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Theme: Spinal disordersA.OsteomyelitisB.Potts disease of the spineC.Scheuermanns diseaseD.Transverse myelitisE.Tabes dorsalisF.Subacute degeneration of the cordG.Brown-Sequard syndromeH.SyringomyeliaI.Epidural haematomaWhich is the most likely diagnosis for the scenario given. Each option may be used once, more than once or not at all.1. A 68 year old man presents to the plastics team with severe burns to his hands. He is not distressed by the burns. He has bilateral charcot joints. On examination there is loss of pain and temperature sensation of the upper limbs.You answered Subacute degeneration of the cord The correct answer is SyringomyeliaThis patient has syringomyelia which selectively affects the spinotholamic tracts.Syringomyelia is a disorder in which a cystic cavity forms within the spinal cord. The commonest variant is the Arnold- Chiari malformation in which the cavity connects with a congenital malformation affecting the cerebellum. Acquired forms of the condition may occur as a result of previous meningitis, surgery or tumours. Many neurological manifestations have been reported, although the classical variety spares the dorsal columns and medial lemniscus and affecting only the spinothalamic tract with loss of pain and temperature sensation. The bilateral distribution of this patients symptoms would therefore favor syringomyelia over SCID or Brown Sequard syndrome. Osteomyelitis would tend to present with back pain and fever in addition to any neurological signs. Epidural haematoma large enough to produce neurological impairment will usually have motor symptoms in addition to any selective sensory loss, and the history is usually shorter. 2. A 24 year old man presents with localised spinal pain over 2 months which is worsened on movement. He is known to be an IVDU. He has no history suggestive of tuberculosis. The pain is now excruciating at rest and not improving with analgesia. He has a temperature of 39 oC.OsteomyelitisIn an IVDU with back pain and pyrexia have a high suspicion for osteomylelitis. The most likely organism is staph aureus and the cervical spine is the most common region affected. TB tends to affect the thoracic spine and in other causes of osteomyelitis the lumbar spine is affected.3. A 22 year man is shot in the back, in the lumbar region. He has increased tone and hyper-reflexia of his right leg. He cannot feel his left leg.Brown-Sequard syndromeTheme from January 2012 examBrown -Sequard syndrome is caused by hemisection of the spinal cord. It may result from stab injuries or lateral vertebral fractures. It results in ipsilateral paralysis (pyramidal tract) , and also loss of proprioception and fine discrimination (dorsal columns). Pain and temperature sensation are lost on the contra-lateral side. This is because the fibres of the spinothalamic tract have decussated below the level of the cord transection.Spinal disordersDorsal column lesionLoss vibration and proprioceptionTabes dorsalis, SACDSpinothalamic tract lesionLoss of pain, sensation and temperatureCentral cord lesionFlaccid paralysis of the upper limbsOsteomyelitisNormally progressiveStaph aureus in IVDU, normally cervical region affectedFungal infections in immunocompromisedThoracic region affected in TBInfarction spinal cordDorsal column signs (loss of proprioception and fine discriminationCord compressionUMN signsMalignancyHaematomaFractureBrown-sequard syndromeHemisection of the spinal cordIpsilateral paralysisIpsilateral loss of proprioception and fine discriminationContralateral loss of pain and temperatureImage sourced from Wikipedia Image sourced from Wikipedia DermatomesC2 to C4 The C2 dermatome covers the occiput and the top part of the neck. C3 covers the lower part of the neck to the clavicle. C4 covers the area just below the clavicle.C5 to T1 Situated in the arms. C5 covers the lateral arm at and above the elbow. C6 covers the forearm and the radial (thumb) side of the hand. C7 is the middle finger, C8 is the lateral aspects of the hand, and T1 covers the medial side of the forearm.T2 to T12 The thoracic covers the axillary and chest region. T3 to T12 covers the chest and back to the hip girdle. The nipples are situated in the middle of T4. T10 is situated at the umbilicus. T12 ends just above the hip girdle.L1 to L5 The cutaneous dermatome representing the hip girdle and groin area is innervated by L1 spinal cord. L2 and 3 cover the front part of the thighs. L4 and L5 cover medial and lateral aspects of the lower leg.S1 to S5 S1 covers the heel and the middle back of the leg. S2 covers the back of the thighs. S3 cover the medial side of the buttocks and S4-5 covers the perineal region. S5 is of course the lowest dermatome and represents the skin immediately at and adjacent to the anus.MyotomesUpper limbElbow flexors/BicepsC5Wrist extensorsC6Elbow extensors/TricepsC7Long finger flexorsC8Small finger abductorsT1Lower limbHip flexors (psoas)L1 and L2Knee extensors (quadriceps)L3Ankle dorsiflexors (tibialis anterior)L4 and L5Toe extensors (hallucis longus)L 5Ankle plantar flexors (gastrocnemius)S1The anal sphincter