Surgery - T&O Flashcards
How long is traction applied for and why?
Causes ligamentous laxity - 3 mins 30 secs applied
Describe the steps of secondary bone healing.
Why is primary bone healing preferred in intra-articular fractures and why?
Secondary bone healing = Haematoma, Inflammation, Angiogenesis, Soft Callus, Hard Callus, Lamellar Bone, Remodelling
Primary leads to osteoclast/blast based healing using compression eg. from a plate. Avoids the production of calluses, which interfere in the joint.
Paediatric fractures
What is the process by which child bone grow?
What is an easy way of determining child age?
Name the two types of paediatric fracture
Endochondral ossification from the physis
Can determine a child’s age via the carpal bones of the hand
Greenstick fracture (bendy fracture) and Torus fracture (crushing fracture)
Define the Salter Harris Classification
Type 1 - Separation of the physis from the bone Type 2 - Fracture above the physis Type 3 - Fracture below the physis Type 4 - Through the physis Type 5 - Crushing injury of the physis
Developmental Hip Defects
Name the 4 types of Hip Defect
Perthes Disease, DDH (developmental dysplasia of the hip), SUFE (slipped upper femoral epiphysis), Congenital Talipes Equinovarus
Perthes Disease Pathophysiology: Symptoms: Investigations: Management:
Pathophysiology: Blood supply disrupted, causing AVN
Symptoms: Hip pain, knee or groin, difficulty walking, limp
Investigations: X-ray to show AVN
Management: Can do conservative management with NSAIDs, physio and braces, or osteotomy to keep hip in acetabulum
SUFE (Slipped Upper Femoral Epiphysis) Pathophysiology: Symptoms: Investigations: Management:
Pathophysiology: Head of femur (metaphysis) slips backwards off the femur. Normally occurs at puberty.
Symptoms: Pain in hip, knee or groin, difficult walking, limp.
Investigations: X-ray
Management: Screw insertion and avoid weight bearing for 6 weeks
Congenital talipes equinovarus
Pathophysiology:
Management:
Pathophysiology: Tendons shortened, leading to feet rotated inward
Management: Tendon cutting (eg. achilles tendon) and adding pins and casting
Developmental dysplasia of the hip (DDH) Pathophysiology: Risk factors: Symptoms: Investigations: Management:
Pathophysiology: Acetabulum is too shallow, leading to consistent hip dislocations and subluxation
Risk factors: Breach birth, FH
Symptoms: Hip pain, restrictive movement in 1 leg, uneven skin folds/abnormal leg length
Investigations: 6-week baby checks (Barlow and Ortolani tests)
Management: Pavlik harness to secure the hips
What is the bone at the base of the thumb? What is it associated with?
Trapezium, OA of the thumb
Where should: Radial nerve Median nerve Ulnar nerve Innervations be tested?
Radial - snuffbox/1st dorsal webspace
Median - palmar aspect of tip of index finger
Ulnar - ulnar border of hand
How should Radial nerve Median nerve Ulnar nerve Motor functions be tested?
Radial: Extend the wrist, extend the thumb
Median: OK sign + Thumb to little finger
Ulnar: Spread fingers against resistance, adduction of the thumb
What does the cubital fossa contain?
What are its borders?
Really need beer to be at my nicest: Radial nerve Biceps tendon Brachial artery Median nerve
Superior: Imaginary line between epicondyles
Medial: Pronator teres
Lateral: Brachioradialis
What are the stabilisers of the shoulder?
Name the 4 rotator cuff muscles
Static - Glenoid Labrum, Bony anatomy
Dynamic - Rotator cuff muscles, long head of biceps tendon
Rotator cuff: Supraspinatus, Infraspinatus, Teres minor, Subscapularis
What are the separate sections of the Brachial Plexus?
Real teenagers drink cold beer
Roots Trunk Division Cords Branches
What are the nerve roots for each of the nerves of the brachial plexus?
Musculoskeletal -3 musketeers - C5, C6, C7 Axillary - Assassinated - C5, C6 Radial - By 5 rats - C5, C6, C7, C8, T1 Median - 4 mice - C6, C7, C8, T1 Ulnar - 2 unicorns - C8, T1
What is the main blood supply to the neck of the femur?
Medial circumflex femoral artery
Which side of the tibia is wider?
Where are the menisci sat?
Medial side is wider
Menisci sit on the tibia
What are the components of the foot? (both the triad and the individual bones)
In which configuration is the ankle most stable and why?
Tarsals, metatarsals, phalanges
Talus, calcaneus, navicular, cuboid, cuneiforms
The talus is wedge shaped - narrower at the back. This means it is most stable in dorsiflexion.
What are the 4 principles of fracture management?
Resuscitate
Reduce
Immobilise
Rehabilitate
Why is reduction carried out?
Tamponades any bleeding, reduces traction from surrounding tissues and inflammation (which increases complications), reduces risk of nerve entrapment, reduces pressure on blood vessels
Plaster casting
What 2 key concepts must be remembered with regards to a new cast being put on?
What is an important risk of plaster casting?
- Must not be a fully circumferential cast, to allow the fracture to swell
- Must cast joint above and below if axial instability - for most, only needs to cross distal joint
Compartment syndrome is a risk
Open Fractures
What is the classification for open fractures?
