Yr 2 management of common orthopaedic conditions (main lecture)

Question 1

Session plan

Answer 1

Question 2

General principles in Trauma and orthopaedics

Answer 2

• These are pegs to hang your hat/scarf on
• With these principles you should be able to take a history and examine any part of the limbs and hold your own.

We divide MSK into trauma, orthopaedics and rheumatology (will cover later on)

Question 3

Bone cells

Answer 3

-Osteoclasts are phagocytic cells

Question 4

Organization of compact/cortical bone: osteons

Answer 4

In cortex where osteons exists and these consist of a haversian canal which has blood vessels nerves and lymphatics.

These canals have concentric lamellae of bone tissue and these contain osteocytes. The osteoblasts and clasts are mainly in the lining of bone so endosteum and periosteum

Question 5

Structure of long bones

Answer 5

Centre is medulla-spongey part of bone

Outer bit is cortex

Physis one proximally and one distally

When you have a physis, the bit closest to the joint is the epiphysis, just beneath the physis away from the joint is the metaphysis and long aspect of bone is diaphysis.

Question 6

Trauma/fractures

Mechanisms of Bone Fracture

Answer 6

How can bones break?-trauma eg injury –low-fall from standing height

Abnormal on normal eg marathon

Normal on abnormal-pathological fracture

Question 7

Pathological or insufficiency – Normal stresses on abnormal Bone: local or general

Answer 7

Pathological fractures can be caused by abnormal density, abnormal mineralization or malignancy,

Pagets disease is an abnormal turnover of the bone

Insufficiency-where bone is weak due to metabolic diseases eg osteoporosis or osteomalacia

Pathological-anything where bone is abnormal

Osteoporosis can be both

Question 8

Fracture Patterns

Answer 8

Is skin covered over fracture?

Is it just 2 fragments or is it comminuted ie many)

Is it displaced?

Are the Soft Tissues Intact?

• Yes – Closed
• No – Open

Is the break complete?

• Yes – How many pieces?
• 2 – simple
• >2 – comminuted
• No – Greenstick

Are the bony ends aligned?

• Yes – Displaced
• No - Displaced

Question 9

Fracture Healing

Answer 9

When fractures happen you get bleeding, haematoma formed, cells and cytokines start producing collagen and then then turns into callous, initially type 2 collagen and then callous harden with type 1 collagen

Then osteoclasts and blasts remodel bone based on stresses put on it.

Step 1: Bleeding/Haematoma – prostaglandins/cytokines released; growth factors increase local blood flow – Periosteal supply takes over

Step 2: Granulation Tissue/connective tissue/Fibrous tissue laid down / Soft Callus

Step3: Once fracture is bridged with soft callus- hard callus is formed ( laying down of Osteoid/ bone)

Step4 : Bone is remodelled via endochondral ossification lamellar bone in its place.

Question 10

Trauma/fractures

What are the clinical signs of a fracture?

Answer 10

What could be damaged?

What is damaged and what is around structure that energy could have damaged

Question 11

Investigations of fracture

Answer 11

MRI for soft tissue (also getting good at architecture of bone)

CT-architecture of bone

Bone scan-invasive (need dye) and a lot of radiation, so do these rarely, only in bone disease

Question 12

Describing a fracture radiograph

Answer 12

4th picture of leg is diaphyseal fracture

Middle-between diaphysis and metaphysis so metaphyseal diaphyseal junction

An avulsion fracture is an injury to the bone in a location where a tendon or ligament attaches to the bone

Question 13

Displacement

Answer 13

Translation-movement occurs in staright line

Or rotation

Injury and healing lecture has more detail on this

Here we have left femur, say fracture is midshaft and distal fragment has moved In straight line away from midline so lateral translation

With angulation again have 3 planes

Coronal plane-from front

Varus-towards midline

Axial plane-from foot upwards, can have internal/extrenal rotation

Question 14

Describe this radiograph

Answer 14

Question 15

Describe this radiograph 2

Answer 15

Question 16

Management of fractures

General principles

Answer 16

May get a question –tibial fracture-what are principles of management and what are order?

Question 17

Reduction:

Answer 17

Question 18

Hold

Answer 18

Might hold with plaster or stick pin in bone-traction, don’t do this often as lots of time in bed, better to use fixation

Question 19

Fixation

Answer 19

Internal-under skin

External-through the skin

Extramedullary-plate on surface of bone

Question 20

Rehabilitate

Answer 20

Is lower limb-get patient to weight bare

Strengthen muscles and helps remodelling

Question 21

What types of fixation are these (internal/external; medullary; mono/multiplanar)?

Answer 21

Different types of holding fracture

Plate is on surface of bone so extramedullary fixation but its under the skin so is internal

Pin going through bone is intramedullary internal fixation

External can be in different planes so monoplanar or multiplanar

Reduction-may involve pulling on it, or may have to do an open fixation if doesn’t go back to correct location.

Question 22

Answer 22

Question 23

Fracture Complications

Answer 23

Divide into general-affecting whole body, or local-at the fracture site

General include:

• Fat embolus-fat from bone marrow can enter blood and travel to lung etc.
• Can have blood clot in that limb
• Or blood clot can travel from limb, so thromboembolic pulmonary pathology
• Systemic infection in form of sepsis
• Traction-have to lie in bed for 2 months so chest infections as not breathing as deeply, pressure sores as one position, hence this isn’t preferred

Question 24

Local Complications of fractures

Answer 24

Urgent-immediate-think muscles, veins, nerves, tendons, plaster can be on too tight and can trap nerve

Early-within 30 days

Late-after 30 days

algodystrophy, also known as complex regional pain syndrome (CRPS),-stiffness of muscles and abnormal pain response due to long term bone problem

Question 25

Fractured neck of femur

Answer 25

Need to know this! Common due to osteoporosis leading to insufficiency fractures Want to know their risk factors and cormorbidities for doing operation

Question 26

Nof Anatomy: label these parts

Answer 26

Intertrochanteric line inbetween Capsule attaches to Intertrochanteric line line at front and half way up the neck on the back

Question 27

Types of NoF fractures by location: can you label? Intra or extracapsular?

