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Finals COPY (FdCi) > Trauma and Orthopaedics > Flashcards

Trauma and Orthopaedics Flashcards

1
Q

where does the achilles tendon insert distally?

where is the most likely site of achilles tendon rupture?

A

calcaneus

roughly 5cm proximal to its insertion

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2
Q

what action can a patient with achilles tendon rupture not do?

what is the test for achilles tendon rupture?

A

raise the heel from the floor when standing on that leg

Simmond’s/Thompson’s test - kneel on chair and squeeze the calf, lack of foot plantar flexion indicates tendon rupture

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3
Q

how do you manage achilles tendon rupture?

A

>50, diabetic, smoker, unfit - casting in equinus position with gradual (6-8 weeks) return to neutral. typically no weight baring for this whole time

young, fit, late presenting injury - percutaneous or open tendon repair

  • graded physio program, motivational interviewing
  • analgesia up the WHO pain ladder
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4
Q

what is the AO Weber classification of malleolar fractures?

how does this affect the management?

A

A - below the malleolus

B - at the level of the malleolus

C - above the malleolus

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5
Q

what is a maisonneuve’s fracture?

what is the management?

A

due to rotational force in the lower leg

  • # proximal 1/3rd of fibula
  • interosseuous membrane tear
  • # medial malleolus or deltoid legament tear

always surgical fixation - restore the ankle mortise and placement of 1/2 suprasyndesmotic screws at the proximal fibula

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6
Q

a displacement of one or more metatarsal bones from the tarsus is known as a …

A

Lisfranc fracture/dislocation

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7
Q

what is the management of a lisfranc fracture/dislocation?

A

needs surgical repair because of high risk of medial foot compartment syndrome

can be difficult to characterise the injury on plain film, MRI foot maybe necessary

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8
Q

what is a bunion?

A

a foot deformity in which hallux deviates laterally (valgus) at the metatarsophalangeal joint, typically presenting bilaterally

pressure of the MTP against the shoe causes soft tissue reaction and formaiton of a growth and induration which is disfiguring

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9
Q

what are the risk factors for halux valgus?

A
  • F>M
  • type of shoe wear
  • older age
  • hypermobile joints
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10
Q

what is the main complication of halux valgus?

A

OA of the affected joint

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11
Q

management options for halux valgus?

A
  • education
    • appropriate footwear (low-heel, flat, wide)
    • foot muscle stregthening exercises
    • bunion pads and plastic wedges (between big and 2nd toes)
  • correction of deformity requires surgery
    • aim to achieve toe alignment
    • relieve pain
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12
Q

what is morton’s neuroma?

diagnosis and treatment

A

compression of the foot for a long period of time (tight high heels) causes growth of a neuroma in the interdigital space

neuroma compresses the surrounding structures and leades to pain on the lateral aspect of one metatarsal and the medial aspect of the other

diagnosis: MRI or US
treatment: surgical excision

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13
Q

what is plantar fasciitis?

A

plantar fascia supports the arch of the foot

can affect obese/immobile or the highly active

damage due to microtrauma and erosions - not inflammatory

treatment: stretch achilles tendon, orthotics, shockwave therapy.
encourage activity in the inactive, and encourage patience in athletes

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14
Q

what is the course of the blood supply to the femoral head?

A
  • external iliac
  • femoral
  • profunda femoris
  • lateral and medial circumflex femoral
  • ascending retinacular

AND

  • internal iliac
  • obturator, lateral branch
  • small foveal artery in the ligamentum teres
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15
Q

is traumatic or elective hip arthroplasty more likely to be total hip replacement?

A

elective is more likely to he THR

traumatic is more likely to be a hemi, due to comorbidites

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16
Q

what is the garden classification of intercapsular neck of femur fractures?

A
  1. undisplaced, incomplete
  2. undisplaced, complete
  3. partial displacement, complete
  4. displaced, complete
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17
Q

what are all of these called?

how do these relate to management?

A
  1. sub-capital - garden class.
  2. transcervical - garden class.
  3. basi-cervical - DHS
  4. intertrochanteric - DHS
  5. reverse oblique/transtrochanteric - intramedullary hip screw
  6. subtrochanteric - intramedullary hip screw
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18
Q

what are the images needed for managing #NOF?

