Flashcards in sarah gill trying to kill us Deck (114):
Fall with shoulder in external rotation?
Anterior dislocation of shoulder
What should you check if you have anterior shoulder dislocation?
Axillary badge patch!!
Fall with shoulder in internal rotation?
Arm held in abduction
Humeral head inferior to the glenoid
-NEEDS PROMPT NEUROVASCULAR ASSESSMENT AND REDUCTION
Light bulb sign on x-ray, which type of shoulder dislocation?
Posterior shoulder dislocation
Elbow dislocation gives small risk of which two fractures?
Coronoid process and radial head
Say you pull a child's arm upwards, what could you dislocate?
Management of shoulder dislocation?
Closed reduction under sedation
Stabilisation & rehabilitation
Management of elbow dislocation?
Closed reduction under sedation
Open reduction rarely required
2 weeks in sling & rehabilitation
Hippocratic, Kocher’s, in-line traction used to reduce which type of dislocation?
Traction in extension +/- pressure over olecranon used to reduce which type of dislocation?
Closed reduction under digital or metacarpal block
Open reduction rarely required
2 weeks in neighbour strapping
Volar slab in Edinburgh position if unstable ++
Which way will the patella dislocate?
It will always be a LATERAL dislocation
Always a lateral dislocation?
Who is most likely to sustain a patella knee dislocation?
Associations/causes of patella dislocation?
Under-developed (hypoplastic) lateral femoral condyle
Increased femoral neck anteversion
Lateral quads insertions or weak vastus medialis
Line 1: ASIS to midpoint of patella
Line 2: Tibial tuberosity to midpoint of patella
Examination of dislocated knee cap?
Pain medially (from torn medial retinaculum)
Patella apprehension test +ve
Management of knee dislocation
Reduce with knee extension
Surgery for repeat dislocations of the knee
Lateral release with medial reefing
Patellar tendon reallignment
Lateral collateral ligament injury and peroneal nerve injury, what have you probably done to your knee?
-beware of spontaneous relocation, you do not want to miss diagnosis of dislocation!!
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
How would you stabilise a knee after reduction?
Splint or external fixation
Time window for vascular repair following knee dislocation?
Complications of knee dislocation
Arthrofibrosis and stiffness
Nerve or arterial injury
Fractures associated with hip dislocation?
Posterior acetabular wall
Flexed, internally rotated and adducted knee
Complications of hip dislocation
Sciatic nerve palsy
Avascular necrosis of the femoral head
Secondary osteoarthritis of hip
General principles for treatment of open fractures?
Antibiotics, tetanus, early debridement and operative stabilisation
Approx blood loss in femoral fracture?
Risks associated with femoral shaft fracture?
Fat embolism, ARDS
Analgesia for femoral shaft fracture?
Splintage for femoral shaft fracture?
Treatment for unstable femoral shaft fracture?
Treatment for distal femur fractures?
If not too distal, can nail
Distal = plating
Anatomical reduction, rigid fixation
Plate and screws
Usual fracture of proximal tibia?
High energy young, low energy old
Usually Valgus stress lateral tibial plateau # with disruption articular surface
What investigation should you carry out for proximal tibial fracture?
CT scan!! (to determine personailty of fracture)
Internal rotation and tibial shaft fracture?
Internal rotation POORLY toerated
Can tolerate 5 degress angulation any plane, 50% bony contact
Intra-articular distal tibial fracture
Injuries associated with a distal tibial fracture?
(distal tibial fracture is usually high energy)
THIS IS A SIGNIFICANT SOFT INJURY
- +/- limited internal fixation
What happens if you have a distal fibular fracture with deltoid ligament rupture?
Often avulsion fracture from triceps contraction
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
Fracture of radius, dislocation of DRUJ
Fracture of ulna and dislocation of radial HEAD
Management of night stick fracture?
(direct blow to ulna *may* cause isolated ulna fracture
Management of galeazzi or monteggia?
ORIF fractured bone
Once reduced, radial head or distal ulna should reduce
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
Complications of colles fracture
Complications – Median nerve compression, EPL rupture, CRPS, loss grip strength
(CRPS: complex regional pain syndrome)
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)
Which x-ray view do you need for Barton's wrist fracture?
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
Lethal triad associated with polytrauma?
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
Fractures to prioritise in polytrauma?