Define the types of this classification
Management of an open fracture
Classification: Gustillo-Anderson
Type 1 - <1cm clean
Type 2 - 1-10cm clean
Type 3a - > 10cm with good soft tissue coverage (orthopaedic)
Type 3b - >10cm but not good tissue coverage (plastics)
Type 3c - >10cm with vascular impairment
Management: Urgently realign and splint, neurovascular exam, antibiotics and tetanus vaccine, photograph of the wound
Must eventually debride and wash out the wound
Scaphoid fracture Pathophysiology: Target demo: Symptoms: Signs: Risk factors: Investigations: Management: Complications:
Pathophysiology: Scaphoid has 3 parts (proximal pole, waist, distal pole) and blood supply is from radial artery. Enters distal pole and supplies proximal in retrograde fashion. Proximal scaphoid fractures = higher risk
Target demo: Men, Age 20-30, fall on hyperextended wrist
Symptoms: Wrist pain, bruising in anatomical snuffbox, pain on telescoping (pushing inwards) of the thumb
Signs:
Risk factors:
Investigations: Plain radiograph - “Scaphoid series” (AP, lateral, oblique) - not amazing at diagnosing, may need MRI
Management:
Un-displaced: Thumb spica splint
Displaced/proximal: Percutaneous compression screw
Complications: Degenerative wrist disease, AVN, non-union due to poor blood supply
What are the contents of the anatomical snuffbox?
Radial artery, radial nerve, cephalic vein, scaphoid
Distal Radius Fractures Pathophysiology: Target demo: Types: Symptoms: Risk factors: Investigations: What is the rule of 11s? Management: Complications:
Pathophysiology: Distal metaphysis fracture with or without articular involvement. FOOSH.
Target demo: 25% of all adult fractures. Increasing age (osteoporosis), but also children.
Types:
Colles’ - extra-articular, dorsal angulation
Smith’s - extra-articular, volar angulation
Barton’s - intra-articular fracture with associated dislocation of radiocarpal joint (usually volar)
Risk factors: Increasing age, female, early menopause, smoking/alcohol excess, prolonged steroid use
Investigations: Must evaluate neurovascular status, particularly muscle involvement. X-ray (rule of 11s).
Rule of 11s: Radial height > 11cm, Radial inclination <22 degrees, Radial volar tilt > 11 degrees
Management: Closed reduction using haematoma block, below elbow backslab cast, physio
Surgical: Intra-articular, young, or high-demand occupation - ORIF/K-wire fixation
Complications: Mal-union (would need osteotomy to repair shortened radius), median nerve compression, OA
Define Monteggia and Galeazzi fractures
Monteggia = Manchester United = Ulnar fracture, proximal, with radio-ulnar joint dislocation Galeazzi = Glasgow Rangers = Radial fracture distal, with radio-ulnar joint dislocation
Radial Head Fractures Pathophysiology: Symptoms: Investigations: Classification: Management:
Pathophysiology: Most common elbow fracture. Usually FOOSH with arm pronated.
Symptoms: Pain on supination/pronation
Investigations: AP and lateral elbow X-ray. Can see “Sail Sign”, which is elevation of the anterior fat pad.
Classification: Mason classification - <2mm displacement, >2mm displacement, complete displacement (Types 1-3)
Management: Type 3 needs ORIF or radial head replacement
Olecranon fracture Pathophysiology: Ages affected: Symptoms: Investigations: Management:
Pathophysiology: Fracture of the olecranon, site of insertion for the triceps muscles
Ages affected: Bimodal
Symptoms: Inability to extend elbow against gravity, elbow swelling
Investigations: AP and lateral
Management: Based on degree of displacement due to triceps -
<2mm = immobilisation at 60 degrees flexion
>2mm = olecranon plating
Supracondylar Humerus Fractures Target demo: Symptoms: Classification: Investigations: Management: Complications:
Target demo: Almost only children 5-7 years old
Symptoms: Limited range of elbow movement with ecchymosis of the anterior cubital fossa
Classification: Gartland, based on displacement
Investigations: Must examine nerves, AP and lateral - will see “Sail sign”
Management: Type 1 and 2 = Above elbow cast in 90 degrees flexion
Surgical: Closed reduction and K-wire fixation
Complications: - Neurovascular injury and vascular compromise is common:
Anterior interosseous nerve most commonly affected, ulnar nerve can be damaged by K-wire
- Malunion - “Gunstock deformity” (varus deformity of forearm)
- Volkmann’s ischaemic contracture - vascular compromise causes flexor muscle necrosis/fibrosis/contraction, leading to hand held in permanent “claw” flexion
Clavicle Fracture Target demo: Symptoms: Classification: Investigations: Management: Complications:
Target demo: Usually young people
Symptoms: Medial fragment will displace superiorly due to SCM, lateral fragment will displace inferiorly due to arm
Classification: Allman - Type 1 - Middle third (75%), Type 2 - Lateral third (unstable, malunion risk), Type 3 - Medial third (Neurovascular risk/pneumothorax risk)
Investigations: Must do neurovascular assessment (brachial plexus) and look for open fractures/tented/white/non-blanching skin
AP and modified axial X-ray
Management: Most treated conservatively with a sling supporting the elbow
If open, needs ORIF
Complications: Non-union, neurovascular injury, pneumothorax