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what is the procedure of insertion of a dynamic hip screw?
- patient on special fracture table, foot in traction boot and closed reduction is performed (under imaging)
- incision over greater trochanter and screw inserted into femoral head under imaging
- a plate attaches to the dhs and rests along the shaft of the femur. angle between plate and screw is 135
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how would you describe a colles fracture?
- fracture of distal radius where it is dorsally displaced and radially shifted
- radial shortening due to impaction of the fragments
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colles fracture which neurovasc needs to be checked?
median and radial artery
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where is the plaster for colles fracture placed? and how long on for? and what do if doesn't work?
- elbow to MCP, (don't like to go above elbow due to stiff shoulder SE, except children) and thumb is free to move
- on for 5-6 weeks
- if position is unacceptable then do surgery: ex fix, K wires or ORIF
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what are complications of colles fracture?
- malunion
- median nerve problems
- stiff shoulder
- tendon rupture of EXTENSOR pollicis longus
- carpal tunnel syndrome
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what is the fracture called when you fall onto the back of your arm (reverse colles)
smiths fracture
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how is sscaphoid fracture diagnosed?
clinically tender in anatomical snuff as xray is normal until 10 days
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who is most likely to get supracondylar fracture of humerus and how?
children fall to outstretched arm
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if child has swollen elbow and arm held in semi-flexed position, what fracture?
supracondylar
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which artery is at risk in supracondylar fracture and why?
distal fragment does DORSAL and so sharp edge of proximal humerus may injure BRACHIAL ARTERY
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if neurovasc damage then whats treatment?
MUA to reduce then K-wires
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if no neurvasc damage treatment?
can collar and cuff with arm flexed as much as posse
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what is risk of supracondy fracture?
- compartment syndrome - pain on passive extension of fingers
- volkmanns ischaemic contracture: claw hand as forearm muscles fibrosed and shortened
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in shoulder dislocation, if glenoid labium is pulled of anteriorly what is this called
bankart lesion
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in shoulder dislocation if humeral head impacts against hard anterior glenoid and a defect happens on superior surface of humeral head, whats this called?
Hill Sachs lesion - this can destabilise the glenohumeral joint and predispose to further dislocation
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in shoulder dislocation which nerve is damaged and how assess?
- axillary nerve
- regimental badge sensation
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what is the xray of posterior shoulder dislocation?
- look silk humeral head is sitting in glenoid but looks rounded - lightbulb sign
- cannot see greater tuberosity as it is internally rotated
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what is treatment for femoral or tibial fractures?
intramedulllary nail (from top to end long nail)
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Fracture healing 5 stages:
- 1. bleeding into fracture haematoma
- 2. inflammatory reaction
- 3. cells proliferate and ealry bone and cartilage is formed (callus – woven bone)
- 4. which then consolidates as woven bone is transformed into stronger lamellar bone
- 5. remodelling of bone to the normal stresses it is placed under
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Management of fractures
- 4 R’s
- Resus
- Reduction
- Restriction
- Rehabilitation
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when is open reduction needed?
OPEN REDUCTION – after failure of closed or Displaced intra-articular fractures: ORIF – open reduction internal fixation
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when use an external fixator?
– use for open fracture
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What is the function of the menisci?
Act as shock absorber in the knee
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Which meniscus is more likely to tear and why?
Medial because it is firmly attached to the medial collateral ligament and joint capsule whereas lateral is more mobile, circular and not attached to ligaments.
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What features on examination would point towards a meniscal injury?
- Joint line tenderness
- Inability to fully flex knee passive or active (squat)
- Mc murray’s positive
- Apley’s positive
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What are the symptoms of a meniscal tear?
Lock, catch, swell, pain
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If you see a haemarthrosis what is the differential?
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What are the 3 types of meniscal tears?
- Buckethandle
- Anterior horn
- Posterior horn
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When can a meniscal tear occur?
When knee is bent and forcefully twisted and weight bearing
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If a knee gives way or buckles, what is ruptured?
ACL or patellar dislocation
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If you fall onto a flexed knee, what is ruptured?
PCL
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If there is a contact injury with a pop, what is the cause?
- Collateral ligament tear
- Meniscus tear
- Fracture
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If there is a non-contact injury with a pop, what is the cause?
ACL rupture
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What are the pre-disposing factors to patella dislocation?
- 1. genu valgus
- 2. increased Q angle
- 3. poorly developed quads
- 4. shallow femoral trochlea
- 5. hypoplastic lateral femoral condyle
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what is the management of patella dislocation?
- cylinder cast 4-6 weeks
- physiotherapy: VMO
- surgery if recurrent
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what is the symptom of ruptured quads/patella tendon?