A

AP and lateral hip plain radiograph

may need a CT/MRI as 2-10% of #NOF can be missed on plan films

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19
Q

what are some strategies for preventing #NOF in primary practice?

A
  • exercise, balance training (Tai Chi) and keep fit classes
  • prevent sedation (medicines reconciliation)
  • prevent osteoporosis (bisphosphonates, vitamin D, exercise)
  • occupational therapy visit at home to check lighting and support on stairways and around doors
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20
Q

what is dangerous about a pubic ramus fracture?

A

can lead to laceration of the bladder, vagina or perineum

operative management should be considered

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21
Q

what are the early complications of arthroplasty?

A
  • local
    • dislocation
    • deep infection
    • fracture
    • neurovascular damage
    • limb-length discrepancy
  • general
    • VTE
    • sepsis
    • death
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22
Q

what are the indications for total hip replacement?

A

degenerative

  • OA
  • RhA

congenital

  • congenital dislocation of the hip

traumatic

  • intracapsular fracture neck of femur
  • avascular necrosis of the head of femur
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23
Q

you are considering whether an arthroplasty is loosening or infected.

plain radiographs are inconclusive.

what is the next step in investigation?

A

strontium or technetium bone scan to reveal level of bone activity

in suspected sepsis, US guided arthrocentesis is indicated

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24
Q

what are the major late complication/failures of arthroplasty?

A
  • dislocation (mostly THR)
    • weakness of the muscles that are divided during surgery leads to increased risk of posterior hip dislocation
  • prosthetic loosening
    • chronic pain, increased risk of fracture
    • worst with metal on metal
  • periprosthetic fractures
    • presents after relatively minor trauma to the joint
  • infection
    • catastrophe
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25
Q

what is the mechanism of injury for ACL tear?

A

twisting injury to the knee with foot fixed on the ground

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26
Q

what is the management of ACL tear?

A
  • rest the knee for 3 weeks with adequate pain relief
  • if young, perform ACL reconstruction after this time

otherwise..

rest, physio and exercise gradually, pain control

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27
Q

what is the main complication of leaving an ACL unrepaired (i.e. chronic ACL insufficiency)?

A

OA of that joint

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28
Q

what is the mechanism of injury in a PCL tear?

A

car crash as the knee hits the dashboard and is driven backwards

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29
Q

explain ‘knee locking’ as a sign following trauma?

A

indicates damage to the meniscus

displaced meniscal segment becomes trapped between the femoral and tibial condyles

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30
Q

what is the management of meniscal tear?

A

PRICER - protect, rest, ice, compression, elevation, rehabilitate

orthopaedic surgeons will assess:

  • partial or total mesicectomy (not really done anymore)
  • implantation of biodegradable scaffold
  • meniscal repair (favoured)
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31
Q

sum up the difference in management between PCL and ACL tear

A

PCL is much stronger so tears much less frequently than AClL

also, reconstruction is much more difficult and outcomes are less predictable

management is often conservative

32
Q

what is the management of a medial collateral ligament tear?

A

medial - treated conservatively

PRICER

firm support is needed during rehab using splints and braces

33
Q

what is the management of a lateral collateral ligament tear?

A

lateral collateral tear will be a more high energy injury than a medial, so there is likely to be damage to other structures such as:

  • ACL/PCL
  • common peroneal nerve

look for signs of this damage and surgery is more likely to be required

34
Q

what are the signs of IT band pain syndrome? what is the pathology?

A

irritation and pain produced when the IT band slides over the lateral tibial tuberosity during knee flexion

lateral pain on knee flexion and palpation of the lateral tibial tuberosity

35
Q

what is patellofemoral pain syndrome?

who gets it? what is the main priciple of treatment?

what is the clinical sign for diagnosis?

A

PFPS - overuse injury of the lower limb also associated with previous patella dislocation/subluxation, trauma, muscle imbalance or malalignment
medial retropatellar tenderness on compression

young atheles with recent increase in exercise reigme

Rx - rest initially, then graded return to exercise program with quadraceps muscle stregthening

diagnosis - Clarke’s sign = retropatellar pain on patellar crompression with tensed quadraceps

36
Q

do hip or knee replacements last longer?

