Trauma & Orthopaedics Flashcards by Lucy McGarvey

Compartment Syndrome - presentation

Pain out of proportion of injury 
Pain on passive stretch
Paraesthesia 
Pale/pallor
High pressures
Paralysis

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Compartment Syndrome - management

Management:
Initial
• Notify trauma/ortho team - reg/consultant input needed
• Removed external dressings or bandages
• Elevate limb above heart
• Maintain good pressure control - avoid hypotension
Definitive
• Emergency fasciotomy - cut down & release fascia & relieve pressure
○ Explore, debride & remove any necrotic tissue
○ Wound left open but dressed
○ Plastics input for repair & potential grafts

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Necrotising fasciitis - definition & aetiology/risk factors

rapidly progressing soft tissue infection which spreads along fascial planes
when involves penis/scrotum = Fournier’s gangrene

caused by polymicrobial infection or group a strep

trauma (open fractures), diabetes, immunocompromised, malignancy, IVDU, abscesses, age >60 - older age increases risk

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Necrotising fasciitis - clinical features

Pain - precedes by 24-48hrs
Stages:
○ Stage I - Erythema, tenderness, swelling and warmth.
○ Stage II - Bullae formation, blistering and fluctuation of the skin.
○ Stage III - Haemorrhagic bullae, crepitus and tissue necrosis.
Fever, shock, AKI

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Necrotising fasciitis - management

Imaging

Resuscitation
Surgical exploration & radical debridement +/- amputation
Board spec IV abx

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Osteomyelitis - definition & pathogenesis

infection/inflammation of bone
causative organisms - staph aureus or pseudomonas aeruginosa (IVDU)

PATHOGENESIS
Haematogenous spread- refers to the spread via the blood
Non-haematogenous - breakdown or removal of the normal protective barriers

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Osteomyelitis - clinical presentation

fever, pain, local inflammation
erythema
swelling

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Osteomyelitis - risk factors

open fractures
ortho ops inc prostetics
IVDU
diabetes - diabetic foot ulcers
immunosuppressed
PVD

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osteomyelitis - investigations

Bloods
	• FBC - high WCC
	• CRP/ESR - high
	• U&Es - due to abx therapy 
	• LFTs
	• HbA1c - DM = risk factor
Imaging
	• X-rays; often won't show early changes, MRI; gold std used for dx

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Osteomyelitis - management

Management:
• Medical; 6 week abx therapy
• Surgical; debridement of infected bone/tissu

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Cauda Equina Syndrome - definition & classes

Compression of cauda equina (L2/L3)
Early - pain
Incomplete - + urinary difficulties
Retention – as above with painless retention

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CES - causes

Lumbar disc herniation (L5/S1 and L4/L5 level most common)
Metastasis/malignancy
Lumbar cord stenosis 
Trauma
NTD
Infection (abscesses)

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CES - Clinical Features

Lower back pain
- Unilateral or bilateral leg pain
- Paraesthesia in lower limbs
- Weakness in lower limbs
- Incontinence - bladder/bowels
- Loss of sensation in perianal region
- Urinary retention

On examination CES will have LMN signs

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CES - Investigations

Bedside
	• Observations
	• Urinalysis
	• Full neurological examination
	• PR exam
Bloods
	• FBC & CRP

Imaging
• Bladder scan - if retention suspected
• X-rays - AP, lateral
• Emergency MRI - gold std to r/o or dx CES

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CES - Management

• Surgical emergency - neurosurgical opinion & input is needed urgently
○ Lumbar decompression surgery

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Red flags for back pain

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Trauma
Unexplained W/L
Neurological sex
Age>50
Fever
IVDU
Steroid use
History of Ca

Hip Fractures - types & classification

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above INTERtrochanteric line = INTRAcapsular
below INTERtrochanteric line = extracapsular (includes trochanteric & subtrochanteric lines)

Garden’s (for intracapsular fractures)

- Type I; incomplete & non-displaced
- Type II; completed but non-displaced 
- Type III; partial displacement 
- Type IV; fully displaced

Risk factors for hip fracture

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Trauma - low E in elderly, high E in younger patients
Age
Osteoporosis
Sex
Steroid Use
Low BMI 
Smoking 
Excess alcohol intake
Metastatic spread of cancer to bone

Clinical Features of Hip Fracture

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• Pain over area
• Pain in groin or hip, may radiate to knee
• Unable to weight bear
• Leg shortened & externally rotated
○ only present if significant displacement
• Limited ROM
• Swelling

Investigations in A&E - Hip Fracture

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Hip fracture is a radiological diagnosis but wider investigations & assessment should always take place into why the patient has fallen

Bedside
	• Observations
	• Urinalysis - r/o infection
	• Examination/A to E
	• ECG - r/o cardiac cause

Bloods
	• FBC - Hb (important for surgery), WCC (signs of infection), Fe
	• U&Es - dehydration, electrolyte abnormalities
	• CRP
	• Clotting - surgery
	• Group & Save x 2
	• Bone profile
	• Vitamin D

Imaging
• CXR: required pre-operatively.
• Plain films: XR pelvis, AP and lateral of affected hip. Full length views of the femur may be obtained, particularly if metastatic disease in the bone is suspected.
• MRI/CT: if plain films are inconclusive, to rule out occult fracture. MRI is gold-standard, CTs are generally more readily available

Management of Hip Fracture

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Dependent on type of fracture i.e. intracapsular vs extracapsular, displaced vs non-displaced

Initial
• Any resuscitation needed e.g. fluids
• Analgesia
• Medication review - anticoagulants