is innervated by S2,3,4A 24 year old man is brought to the emergency department have suffered a crush injury to his forearm. Assessment demonstrates that the arm is tender, red and swollen. There is clinical evidence of an ulnar fracture and the patient cannot move their fingers. Which is the most appropriate course of action?A.Application of an external fixation deviceB.Closed reductionC.Debridement D.Discharge and review in fracture clinicE.FasciotomyTheme from April 2012The combination of a crush injury, limb swelling and inability to move digits should raise suspicion of a compartment syndrome that will require a fasciotomyCompartment syndromeThis is a particular complication that may occur following fractures (or following ischaemia reperfusion injury in vascular patients). It is characterised by raised pressure within a closed anatomical space. The raised pressure within the compartment will eventually compromise tissue perfusion resulting in necrosis. The two main fractures carrying this complication include supracondylar fractures and tibial shaft injuries. Symptoms and signsPain, especially on movement (even passive)Parasthesiae Pallor may be presentArterial pulsation may still be felt as the necrosis occurs as a result of microvascular compromiseParalysis of the muscle group may occurDiagnosisIs made by measurement of intracompartmental pressure measurements. Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic.Treatment This is essentially prompt and extensive fasciotomiesIn the lower limb the deep muscles may be inadequately decompressed by the inexperienced operator when smaller incisions are performedMyoglobinuria may occur following fasciotomy and result in renal failure and for this reason these patients require aggressive IV fluids Where muscle groups are frankly necrotic at fasciotomy they should be debrided and amputation may have to be consideredDeath of muscle groups may occur within 4-6 hoursTheme: Disorders of the kneeA.Chondromalacia patellaeB.Dislocated patellaC.Undisplaced fracture patellaD.Displaced patella fractureE.Avulsion fracture of the tibial tubercleF.Quadriceps tendon ruptureG.Osgood Schlatters diseasePlease select the most likely explanation for the scenario given. Each option may be used once, more than once or not at all.5. A 19 year old sportswoman presents with knee pain which is worse on walking down the stairs and when sitting still. On examination there is wasting of the quadriceps and pseudolocking of the knee.You answered Dislocated patella The correct answer is Chondromalacia patellaeA teenage girl with knee pain on walking down the stairs is characteristic for chondromalacia patellae(anterior knee pain). Most cases are managed with physiotherapy.6. A tall 18 year old male athlete is admitted to the emergency room after being hit in the knee by a hockey stick. On examination his knee is tense and swollen. X-ray shows no fractures.You answered Avulsion fracture of the tibial tubercle The correct answer is Dislocated patellaA patella dislocation is a common cause of haemarthrosis and many will spontaneously reduce when the leg is straightened. In the chronic setting physiotherapy is used to strengthen the quadriceps muscles.7. An athletic 15 year old boy presents with knee pain of 3 weeks duration. It is worst during activity and settles with rest. On examination there is tenderness overlying the tibial tuberosity and an associated swelling at this site.You answered Chondromalacia patellae The correct answer is Osgood Schlatters diseaseAthletic boys and girls may develop this condition in their teenage years. It is caused by multiple micro fractures at the point of insertion of the tendon into the tibial tuberosity. Most cases settle with physiotherapy and rest.Knee injuryTypes of injuryRuptured anterior cruciate ligamentSport injuryMechanism: high twisting force applied to a bent kneeTypically presents with: loud crack, pain and RAPID swelling knee (haemoarthrosis)Poor healingManagement: intense physiotherapy or surgeryRuptured posterior cruciate ligamentMechanism: hyperextension injuriesTibia lies back on the femurParadoxical anterior draw testRupture of medial collateral ligamentMechanism: leg forced into valgus via force outside the legKnee unstable when put into valgus positionMenisceal tearRotational sporting injuriesDelayed knee swellingJoint locking (Patient may develop skills to "unlock" the kneeRecurrent episodes of pain and effusions are common, often following minor traumaChondromalacia patellaeTeenage girls, following an injury to knee e.g. Dislocation patellaTypical history of pain on going downstairs or at restTenderness, quadriceps wastingDislocation of the patellaMost commonly occurs as a traumatic primary event, either through direct trauma or through severe contraction of quadriceps with knee streched in valgus and external rotationGenu valgum, tibial torsion and high riding patella are risk factorsSkyline x-ray views of patella are required, although displaced patella may be clinically obviousAn osteochondral fracture is present in 5%The condition has a 20% recurrence rateFractured patella2 types: i. Direct