A

knee

90% last 15 years

37
Q

define a knee replacement

A

can be total or partial (unicompartmental)

involves resection of the articular surfaces of the knee and replacement with metal or polyethylene components

38
Q

what are the indications for knee replacement?

A
  • (mostly) osteoarthritis
    • debilitating pain, gets pt up at night, interferes with ADLs, stops social function
  • rheumatoid arthritis
  • post-traumatic (haemarthrosis) arthritis
39
Q

what are the phases of adhesive capsulitis?

A
  1. painful phase (up to 1 yr) - pain on acitve and passive movement, reduced ROM (esp ABduction and external rotation)
  2. frozen phase (6-12 months) - pain settles but shoulder is still stiff
  3. thawing phase (1-3 years) - no pain, shoulder slowly regains movement
40
Q

what are the association of adhesive capsulitis?

A
  • cervical spondylosis
  • diabetes
  • thyroid disease

always check glucose, HbA1c and TFTs

41
Q

what is the role of steroids in adhesive capsulitis?

A

can be given intra-articularly for the painful phase

no use of systemic steroids, not used in clinical practice

42
Q

what are the surgical management options for adhesive capsulitis?

A
  • manipulation under anaesthesia
  • arthroscopic arthrolysis
43
Q

what is the test for biceps tendonopathy?

A

Speed’s test - elbow extended, sholder flexed to 60deg

shoulder flexion against resistance and palpation of biceps tendon ilicits pain

44
Q

what are the origin sites for the long and short head of the biceps tendon?

A

long - supraglenoid tubercle

short - coracoid process of scapula

45
Q

how do you test for biceps tendon rupture?

A

bruising and pain in the upper arm

Popeye sign - flexion of the elbow shows a swelling in the distal portion of the arm caused by the muscle belly of biceps brachii contracting against no resistance

Ludington’s test - both hands behind the patients head, clinician behind the patient, observing for asymmetry and painful swelling

46
Q

what is the movement most sensitive for proximal biceps tendon rupture?

A

forearm supination

NB not elbow flexion, as the other flexor muscles of the arm contribute more to this

47
Q

mostly what is the management of biceps tendon rupture?

what factors would affect the decision?

A

PRICER and slow rehab - surgery not usually indicated

young, fit, active and healthy patient maybe considered for surgical repair

48
Q

what point along the clavicle is most likely to fracture?

A

middle 1/3rd, with the proximal segment pulled superiorly by action of SCM contraction

49
Q

what are the complications of a clavicle # that you should always consider?

A

neurovascular (subclavian artery and brachial plexus)

pneumothorax

50
Q

what active movement will bring pain to a patient with a dislocated AC joint?

A

ADduction of the arm across the body

51
Q

what are the two main options for managing AC joint dislocations?

A
  • rest in broad arm sling (minor injury with minimal displacement)
  • open reduction and rotator cuff/ligament repair
52
Q

what is one of the most important nerves to test in a AC joint dislocation?

A

axillary nerve supplying sensation to the regemental patch (pre- and post-reduction)

53
Q

who gets proximal humerus fracture?

A

elderly osteoporotics, injury = FOOSH

54
Q

what is the management of a mid-humeral shaft fracture

A

rarely surgical - treat with brace and ‘collar and cuff’ sling gives satisfactory reduction

immobilize 8-12 weeks

55
Q

what is the complication of a mid-humeral shaft fracture?

A

damage to the radial nerve as it passes around the spiral groove of the humerus

sings - wrist drop and loss of digit extension

56
Q

what are the shoulder lesions associated with AC dislocation?

A

Bankhart - avulsion injury of the anterior inferior glenoid labrum

Hill-Sachs - impaction fracture of the posterior lateral humeral head, seen on lateral shoulder plain film with medial arm rotation

57
Q

what is the referral criteria for impingement syndrome?

A

if pain has lasted >6 months refractory to physiotherapy, subacromial bursa injection of steroids and local anaesthetic, and NSAIDs

58
Q

at what level(s) is disc herniation most likely to occur?