Answer 27

Subcapital and transcervical fractures are considered intracapsular fractures.

Question 28

=transcerviacal fracture Hard to say if extra or intra 2-completely out of position so displaced, but 1 is not

Answer 28

Question 29

If extracapullar fracture-risk of bone dying is low If intra-risk of head of femur dying is higher so might want to chuck head away and replace it, except for younger placements as they will have these replacements for years

Answer 29

Question 30

Neck of femur management:

Answer 30

Extra-fix Intra- if displaced-depends on age of patient

Question 31

How do we classify joints?

Answer 31

Articular surface of hip joint is bits that move against itself, so even an intracapsular fracture can be extraarticular as may not directly affect the joint surface Fibrous-in skull and in tubia and fibula in ankle Cartilaginous-where true bit of cartilage between joints eg between vertebra in spine

Question 32

Components of a synovial joint

Answer 32

Has an articular surface which is made up of hyaline cartilage They also have a capsule which is fibrous structure made up of collagen Synovium produces synovial fluid

Question 33

Cartilage:

Answer 33

Articular cartilage is trying to reduce friction so has specialized cells called chondrocytes, it has arrangement of cells more horizontal Extracellular matrix

Question 34

Joint diseases - overview

Answer 34

Osteoarthritis-mainly disease of articular cartilage Rhematoid is inflammation of synovial membrane

Question 35

Radiographic changes in Rheumatoid Arthritis vs.

Answer 35

In both-joint space can be narrowed Sclerosis is extra bone formation Osteoarthritis has mainly thick bone at surface but in RA it is mainly thin here

Question 36

Pathophysiology

Answer 36

Can result in inflammation but this is a late bit of the disease and there are lots of inflammatory mediators of the disease. Inflammation occurs after articular surface has been damaged Can result due to obesity or after trauma where surface is no longer smooth so will wear out fater Analgesics, injections and sometimes surgery

Question 37

Risk factors:

Answer 37

Weight and obesity and estrogen deficiency are modifiable, some are not modifiable eg gender or age or trauma

Question 38

Osteoarthritis How do patients present?

Answer 38

Question 39

Assessment for any joint

Answer 39

* Look * Feel * Move * Special tests

Question 40

Look

Answer 40

Valgus deformity as distal bit going away from midline Valgus is a term for outward angulation of the distal segment of a bone or joint. (Think you move away from valgor things!) Coronal plane Knee replacement scar

Question 41

Feel

Answer 41

Palpation there is a small effusion

Question 42

Move

Answer 42

Question 43

Special tests

Answer 43

Question 44

Special tests

Answer 44

Think would be valgus ie distal limb going out as it was the medial cruciate lig at knee attaching it.

Question 45

In summary

Answer 45

Question 46

Plan

Answer 46

Question 47

Answer 47

More wear produces more bone and as get more wear get more fluid entering joint space

Question 48

Answer 48

Patient lying down vs standing up Important to stress the limb by weight bearing

Question 49

OA management

Answer 49

In management of anything say conservative or operative

Question 50

Answer 50

Question 51

Answer 51

Question 52

Answer 52

Normal ankle of right and on left arthritic ankle joint and they put screws through so joint not moving so no pain, although have stiff joint can still weight bear better than replacing joint which can’t take much weight.

Question 53

Bone infection

Answer 53

Bacteria seeded on metal from surgery so could be secondary or direct bacteria into blood If chronic infection can get weight loss Bacteria in joint start eating away and ligaments, synvium, lots of pus, red hot painful, hard to move

Question 54

Septic arthritis

Answer 54

Can come from cut, insect bite etc Emergency as bugs eating joint surface

Question 55

Investigations

Answer 55

The indium white blood cell scan, is a nuclear medicine procedure in which white blood cells are removed from the patient, tagged with the radioisotope Indium-111, and then injected intravenously into the patient. The tagged leukocytes subsequently localize to areas of relatively new infection.

Question 56

Treatment

Answer 56

Bone infection-takes a lot of antibiotics to clear it as bone doesn’t have great blood supply

Question 57

Some joint examination tips Shoulder

Answer 57

Question 58

Shoulder conditions

Answer 58

Question 59

Hip

Answer 59

Question 60

Hip Conditions:

Answer 60

Question 61

Knee

Answer 61

Question 62

Knee conditions

Answer 62

Question 63

Spine:

Answer 63

Question 64

Bone infection

Answer 64

Question 65

Investigations

Answer 65

Question 66

Treatment:

Answer 66

Question 67

Synovial Joints: functional types Classified according to shape and how they move Ankle hinge-as moves in one direction Knee-modified hinge joint as there are some other forms of movement too How are synovial joints stabilized?

Answer 67

How much of these contribute in each joint vary eg in hip-bone congruity big, tendons and lug small Shoulder-bony-small factor but tendons and lig big factor

Question 68

Session Plan: common conditions, exam questions, principles of management

Answer 68