blow to patella causing undisplaced fragments ii. Avulsion fractureTibial plateau fractureOccur in the elderly (or following significant trauma in young)Mechanism: knee forced into valgus or varus, but the knee fractures before the ligaments ruptureVarus injury affects medial plateau and if valgus injury, lateral plateau depressed fracture occursClassified using the Schatzker system (see below)Schatzker Classification system for tibial plateau fracturesTypeFeatures1- vertical split of lateral condyleFracture through dense bone, usually in the young. It may be virtually undisplaced, or the condylar fragment may be pushed inferiorly and tilted2- a vertical split of the lateral condyle combined with an adjacent loadbearing part of the condyleThe wedge fragement (which may be of variable size), is displaced laterally; the joint is widened. Untreated, a valgus deformity may develop3- depression of the articular surface with intact condylar rimThe split does not extend to the edge of the plateau. Depressed fragments may be firmly embedded in subchondral bone, the joint is stable4- fragment of the medial tibial condyleTwo injuries are seen in this category; (1) a depressed fracture of osteoporotic bone in the elderly. (2) a high energy fracture resulting in a condylar split that runs from the intercondylar eminence to the medial cortex. Associated ligamentous injury may be severe5-fracture of both condylesBoth condyles fractured but the column of the metaphysis remains in continuity with the tibial shaft6-combined condylar and subcondylar fracturesHigh energy fracture with marked comminutionA 10 year old boy presents with symptoms of right knee pain. The pain has been present on most occasions for the past three months and the pain typically lasts for several hours at a time. On examination he walks with an antalgic gait and has apparent right leg shortening. What is the most likely diagnosis?A.Perthes DiseaseB.Osteosarcoma of the femurC.Osteoarthritis of the hipD.Transient synovitis of the hipE.Torn medial meniscusTheme from September 2012 ExamThere are many causes of the irritable hip in the 10-14 year age group. Many of these may cause both hip pain or knee pain. Transient synovitis of the hip the commonest disorder but does not typically last for 3 months. An osteosarcoma would not usually present with apparent limb shortening unless pathological fracture had occurred. A slipped upper femoral epiphysis can cause a similar presentation although it typically presents later and with different patient characteristics.Perthes diseasePerthes diseaseIdiopathic avascular necrosis of the femoral epiphysis of the femoral headImpaired blood supply to femoral head, causing bone infarction. New vessels develop and ossification occurs. The bone either heals or a subchondral fracture occurs.Clinical featuresMales 4x's greater than femalesAge between 2-12 years (the younger the age of onset, the better the prognosis)LimpHip painBilateral in 20%DiagnosisPlain x-ray, Technetium bone scan or magnetic resonance imaging if normal x-ray and symptoms persist.Catterall stagingStageFeaturesStage 1Clinical and histological features onlyStage 2Sclerosis with or without cystic changes and preservation of the articular surfaceStage 3Loss of structural integrity of the femoral headStage 4Loss of acetabular integrityManagementTo keep the femoral head within the acetabulum: cast, bracesIf less than 6 years: observationOlder: surgical management with moderate resultsOperate on severe deformitiesPrognosisMost cases will resolve with conservative management. Early diagnosis improves outcomes.Which of the following types of growth plate fractures may have similar radiological appearances?A.Salter Harris types 1 and 5B.Salter Harris types 4 and 5C.Salter Harris types 3 and 5D.Salter Harris types 1 and 2E.Salter Harris types 1 and 3Salter Harris injury types 1 and 5 (transverse fracture through growth plate Vs. Compression fracture) may mimic each other radiologically. Type 5 injuries have the worst outcomes. Radiological signs of type 5 injuries are subtle and may include narrowing of the growth plate.Epiphyseal fracturesFractures involving the growth plate in children are classified using the Salter - Harris system.There are 5 main types.Salter Harris ClassificationTypeDescriptionType 1Transverse fracture through the growth plateType 2Fracture through the growth plate to the metaphysis (commonest type)Type 3Fracture through the growth plate and the epiphysis with metaphysis sparedType 4Fracture involving the growth plate, metaphysis and epiphysisType 5Compression fracture of the growth plate (worst outcome)ManagementNon displaced type 1 injuries can generally be managed conservatively. Unstable or more extensive injuries will usually require surgical reduction and/ or fixation, as proper alignment is crucial.Theme: Pathological fracturesA.OsteosarcomaB.OsteomalaciaC.OsteoporosisD.Metastatic carcinomaE.OsteoblastomaF.Giant cell tumourG.Ewing's sarcomaFor each pathological fracture please select the most likely aetiology for the scenario given. Each option may be used once, more than once or not at all.2. A 30 