triceps contraction

Olecranon fracture

43

Radial head fracture

# can occur with dislocation elbow

Minimally displaced marginal fractures treated conservatively (unless fragment blocking ROM)
Can fix displaced fractures with large fragments

Comminuted fractures  excise +/- replacement

44

Galeazzi fracture

Fracture of radius, dislocation of DRUJ

45

Monteggia

Fracture of ulna and dislocation of radial HEAD

46

Management of night stick fracture?

Conservative
(direct blow to ulna *may* cause isolated ulna fracture

47

Management of galeazzi or monteggia?

ORIF fractured bone
Once reduced, radial head or distal ulna should reduce

48

Treatment for Colles fracture

Colles fracture – FOOSH  extra-articular #, dorsal angulation, dorsal displacement
Stable, minimally displaced / angulated  POP
Displaced simple #  MUA
Displaced, comminution  MUA & K-wiring, ORIF

49

Complications of colles fracture

Complications – Median nerve compression, EPL rupture, CRPS, loss grip strength
(CRPS: complex regional pain syndrome)

50

Treatment for smiths fracture?

Smiths fracture is VERY UNSTABLE!!! Colles you might be able to get away with conservative but smiths you need to ORIF!
(Smiths = fall on back of hand, extra-articular, volar displacement and angulation)

51

Which x-ray view do you need for Barton's wrist fracture?

Lateral view

52

What is a bartons fracture?

INTRA-articular fracture of the radius
-extend through dorsal aspect
-Usually associated with carpal displacement
(colles and smiths = extra articular)
Need a lateral view
Ex-fix +/- k wires

53

Lethal triad associated with polytrauma?

Hypothermia
Acidosis
Coagulopathy

54

Polytrauma --> what do you do?! This is serious

Aim for rapid skeletal stabilisation with reduced biological load  reduce bleeding & fat embolism

Ex-fix, rapid plate fixation, ?nailing

Leave minor fractures until later

55

Fractures to prioritise in polytrauma?

Treat only :
Unstable pelvic #, femoral #, tibial #
Injuries with vascular compromise
Open fractures
(Impending) Compartment syndrome

56

Open debridement / removal of osteophytes suitable for which joints?

Ankle
1st MTP
Elbow

57

Arthrodesis is gold standard for which joints?

Hallux rigidus
Ankle
Wrist
PIP and DIPJ hand
Spine (temporarily)

58

Gold standard for hallux valgus?

Osteotomy

59

Gold standard for hallux rigidus?

Excision arthroplasty

60

Main indication for joint replacement (lower limb)?

Pain relief
-May not improve ROM
(upper limb, may improve function)

61

Success and survival rates for joint replacement?

Success rate = 80%
Lasts for 15-20 years

62

Gold standard surgery for shoulder arthritis?

Total shoulder replacement
-not if glenoid bone loss
-needs intact rotator cuff

63

Requirements for shoulder replacement?

Not if glenoid bone loss
Needs intact rotator cuff

64

Reverse polarity shoulder replacement?

Allows fulcrum for deltoid to work
Can give decent function in difficult cases
High complication rate – glenoid loosening 25- 50%

65

Scarf test

Acromioclavicular joint

66

Maximum lifting in elbow replacement?

5 kg
Total elbow replacement
Best results for RA
For low demand
Max 5kg lifting
14-25% complication rate – infection, loosening, fracture, triceps dysfunction, ulnar nerve injury

67

Gold standard for wrist arthritis?

Fusion!! (arthrodesis)
-maintains movement (90 degrees)
-high complication rate
-reduced grip strength

68

DRUJ and ulno-carpal arthritis

Excision arthroplasty
Hemiresection arthroplasty
Fusion & osteotomy
Replacement (long term results not known)

69

Treatment for extensor tendon rupture?

Tendon transfer

70

Boutonniere and swan neck surgery treatment?

Boutonniere & swan neck
Complex! Splintage first line
Tendon releases & reconstructions
PIP fusion vs replacement for severe Boutonniere
DIPJ fusion for swan neck

71

Treatment for 1st CMC joint arthritis?

Trapeziectomy
Good pain relief
Can have weakness pinch

Arthrodesis

72

Most common cause of acquired flatfoot deformity in adults?

Posterior tibial dysfunction

73

Primary dynamic stabiliser of medial longitudinal arch – elevates arch
Invertor & plantar-flexor

Tibialis posterior

74

Where does the tibialis posterior attach?

The navicular tuberosity and the plantar aspect of the medial and middle cuneiforms

75

Risk factors for posterior tibialis dysfunction?

Obese middle aged female
Increases with age
Flat foot
Hypertension
Diabetes
Steroid injection
Seronegative arthropathies
Due to a tendinosis of unknown aetiology

76

Pain and/or swelling posterior to the medial malleolus (very specific)

Posterior tibialis dysfunction

77

Pain and/or swelling posterior to medial malleolus – very specific
Change in foot shape
Diminished walking ability/balance
Dislike of uneven surfaces
More noticeable hallux valgus
Lateral wall “impingement” pain

Tibialis posterior dysfunction

78

Type 1-3 of posterior tibial dysfunction?