Unable to SLR
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What is the Rx of ruptured quads/patella tendon?
Surgical repair
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What are the symptoms of ligamentous injuries?
- Swelling
- Point tenderness
- Decreased ROM
- Instability
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What is the most common knee ligament injury? And what strain causes this? What are the symptoms?
- Medial collateral ligament
- Valgus strain (usually traumatic)
- Symptoms: swelling, bruising (after 2 days), pain over ligament, if severe may be associated with instablity
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What is the treatment for collateral ligament injury?
- MCL: conservative RICE, knee brace, physio
- LCL: conservative or surgical reconstruction depending on level of instability
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What is the function of ACL?
Stop tibia falling in front of femur
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What do ACL injuries occur?
Running (football), jumping (basketball), cutting manouevres
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What are the 2 cardinal features/symptoms of ACL rupture
- Pop and giving way of knee
- Early swelling
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What is O’Donoghue’s unhappy triad?
- ACL rupture
- MCL rupture
- Medial or lateral meniscus
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Why are women more susceptible to non-contact ACL injuries?
- Increased Q angle
- Thinner ACL
- Smaller muscle bulk
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What are 3 causes of ACL rupture – contact and non contact?
- 1. sudden deceleration or change in direction (so bones of leg twist in opposite directions under full body weight!)
- 2. hyperextension of knee joint
- 3. trauma
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name 3 tests on examination done to check for ACL rupture?
- Anterior drawer test
- Lachmans test
- Pivot shift test – extended knee held in valgus, foot internally rotated then slowly flex knee past 30 degrees and feel knee sublux back into position
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How are ACL tears managed
- Conservative: physio, knee support
- Surgical if symptomatic: ACL reconstruction using hamstring
- Physio pre and post surgery
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In sports, which cruciate ligament is more injured?
- ACL
- When do you get PCL injuries?
- RTA – knee impacting dashboard
- Ie fall on flexed knee or blow to front of knee
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What is the treatment of PCL injury?
- Conservate: can spont heal, more easily compensated for than ACL, RICE, physio, brace
- Surgical reconstruction: if persistent instability, meniscal tear or multi-ligament injury
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On examination: leg is externally rotated and shortened. Why?
Iliopsoas is attached to lesser trochanter - this pulls it up
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What is an intracapsular hip #?
Fracture proximal to capsular insertion
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What is an extracapsular # of hip?
Distal to capsular insertion
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Why is intracapsular # dangerous?
Because blood supply to head of femur is from vessels that travel under the capsule and along the NOF so if theres a fracture there then get AVN
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How are intracapsular fracture of hip classified?
- Garden classification according to displacement
- I and II: undisplaced
- III and IV: displaced
- (I, II screw; III, IV austin moore which is type of uncemented prosthesis)
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How are undisplaced intracapsular hip fractures treated?
Screws: stabilise with parallel screws through neck into head
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How are displaced intracapsular hip fractures treated?
- Old, Dependent, low cognition: as high risk AVN do hemiarthroplasty (Austin-Moore is uncemented)
- Old, independent, mentally alert, active: total hip replacement
- Young: (<60) want to conserve own joint so do internal fixation with screws as an EMERGENCY. Follow up for 2 years, if develop AVN then do total hip replacement.
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How are extracapsular fractures treated?
Dynamic hip screw: pt on table and do traction then closed reduction – then incision over GT and screw into femoral head. This is a form of internal fixation
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What are the different types of DVT prophylaxis?
- TED stockings
- Foot pumps
- LMWH
- Early mobilisation
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What are the causes of hip fractures?
- Weak bone
- Impact on bone/hip
- Inadequate protective response
- Inadequate shock absorbers
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What increases your risk of falls?
- Age
- Dementia
- Muscle weakness
- Tranquilisers
- Polypharmacy
- Postural drop
- Walking difficulties
- Parkinsons
- Arrhythmia
- Visual impairment
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How are falls prevented?
- Increase Bone mineral density (ie treat Osteoporosis)
- Improve vision
- Optimal medical condition
- Avoid polypharmacy
- Hip protectors
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Which investigations are done if hip fracture is suspected?
- Temperature of joint
- AP pelvis and lateral XR
- U&E
- G&S
- FBC
- What is the initial treatment of hip fracture?
- Resus – iv fluids
- Analgesia
- Drug chart: prophylactic antibiotics
- Thromboprophylaxis
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How are extracapsular hip fractures classified?
- Basicervical
- Intertrochanteric
- Subtrochanteric
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What is the treatment of a closed fracture of femoral shaft?
Intramedullary nailing – as it stabilises fracture, promotes union and early mobilisation
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What is the treatment of a distal radial fracture?