year old woman presents with pain and swelling of the left shoulder. There is a large radiolucent lesion in the head of the humerus extending to the subchondral plate.You answered Osteomalacia The correct answer is Giant cell tumourGiant cell tumours on x-ray have a 'soap bubble' appearance. They present as pain or pathological fractures. They commonly metastasize to the lungs.3. A 72 year old woman has a lumbar vertebral crush fracture. She has hypocalcaemia and a low urinary calcium.You answered Osteoporosis The correct answer is OsteomalaciaHypocalcemia and low urinary calcium are biochemical features of osteomalacia. Unfortunately surgeons do need to look at some blood results!4. A 16 year old boy presents with severe groin pain after kicking a football. Imaging confirms a pelvic fracture. A previous pelvic x-ray performed 2 weeks ago shows a lytic lesion with 'onion type' periosteal reaction.Ewing's sarcomaA Ewings sarcoma is most common in males between 10-20 years. It can occur in girls. A lytic lesion with a lamellated or onion type periosteal reaction is a classical finding on x-rays. Most patients present with metastatic disease with a 5 year prognosis between 5-10%.Pathological fracturesA pathological fracture occurs in abnormal bone due to insignificant injuryCausesMetastatic tumoursBreast LungThyroidRenalProstateBone diseaseOsteogenesis imperfectaOsteoporosis Metabolic bone disease Paget's diseaseLocal benign conditionsChronic osteomyelitis Solitary bone cystPrimary malignant tumoursChondrosarcomaOsteosarcoma Ewing's tumourTheme: Shoulder injuriesA.Glenohumeral dislocationB.Acromioclavicular dislocationC.Sternoclavicular dislocationD.Biceps tendon tearE.Supraspinatus tearF.Fracture of the surgical neck of the humerusG.Infra spinatus tearFor each scenario please select the most likely underlying diagnosis. Each option may be used once, more than once or not at all.5. A 23 year old rugby player falls directly onto his shoulder. There is pain and swelling of the shoulder joint. The clavicle is prominent and there appears to be a step deformity.Acromioclavicular dislocationAcromioclavicular joint (ACJ) dislocation normally occurs secondary to direct injury to the superior aspect of the acromion. Loss of shoulder contour and prominent classical are key features. NB rotator cuff tears rarely occur in the second decade.6. A 22 year old man falls over and presents to casualty. A shoulder x-ray is performed, the radiologist comments that a Hill-Sachs lesion is present.You answered Biceps tendon tear The correct answer is Glenohumeral dislocationA Hill-Sachs lesion is when the cartilage surface of the humerus is in contact with the rim of the glenoid. About 50% of anterior glenohumeral dislocations are associated with this lesion.7. An 82 year old female presents to A&E after tripping on a step. She complains of shoulder pain. On examination there is pain to 90o on abduction.Supraspinatus tearA supraspinatus tear is the most common of rotator cuff tears. It occurs as a result of degeneration and is rare in younger adults.Shoulder disordersProximal humerus fracturesVery common. Usually through the surgical neck. Number of classification systems though for practical purposes describing the number of fracture fragments is probably easier. Some key points:It is rare to have fractures through the anatomical neck.Anatomical neck fractures which are displaced by >1cm carry a risk of avascular necrosis to the humeral head.In children the commonest injury pattern is a greenstick fracture through the surgical neck.Impacted fractures of the surgical neck are usually managed with a collar and cuff for 3 weeks followed by physiotherapy.More significant displaced fractures may require open reduction and fixation or use of an intramedullary device.Types of shoulder dislocationGlenohumeral dislocation (commonest): anterior shoulder dislocation most commonAcromioclavicular dislocation (12%): clavicle loses all attachment with the scapulaSternoclavicular dislocation (uncommon)Types of glenohumeral dislocation:Anterior shoulder dislocationExternal rotation and abduction35-40% recurrent (it is the commonest disorder)Assocociated with greater tuberosity fracture, Bankart lesion, Hill-Sachs defectInferior shoulder dislocationLuxatio erectaPosterior shoulder dislocationProportion misdiagnosed.Rim's sign, light bulb sign.Assocociated with Trough signSuperior shoulder dislocationRare and usually follow major trauma.TreatmentPrompt reduction is the mainstay of treatment and is usually performed in the emergency department. Neurovascular status must be checked pre and post reduction and x-rays should be performed again post reduction to ensure no fracture has occurred. In recurrent anterior dislocation there is usually a Bankart lesion and this may be repaired surgically. Recurrent posterior dislocations may be repaired in a similar manner to anterior lesions but using a posterior (or arthroscopic) approach.Which of the following statements relating to menisceal tears is false?A.The medial meniscus is most often affectedB.True locking of the knee joint may occurC.Most established tears will heal