Surgical management
• Intracapsular fractures - assess risk of AVN
○ Minimally or non-displaced fractures –> hip screws
○ Displaced fractures –> THR or hemiarthroplasty (choice depends on patient’s performance status)
• Extracapsular fractures
○ Intertrochanteric (bet greater & lesser trochanters) –> DHS
○ Subtrochanteric (within 5cm below lesser trochanter) –> IM nail

Open fractures - definition, classification & management

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Any fracture complicated by one or more wounds
Classified using Gustilo Anderson Classification

Management:
Initially resuscitate & stabilise
Photographs
Cover/dress/clean superficially 
Realign & splint 
Board spectrum antibiotics
Tetanus vaccination 
Surgical repair & debridement

Red Flag Causes of Back Pain & Hallmark Symptoms

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Spinal fracture (e.g., major trauma)

Cauda equina (e.g., saddle anaesthesia, urinary retention, incontinence or 
bilateral neurological signs)

Spinal stenosis (e.g., intermittent neurogenic claudication)

Ankylosing spondylitis (e.g., age under 40, gradual onset, morning stiffness or night-time pain)

Spinal infection (e.g., fever or a history of IV drug use)

Metastatic Spinal Cord Compression - Definition

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Metastasis in spine causing compression of spinal cord above the cauda equina -
RADIOLOGICAL EVIDENCE OF INDENTATION OF THECAL SAC 2O TO CANCER

MSSC - Clinical Features

• Back pain ○ Worse on straining or coughing ○ Progressive, severe, radicular, can precede neuro sx by weeks • Motor symptoms - weakness, paralysis • Sensory symptoms - pins & needles, loss of sensation On examination MSSC will give UMN signs (hypertonia, hyperreflexia, positive Babinski)

MSSC - Common primary sites

Lung, breast, kidney, prostate and thyroid cancers

MSSC - investigations & management

Investigations & Diagnosis: Urgent MRI needed Management • Activate MSSC pathway & notify co-ordinator • High dose dexamethasone • Analgesia • Surgery - dependent on patient's prognosis & perceived benefit

A 32 year old bouncer presents with pain in his right shoulder for 5 weeks. It is worse when he is lifting; sometimes catches when reaching for things. It is affecting his sleep. On examination normal C spine, no visible deformity, no bony tenderness, painful abduction and internal rotation. Positive empty can test. What is the most likely diagnosis? OPTIONS: Adhesive capsulitis, Referred pain from cervical spine, Shoulder Impingement, OA of the gleno-humeral joint

Shoulder Impingement

36 year old woman works in Asda. 12 month history of pain in right heel. Worse when walking, leading to increasing amount of time off work. On examination, mildly over-pronated feet. Tender over medial plantar fascia, pain with passive dorsiflexion of the ankle. Positive Windlass test. Most likely diagnosis?

Plantar fasciitis

What is plantar fasciitis associated with?

``` pronated foot type, Obesity Increased load (runners heel) Increased age (fat pad atrophy) Systemic causes – e.g. RA, Ank Spond ```

55 year old lady, with T2DM. Gradual onset of severe pain and stiffness in her left shoulder. Cannot lie on the affected side, interfering with sleep. Works as a secretary, is struggling to drive. On examination, shoulder joint generally tender throughout to palpation. Restriction of all shoulder movements, both active and passive. What is the likely diagnosis? OPTIONS: OA of Glenohumeral joint, Rotator Cuff Injury, Subacromial Impingement or Adhesive Capsulitis

Adhesive Capsulitis There tends to be three phases: Phase 1 - severe generalised pain associated with stiffness. Daily activities are limited (eg, putting on a jacket). It can last up to nine months. Phase 2 - pain usually gradually subsides but the shoulder is stiff. Movement can become more limited. External rotation is usually very limited. This phase lasts between 4-12 months. Phase 3 - the shoulder becomes less stiff. There is an increase in the range of movement. This phase usually lasts 1-3 years. Symptoms can persist for 18 months to three years or more. However, over 90% of patients with spontaneous frozen shoulder have been shown to recover to normal levels of function and movement by two years without any treatment. Treatment – Analgesia, Physiotherapy, corticosteroid injections, surgery

A 32/40 pregnant woman presents with increasing tingling, numbess and pain affecting her thumb, index and middle fingers of her right hand. What clinical examinations would be most appropriate?

Tinel‘s Sign - tapping lightly over the median nerve at the wrist causes a distal paraesthesia in the median nerve distribution.

What treatments for Carpal Tunnel has the highest success rate?

Surgical Release The others are treatment options though! Avoid overuse of the wrist Analgesia/NSAIDS Wrist splint Steroid injection – helpful but recurrence within 12 months between 50-75% Surgery – carpal tunnel release provides highest success rate (75%).

A 46 year old male presents with pain to his right (dominant) elbow for three weeks. It is most painful when trying to lift a full kettle or when carrying heavy shopping bags. When you examine him you are able to reproduce the pain by flexing (bend) the wrist and then pronating the forearm. Which of the following is the most likely diagnosis? OPTIONS: Medial Epicondylitis (Golfer‘s Elbow), DeQuervains Tenosynovitis, Radial Head Subluxation (Pulled Elbow) OR Lateral Epicondylitis (Tennis Elbow)

Lateral Epicondylitis (Tennis Elbow) Test with Mill's test

Lateral Epicondylitis | Tennis Elbow

A 31 year old woman presents with severe pain in her right wrist which is affecting her ability to pick up and change the nappy of her 8 week old baby. You suspect a diagnosis of De Quervains Tenodynovitis after completing your history and examination. Diagnosis & treatments offers the highest chance of cure?

DeQuervain’s Tenosynovitis Physiotherapy- usually too painful Topical or oral NSAIDs - gels are usually not effective ***Steroid injection- cures 70% and offen all that is needed Thumb spica (not a wrist splint) Surgical release in persistent cases

Trauma & Orthopaedics Flashcards

(36 cards)