A

98% occurs between L4-S1

59
Q

what are some common causes of sciatica/sciatic nerve pain?

A

disc herniation

pregnancy

spinal stenosis

cauda equina syndrome

60
Q

what is the diagnostic investigation for spinal stenosis?

A

MRI back

61
Q

wrist #

dorsal angulation of the distal radial segment…

A

Colle’s #

less dangerous from a neurovascular perspective

62
Q

wrist #…

volar displacement and angulation of the distal radial fragment

A

Smith’s fracture

more dangerous to the neurovascular structures and the distal fragment tends to migrate

63
Q

allergy to which commonly used drug is associated with allergy to sulfasalazine?

A

aspirin

64
Q

what are the causes of a +ve tendelenburg sign?

A

muscle

  • wasting 2ary to surgery
  • wasting 2ary to degenerative arthritis

nerve (superior gluteal)

  • damage 2ary THR
  • damage 2ary developmental dysplasia of the hip
  • GBS
  • old polio
65
Q

what are the extra-articular features of rheumatoid arthritis?

A

eyes

  • keratoconjunctivitis sicca, scleritis (painful), episcleritis

nodules

  • skin, lung, pleura, pericardium, CNS, lymph nodes

lungs

  • restrictive LD (20%), obstructive LD (bronchiolitis - 55%), pleurisy/pleural effusion (5%), cavitating lesion

heart

  • pericardial effusion, pericarditis, restrictive cardiomyopathy

systemic

  • ACD, osteomalacia/osteoporosis, AL amyloidosis, splenomegaly (+/- Felty’s syndrome)
66
Q

what are the causes of dupytren’s contracture?

A
  • A - AIDS
  • B - ‘bent penis’ = peyronie’s disease
  • C - cirrhotic liver disease
  • D - diabetes mellitus
  • E - epilepsy esp. phenytoin
  • F - familial (autosomal dominant)
  • F - fibromatoses
67
Q

which muscles of the hand are innervated by the median nerve?

A
  • first and second Lumbricals
  • Opponens pollicis
  • ABductor pollicis brevis
  • Flexor pollicis brevis
68
Q

how do you isolate median, ulnar and radial nerve motor function in a UL/hand exam?

A

ulnar - finger ADduction (hold piece of paper together between fingers)

median - thumb ABduction (lift thumb to ceiling with hand on table, palm facing upwards)

radial - MCPJ extension

69
Q

what are the causes of carpel tunnel syndrome?

A

anatomy

  • solid - deformity 2ary to #
  • soft - acromegaly, ganglion, obestiy

fluid

  • pregnancy, menopause, hypothyroidism

inflammation

  • RhA and gout

diabetes

  • excess collagen proliferation within the endoneurium
70
Q

at what level does the adult cord terminate?

A

L1-2

71
Q

what are the features of anterior spinal artery syndrome (Beck’s syndrome)?

A
  1. pain (at the level of the lesion)
  2. complete motor paralysis below the level of the lesion
  3. partial sensory deficit below the level of the lesion
    • loss of pain and temperature sensation
    • intact proprioception, vibration and two-point descrimination
  4. autonomic dysfunction - orthostatic hypotension;
    • depending on level of lesion - loss of urinary and anal sphincters, sexular dysfunction
72
Q

what is the difference between cona medullaris and cauda equina syndrome?

A

CM - involvement of the end of the cord (lesion at L1-2 level) so mixed UMN and LMN signs and autonomic dysfunction

CE - only LMN signs with autonomic dysfunction

73
Q

explain urinary retention and faecal incontinence in CE/CM syndromes?

A

loss of tone in both cases

anal sphincter - no tone = loss of continence

bladder atony = no expressive force to pass urine through the autonomous internal sphincter, retention and baldder distension, overflow incontinence

74
Q

what are the common causative organisms for prosthetic joint infection?

A

staph aureus

then coagulase negative staphylococcus

  • S. epidermidis, S. haemolyticus
75
Q

what is the diagnostic criteria for compartment syndrome?

A

intracompartmental pressure measurement

>20 mmHg is consistent with CS

>40 mmHg is diagnostic

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