with conservative managementD.In the chronic setting there is typically little to find on examination if the knee is not lockedE.An arthroscopic approach may be used to treat most lesionsMenisci have no nerve or blood supply and thus heal poorly. Established tears with associated symptoms are best managed by arthroscopic menisectomy.Knee injuryTypes of injuryRuptured anterior cruciate ligamentSport injuryMechanism: high twisting force applied to a bent kneeTypically presents with: loud crack, pain and RAPID swelling knee (haemoarthrosis)Poor healingManagement: intense physiotherapy or surgeryRuptured posterior cruciate ligamentMechanism: hyperextension injuriesTibia lies back on the femurParadoxical anterior draw testRupture of medial collateral ligamentMechanism: leg forced into valgus via force outside the legKnee unstable when put into valgus positionMenisceal tearRotational sporting injuriesDelayed knee swellingJoint locking (Patient may develop skills to "unlock" the kneeRecurrent episodes of pain and effusions are common, often following minor traumaChondromalacia patellaeTeenage girls, following an injury to knee e.g. Dislocation patellaTypical history of pain on going downstairs or at restTenderness, quadriceps wastingDislocation of the patellaMost commonly occurs as a traumatic primary event, either through direct trauma or through severe contraction of quadriceps with knee streched in valgus and external rotationGenu valgum, tibial torsion and high riding patella are risk factorsSkyline x-ray views of patella are required, although displaced patella may be clinically obviousAn osteochondral fracture is present in 5%The condition has a 20% recurrence rateFractured patella2 types: i. Direct blow to patella causing undisplaced fragments ii. Avulsion fractureTibial plateau fractureOccur in the elderly (or following significant trauma in young)Mechanism: knee forced into valgus or varus, but the knee fractures before the ligaments ruptureVarus injury affects medial plateau and if valgus injury, lateral plateau depressed fracture occursClassified using the Schatzker system (see below)Schatzker Classification system for tibial plateau fracturesTypeFeatures1- vertical split of lateral condyleFracture through dense bone, usually in the young. It may be virtually undisplaced, or the condylar fragment may be pushed inferiorly and tilted2- a vertical split of the lateral condyle combined with an adjacent loadbearing part of the condyleThe wedge fragement (which may be of variable size), is displaced laterally; the joint is widened. Untreated, a valgus deformity may develop3- depression of the articular surface with intact condylar rimThe split does not extend to the edge of the plateau. Depressed fragments may be firmly embedded in subchondral bone, the joint is stable4- fragment of the medial tibial condyleTwo injuries are seen in this category; (1) a depressed fracture of osteoporotic bone in the elderly. (2) a high energy fracture resulting in a condylar split that runs from the intercondylar eminence to the medial cortex. Associated ligamentous injury may be severe5-fracture of both condylesBoth condyles fractured but the column of the metaphysis remains in continuity with the tibial shaft6-combined condylar and subcondylar fracturesHigh energy fracture with marked comminutionTheme: Developmental bone disordersA.RicketsB.CraniocleidodysostosisC.AchondroplasiaD.ScurvyE.Pagets diseaseF.Multiple myelomaG.Osteogenesis imperfectaH.OsteomalaciaI.OsteopetrosisJ.None of the abovePlease select the most likely disease process to account for the clinical scenario. Each option may be used once, more than once or not at all9. A 15 year-old boy presents to the out-patient clinic with tiredness, recurrent throat and chest infections, and gradual loss of vision. Multiple x-rays show brittle bones with no differentiation between the cortex and the medulla.You answered Rickets The correct answer is OsteopetrosisOsteopetrosis is an autosomal recessive condition. It is commonest in young adults. They may present with symptoms of anaemia or thrombocytopaenia due to decreased marrow space. Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone. These bones are very dense and brittle.10. A 12 year-old boy who is small for his age presents to the clinic with poor muscular development and hyper-mobile fingers. His x rays show multiple fractures of the long bones and irregular patches of ossification.You answered Craniocleidodysostosis The correct answer is Osteogenesis imperfectaOsteogenesis imperfecta is caused by defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine. There is a failure of maturation of collagen in all the connective tissues.Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.11. A 1 year-old is brought to the Emergency Department with a history of failure to thrive. On examination, the child is small for age and has a large head. X-ray shows a cupped appearance of the epiphysis of the wrist.RicketsRickets is the childhood form of osteomalacia. It is due to the failure of the osteoid to ossify due to vitamin D deficiency. Symptoms start about the age of one. The child is small for age and there is a history of failure to thrive. Bony deformities include bowing of the femur and tibia, a large head, deformity of the chest wall with thickening of the costochondral junction (ricketty rosary), and a transverse sulcus in the chest caused by the pull of the diaphragm (Harrison's sulcus). X- Rays show widening and cupping of the epiphysis of the long bones, most readily apparent in the wrist.Paediatric fracturesPaediatric fracture typesTypeInjury patternComplete fracture Both sides of cortex are breachedToddlers fracture Oblique tibial fracture in infantsPlastic deformityStress on bone resulting in deformity without cortical disruptionGreenstick fracture Unilateral cortical breach onlyBuckle fracture Incomplete cortical disruption resulting in periosteal haematoma onlyGrowth plate fracturesIn paediatric practice fractures may also involve the growth plate and these injuries are classified according to the Salter- Harris system (given below):TypeInjury patternI Fracture through the physis only (x-ray often normal)II Fracture through the physis and metaphysisIIIFracture through the physis and epiphyisis to include the jointIV Fracture involving the physis, metaphysis and epiphysisV Crush injury involving the physis (x-ray may resemble type I, and appear normal)As a general rule it is safer to assume that growth plate tenderness is indicative of an underlying fracture even if the x-ray appears normal. Injuries of Types III, IV and V will usually require surgery. Type V injuries are often associated with disruption to growth.Non accidental injuryDelayed presentationDelay in attaining milestonesLack of concordance between proposed and actual mechanism of injuryMultiple injuriesInjuries at sites not commonly exposed to traumaChildren on the at risk registerPathological fracturesGenetic conditions, such as osteogenesis imperfecta, may cause pathological fractures. Osteogenesis imperfectaDefective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine.Failure of maturation of collagen in all the connective tissues.Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.SubtypesType I The collagen is normal quality but insufficient quantity.Type II- Poor collagen quantity and quality.Type III- Collagen poorly formed. Normal quantity.Type IV- Sufficient collagen quantity but poor quality.OsteopetrosisBones become harder and more dense. Autosomal recessive condition. It is commonest in young adults. Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone. Theme: Hip fracturesA.Conservative managementB.Percutaneous pinningC.Fracture reduction and internal fixationD.HemiarthroplastyE.Total hip replacementF.Sliding hip screwG.Intramedullary deviceFor each scenario please select the most appropriate management option. Each option may be used once, more than once or not at all.12. A 60 year old male is admitted to A&E with a fall. He lives with his wife and still works as a restaurant manager. He has a past history of benign prostatic hypertrophy and is currently taking tamsulosin. He is otherwise fit and healthy. On examination there is right hip tenderness on movement in all directions. A hip x-ray confirms an undisplaced intracapsular fracture.You answered Sliding hip screw The correct answer is Percutaneous pinningAs this is undisplaced the blood supply to the femoral head may be intact and the fracture may heal. Therefore an attempt at percutaneous fixation is reasonable.13. An 86 year old retired pharmacist is admitted to A&E following a fall. She complains of right hip pain. She is known to have hypertension and is currently on bendrofluazide. She lives alone and mobilises with a Zimmer frame. Her right leg is shortened and externally rotated. A hip x-ray confirms a displaced intracapsular fracture.HemiarthroplastyHemiarthroplasty is offered to older, less mobile individuals compared to fracture reduction and fixation in younger patients.14. A 74 year old male is admitted to A&E with a fall. He is known to have rheumatoid arthritis and is on methotrexate and paracetamol. He lives alone in a bungalow and enjoys playing golf. He is independent with his ADLs. He complains of left groin pain, therefore has a hip x-ray which confirms a displaced intracapsular fracture.You answered Hemiarthroplasty The correct answer is Total hip replacementThis patient has pre-existing joint disease, good level of activity and a relatively high life expectancy, therefore THR is preferable to hemiarthroplasty.Hip fracturesThe hip is a common site of fracture especially in osteoporotic, elderly females. The blood supply to the femoral head runs up the neck and thus avascular necrosis is a risk in displaced fractures.ClassificationThe Garden system is one classification system in common use.Type I: Stable fracture with impaction in valgus.Type II: Complete fracture but undisplaced.Type III: Displaced fracture, usually rotated and angulated, but still has bony contact.Type IV: Complete bony disruption.Blood supply disruption is most common following Types III and IV.Management of hip fractures in older adultsSIGN GuidelinesFracture typePatient co-morbiditiesManagementUndisplaced