- Reduction
- Plaster from elbow to MCP joints so thumb is free to move
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Which nerve and artery are at risk in distal radial fracture?
- Radial artery
- Median nerve
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How do you describe a Colle’s fracture?
- Extra-articular
- Distal radius
- With dorsal displacement and radial shift of the distal fragment
- As the fragments are impacted, there is also radial shortening
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What are the complications of a colles fracture?
- Malunion
- Median nerve problems
- Frozen shoulder – adhesive capsulitis due to immobilisation
- Tendon rupture
- Carpal tunnel syndrome
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How is a scaphoid fracture diagnosed?
- Tenderness in anatomical snuffbox
- XR may be normal for up to 10days after fracture
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What is the treatment of scaphoid fracture?
- NB obliged to treat even if normal XR
- Put wrist in plaster
- Return to fracture clinic in 10 days when see on XR
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What is the main concern with scaphoid fracture? Why?
AVN as the blood supply to the scaphoid is via small vessels that enter the bone distally so if break the bone, the proximal fragment is at risk of becoming avascular especially if displaced
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Which age group are supracondylar fractures most common in?
Children
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If a child falls on an outstreched hand what are the most common fractures? And how tell?
Supracondylar fracture – swollen elbow
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What is the danger in supracondylar fractures?
Distal fragment displaces backward and sharp edge of proximal humerus may injure BRACHIAL ARTERY.
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If there is a non-displaced supracondylar fracture, what is the treatment?
- Flex arm fully, checking radial pulse
- Once flexed, apply collar and cuff or back slab
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Which deformity of the hand can occur as a result of a supracondylar fracture and why?
- Volkmann’s ischaemic contracture – claw hand
- Supracondylar fracture has risk of compartment syndrome
- If there is pain on passive extension of fingers – ie stretching the flexor compartment this is warning
- So need to extend elbow to see if the circulation is restored – but if this fails you get volkmanns…as the forearm muscles become fibrosed and shortened.
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What is perthes disease?
- Avascular necrosis of femoral head – degenerative changes
- Present with limp and maybe pain – antalgic gait
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What will XR of perthes disease show?
Flattened, fragmented femoral head
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What are the causes of avascular necrosis of bone?
- Intracapsular femoral head fracture
- Steroid use
- Perthes disease
- Sickle cell
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What are the borders of the anatomical snuffbox?
- Extensor pollicis longus (ulnar side)
- Extensor pollicis brevis (radial side)
- Abductor pollicis brevis (radial side)
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If a young girl falls off her horse and there is trouble feeling the radial pulse what is the injury? And why?
- Supracondylar fracture of humerus
- The fracture end is pulled forward and may impinge brachial artery
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What movements are painful and where is there tenderness in scaphoid fracture?
- Thumb abduction is painful
- Tenderness in anatomical snuffbox and thenar eminence
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What is game keepers thumb?
Disruption of ulnar collateral ligament of thumb at MCPJ and pain here
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What are the 2 most common associations of posteriod dislocation of shoulder?
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What causes de Quervain’s tenosynovitis?
- Repitive movements eg factory work
- Pain worse at night
- Inflammation of tendon sheath: abductor pollicis longus and extensor pollicis brevis at radial styloid
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What is the test for de quervains?
Finkelsteins test (fist and pull to ulnar side)
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Which nerve is susceptible to injury after anterior dislocation of shoulder?
Axillary nerve
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What does axillary nerve supply?
- Long head of triceps
- Deltoid
- Teres minor (part of rotator cuff)
- Sensory to regimental badge area
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Which fracture creates the classic dinner fork deformity?
Distal radial fracture (colles)
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Where are classic sites for avascular osteonecrosis?
- Head of femur
- Scaphoid
- Lunate
- Talus
- Navicular
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Which nerve injury is associated with posterior dislocation of the hip?
Sciatic nerve – usually affecting common peroneal nerve – get foot drop
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Which nerve injury is associated with fracture of humerus?
Radial nerve
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What is Erb’s palsy?
- Upper brachial plexus lesion at C5/6
- Can occur at burth
- The abductors and external rotators are paralysed so arm is held close to body and internally rotated with loss of senstation in C5/6 dermatomes
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What is a lesion to C8/T1 in the brachial plexus also called and what would be the symptoms?
- Klumpke’s paralysis
- Loss of intrinsic muscles of the hand
- Leads to claw hand with loss of sensation in C8/T1 dermatomes
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What is the difference between the radial nerve being damaged in the radial groove (around shaft of humerus) and it being damaged in the axilla (incorrect crutch use or Saturday night palsy – arm hung over a hair when drunk)?
- If damaged in radial groove: spare triceps as the nerve to the triceps comes off proximal to the lesion
- If damaged in axilla: paralysis of triceps too
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