Type 1: no deformity
Type 2: flat foot deformity, cannot single heel raise, can see "too many toes" at side
-passively correctable!!
Type 3: rigid, deltoid ligament compromise, ANKLE PAIN

79

Treatment for posterior tibialis dysfunction

Physiotherapy
Insole to support medial longitudinal arch
NO steroid injections
Orthoses to accommodate foot shape
Bespoke footwear
Surgery

80

Pes Cavus

Idiopathic commonest
Variety of other causes (mostly neurological: HSMN, CP, Polio, Spina bifida, club foot)
Often clawing of toes
Surgery if required may be complex (soft tissue releases, tendon transfers, calcaneal osteotomy, arthrodesis)

81

Typical ankle sprain?

Lateral (anterior talofibular ligament and calcaneofibular ligament)

82

5th metatarsal injury?

1. Avulsion by peroneus brevis tendon (heal predictably in moonboot, do well)
2. Jones fracture, poor blood supply, 25% risk non-union
3. Proximal shaft (common site for stress fracture)

83

Which muscle might cause an avulsion fracture of the fifth metatarsal?

Peroneus brevis
-this fracture will do well in a moon boot :)

84

Common site for stress fracture of 5th metatarsal?

Proximal shaft

85

Problem with jones fracture of 5th metatarsal?

Poor blood supply, 25% risk of non-union

86

Fall from height = might fracture what?

Calcaneus
-look for other injuries e.g. spinal
-often intra-articular
-lots of swelling
-no proven beenfit of surgery

87

Fracture following forced dorsiflexion/rapid deceleration of foot?

Talus fracture
-Talus has reverse blood supply, risk of AVN and OA

88

Tinel's test positive for Baxter's nerve?

Plantar fasciitis

89

"heel spurs" and "heel pad pain syndrome"

Plantar fasciitis

90

Causes of plantar fasciitis?

overload – excessive exercise, excessive weight
Seronegative arthropathy
Diabetes – why?
Abnormal foot shape – planovalgus or cavovarus
Improper footwear

91

Abnormal foot shape associated with plantar fasciitis?

Planovalgus, cavovarus

92

Treatment for plantar fasciitis?

NSAIDS
Night splints
Taping
Heel cups or medial arch supports
Physiotherapy – eccentric exercise programme
Steroid injection
Usually self-limiting over 18-24 months
Self management

93

Plantar fasciitis is usually self limiting over how many months?

Self limiting over 18-24 months

94

Splayed forefoot assoc with loss of muscle tone and age

Hallux valgus

95

Problems with Hallux valgus?

Problems
Transfer metatarsalgia
Lesser toe impingement
Pain, deformity, cosmesis
Shoe difficulties

Management
Non-operative (shoe modifications,padding)
Operative

96

Operative indications for Hallux valgus?

Operative management
Indications – failure of non-op, pain, lesser toe deformities, lifestyle limitation, overlapping, ulceration, functional limitation
Many osteotomies (not core)
Aim to realign the hallux and decrease the HV angle

97

Operation for Hallux valgus?

Break the bone and move the head laterally?

98

Osteoarthritis of 1st MTPJ is called what?

Hallux rigidus?

99

Drugs associated with tendo-achilles tendinosis?

Ciprofloxacin, steroids

100

Tendo-achilles tendinosis?

Implicated – over-training, some drugs (cipro,steroids), CTDs
Pain, morning stiffness, eases with HEAT/walking

101

Clinical features of tendo-achilles rupture?

Usually over 40s
Often pre-existing tendinosis
Sudden deceleration with resisted calf contraction
Patients often think somebody has hit them
Clinically
Unable to bear weight
Weak plantar flexion
Palpable painful gap
Positive calf squeeze (Simmonds) test

102

Surgery for claw, hammer and mallet toes?

Acquired imbalance between flexors and extensors
Can cause painful callus/corns with skin breakdown
Surgery can include tenotomies (division of tendons), tendon transfer, fusions (PIP) or amputation

103

When do you refer for bow legs?

If painful, asymmetry, height more than 2 SDs below normal
Not resolving
(bow legs normal under 2 years, internal tibial torsion if more than 2 years)

104

Curly toes

Many resolve
3rd/4th toes
6 years
No splints
Tenotomy

105

Getting up from squatting

Meniscal tear

106

Twisting injury to knee

ACL or meniscal tear

107

Dashboard/hyperextension

PCL

108

McMurrays

Meniscal provocation test

109

Grade 1 sprain

Macroscopic structure intact

110

Grade 2 strain

Partial tear - some fascicles disrupted

111

Grade 3 strain

Complete tear

112

LCL injury associated with which nerve injury?

Common peroneal nerve
-complete rupture needs urgent repair (later will need reconstruction)

(MCL usually heals with time, PCL usually damaged with other ligaments = reconstruction, if isolated, can consider leaving alone)

113

Fall onto flexed knee with quads contraction

Extensor mechanism rupture

114

Risk factors for extensor mechanism rupture?

Previous tendonitis, steroids, chronic renal failure, ciprofloxacin