intracapsular fractureNilInternal fixation (especially if young)Undisplaced intracapsular fractureMajor illness or advanced organ specific diseaseHemiarthroplastyDisplaced intracapsular fractureNilIf age <70 then internal fixation (if possible), hip arthroplasty if notDisplaced intracapsular fractureNilAge >70 total hip arthroplastyDisplaced intracapsular fractureMajor/ immobileHemiarthroplastyExtracapsular fracture (non special type)Only major co-morbidities affect managementDynamic hip screwExtracapsular fracture (reverse oblique, transverse or sub trochanteric)Only major co-morbidities affect managementUsually intramedullary deviceA typical image of an intracapsular fracture occurring in an elderly osteoporotic ladyImage sourced from Wikipedia Referencessign.ac.uk/guidelines/fulltext/111/index.htmlOf the list below, which is not a cause of avascular necrosis?A.SteroidsB.Sickle cell diseaseC.RadiotherapyD.MyelomaE.Caisson diseaseCauses of avascular necrosisP ancreatitis L upus A lcohol S teroids T rauma I diopathic, infection C aisson disease, collagen vascular disease R adiation, rheumatoid arthritis A myloid G aucher disease S ickle cell diseaseSteroid containing therapy for myeloma may induce avascular necrosis, however the disease itself does not cause it. Caisson disease as may occur in deep sea divers is a recognised cause.Avascular necrosisCellular death of bone components due to interruption of the blood supply, causing bone destructionMain joints affected are hip, scaphoid, lunate and the talus.It is not the same as non union. The fracture has usually united.Radiological evidence is slow to appear.Vascular ingrowth into the affected bone may occur. However, many joints will develop secondary osteoarthritis.CausesP ancreatitis L upus A lcohol S teroids T rauma I diopathic, infection C aisson disease, collagen vascular disease R adiation, rheumatoid arthritis A myloid G aucher disease S ickle cell diseasePresentationUsually pain. Often despite apparent fracture union.InvestigationMRI scanning will show changes earlier than plain films.TreatmentIn fractures at high risk sites anticipation is key. Early prompt and accurate reduction is essential.Non weight bearing may help to facilitate vascular regeneration.Joint replacement may be necessary, or even the preferred option (e.g. Hip in the elderly).Which of the following is the first radiological change likely to be apparent in a plain radiograph of a 12 year old presenting with suspected Perthes diseaseA.Multiple bone cystsB.Sclerosis of the femoral headC.Loss of bone densityD.Joint space narrowingE.Collapse of the femoral headIn Catterall stage I disease there may be no radiological abnormality at all. In Stage II disease there may be sclerosis of the femoral head.Indication for treatment (aide memoire):Half a dozen, half a headThose aged greater than 6 years with >50% involvement of the femoral head should almost always be treated.Perthes diseasePerthes diseaseIdiopathic avascular necrosis of the femoral epiphysis of the femoral headImpaired blood supply to femoral head, causing bone infarction. New vessels develop and ossification occurs. The bone either heals or a subchondral fracture occurs.Clinical featuresMales 4x's greater than femalesAge between 2-12 years (the younger the age of onset, the better the prognosis)LimpHip painBilateral in 20%DiagnosisPlain x-ray, Technetium bone scan or magnetic resonance imaging if normal x-ray and symptoms persist.Catterall stagingStageFeaturesStage 1Clinical and histological features onlyStage 2Sclerosis with or without cystic changes and preservation of the articular surfaceStage 3Loss of structural integrity of the femoral headStage 4Loss of acetabular integrityManagementTo keep the femoral head within the acetabulum: cast, bracesIf less than 6 years: observationOlder: surgical management with moderate resultsOperate on severe deformitiesPrognosisMost cases will resolve with conservative management. Early diagnosis improves outcomes.Theme: Upper limb injuriesA.Pulled elbowB.Fracture of the coronoid processC.Scaphoid fractureD.Moteggia fractureE.Bennets fractureF.Fracture of the shaft of the radius and ulnarG.Galeazzi fractureH.Fracture of the olecranonI.Fracture of the radial headPlease select the most likely injury for the scenario given. Each option may be used once, more than once or not at all.17. A 32 year old man presents with a painful swelling over the volar aspect of his hand after receiving a hard blow to his palm. On examination, he experiences pain on moving the wrist and on longitudinal compression of the thumb.You answered Bennets fracture The correct answer is Scaphoid fractureScaphoid fractures usually occur as a result of direct hard blow to the palm or following a fall on the out-stretched hand. The main physical signs are swelling and tenderness in the anatomical snuff box, and pain on wrist movements and on longitudinal compression of the thumb18. A 26 year old man presents to the emergency department with a swelling over his left elbow after a fall on an outstretched hand. On examination, he has tenderness over the proximal part of his forearm, and