Treat only :
Unstable pelvic #, femoral #, tibial #
Injuries with vascular compromise
(Impending) Compartment syndrome
Open debridement / removal of osteophytes suitable for which joints?
Arthrodesis is gold standard for which joints?
PIP and DIPJ hand
Gold standard for hallux valgus?
Gold standard for hallux rigidus?
Main indication for joint replacement (lower limb)?
-May not improve ROM
(upper limb, may improve function)
Success and survival rates for joint replacement?
Success rate = 80%
Lasts for 15-20 years
Gold standard surgery for shoulder arthritis?
Total shoulder replacement
-not if glenoid bone loss
-needs intact rotator cuff
Requirements for shoulder replacement?
Not if glenoid bone loss
Needs intact rotator cuff
Reverse polarity shoulder replacement?
Allows fulcrum for deltoid to work
Can give decent function in difficult cases
High complication rate – glenoid loosening 25- 50%
Maximum lifting in elbow replacement?
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
Gold standard for wrist arthritis?
-maintains movement (90 degrees)
-high complication rate
-reduced grip strength
DRUJ and ulno-carpal arthritis
Fusion & osteotomy
Replacement (long term results not known)
Treatment for extensor tendon rupture?
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
Treatment for 1st CMC joint arthritis?
Good pain relief
Can have weakness pinch
Most common cause of acquired flatfoot deformity in adults?
Posterior tibial dysfunction
Primary dynamic stabiliser of medial longitudinal arch – elevates arch
Invertor & plantar-flexor
Where does the tibialis posterior attach?
The navicular tuberosity and the plantar aspect of the medial and middle cuneiforms
Risk factors for posterior tibialis dysfunction?
Obese middle aged female
Increases with age
Due to a tendinosis of unknown aetiology
Pain and/or swelling posterior to the medial malleolus (very specific)
Posterior tibialis dysfunction
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
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
Type 3: rigid, deltoid ligament compromise, ANKLE PAIN
Treatment for posterior tibialis dysfunction
Insole to support medial longitudinal arch
NO steroid injections
Orthoses to accommodate foot shape
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)
Typical ankle sprain?
Lateral (anterior talofibular ligament and calcaneofibular ligament)
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)
Which muscle might cause an avulsion fracture of the fifth metatarsal?
-this fracture will do well in a moon boot :)
Common site for stress fracture of 5th metatarsal?
Problem with jones fracture of 5th metatarsal?
Poor blood supply, 25% risk of non-union
Fall from height = might fracture what?
-look for other injuries e.g. spinal
-lots of swelling
-no proven beenfit of surgery
Fracture following forced dorsiflexion/rapid deceleration of foot?
-Talus has reverse blood supply, risk of AVN and OA
Tinel's test positive for Baxter's nerve?
"heel spurs" and "heel pad pain syndrome"
Causes of plantar fasciitis?
overload – excessive exercise, excessive weight
Diabetes – why?
Abnormal foot shape – planovalgus or cavovarus
Abnormal foot shape associated with plantar fasciitis?
Treatment for plantar fasciitis?
Heel cups or medial arch supports
Physiotherapy – eccentric exercise programme
Usually self-limiting over 18-24 months
Plantar fasciitis is usually self limiting over how many months?
Self limiting over 18-24 months
Splayed forefoot assoc with loss of muscle tone and age
Problems with Hallux valgus?
Lesser toe impingement
Pain, deformity, cosmesis
Non-operative (shoe modifications,padding)
Operative indications for Hallux valgus?
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
Operation for Hallux valgus?
Break the bone and move the head laterally?
Osteoarthritis of 1st MTPJ is called what?
Drugs associated with tendo-achilles tendinosis?
Implicated – over-training, some drugs (cipro,steroids), CTDs
Pain, morning stiffness, eases with HEAT/walking
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
Unable to bear weight
Weak plantar flexion
Palpable painful gap
Positive calf squeeze (Simmonds) test
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
When do you refer for bow legs?
If painful, asymmetry, height more than 2 SDs below normal
(bow legs normal under 2 years, internal tibial torsion if more than 2 years)
Getting up from squatting
Twisting injury to knee
ACL or meniscal tear
Meniscal provocation test
Grade 1 sprain
Macroscopic structure intact
Grade 2 strain
Partial tear - some fascicles disrupted
Grade 3 strain
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)
Fall onto flexed knee with quads contraction
Extensor mechanism rupture