has severely restricted supination and pronation movements.You answered Moteggia fracture The correct answer is Fracture of the radial headFracture of the radial head is common in young adults. It is usually caused by a fall on the outstretched hand. On examination, there is marked local tenderness over the head of the radius, impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination).19. A 56 year old lady presents with a painful swelling over the lower end of the forearm following a fall. Imaging reveals a distal radial fracture with disruption of the distal radio-ulnar joint.Galeazzi fractureGaleazzi fractures occur after a fall on the hand with a rotational force superimposed on it. On examination, there is bruising, swelling and tenderness over the lower end of the forearm. X- Rays reveal a displaced fracture of the radius and a prominent ulnar head due to dislocation of the inferior radio-ulnar joint.Upper limb fracturesColles' fractureFall onto extended outstretched handsDescribed as a dinner fork type deformityClassical Colles' fractures have the following 3 features:Features of the injury1. Transverse fracture of the radius 2. 1 inch proximal to the radio-carpal joint 3. Dorsal displacement and angulationSmith's fracture (reverse Colles' fracture)Volar angulation of distal radius fragment (Garden spade deformity)Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexedBennett's fractureIntra-articular fracture of the first carpometacarpal jointImpact on flexed metacarpal, caused by fist fightsX-ray: triangular fragment at ulnar base of metacarpalMonteggia's fractureDislocation of the proximal radioulnar joint in association with an ulna fractureFall on outstretched hand with forced pronationNeeds prompt diagnosis to avoid disabilityGaleazzi fractureRadial shaft fracture with associated dislocation of the distal radioulnar jointOccur after a fall on the hand with a rotational force superimposed on it. On examination, there is bruising, swelling and tenderness over the lower end of the forearm. X Rays reveal the displaced fracture of the radius and a prominent ulnar head due to dislocation of the inferior radio-ulnar joint.Barton's fractureDistal radius fracture (Colles'/Smith's) with associated radiocarpal dislocationFall onto extended and pronated wristScaphoid fracturesScaphoid fractures are the commonest carpal fractures.Surface of scaphoid is covered by articular cartilage with small area available for blood vessels (fracture risks blood supply)Forms floor of anatomical snuffboxRisk of fracture associated with fall onto outstretched hand (tubercle, waist, or proximal 1/3)The main physical signs are swelling and tenderness in the anatomical snuff box, and pain on wrist movements and on longitudinal compression of the thumb.Ulnar deviation AP needed for visualization of scaphoid Immobilization of scaphoid fractures difficultRadial head fractureFracture of the radial head is common in young adults. It is usually caused by a fall on the outstretched hand. On examination, there is marked local tenderness over the head of the radius, impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination).Theme: Hand injuriesA.Admission and surgical debridementB.Application of futura splint and fracture clinic reviewC.Application of tubigrip bandage and fracture clinic reviewD.Admission for open reduction and fixationE.Discharge with mence oral mence oral diclofenacWhich of the following options is the best management plan? Each option may be used once, more than once or not at all.20. A 42 year old skier falls and impacts his hand on his ski pole. On examination he is tender in the anatomical snuffbox and on bimanual palpation. Xrays with scaphoid views show no evidence of fracture.Application of futura splint and fracture clinic reviewA fracture may still be present and should be immobilised until repeat imaging can be performed.21. A 43 year old man falls over landing on his left hand. Although there was anatomical snuffbox tenderness no x-rays either at the time or subsequently have shown evidence of scaphoid fracture. He has been immobilised in a futura splint for two weeks and is now asymptomatic.Discharge with reassuranceThis patient is at extremely low risk of having sustained a scaphoid injury and may be discharged.22. A builder falls from scaffolding and lands on his left hand he suffers a severe laceration to his palm. An x-ray shows evidence of scaphoid fracture that is minimally displaced.You answered Application of tubigrip bandage and fracture clinic review The correct answer is Admission and surgical debridementThis is technically an open fracture and should be debrided prior to attempted fixation (which should occur soon after).Scaphoid fractures:80% of all carpal fractures80% occur in men80% occur at the waist of the scaphoidScaphoid fracturesScaphoid fractures are the commonest carpal fractures.Surface of scaphoid is covered by articular cartilage with small area available for blood vessels (fracture risks blood supply)Forms floor of anatomical snuffboxRisk of fracture associated with fall onto outstretched hand (tubercle, waist, or proximal third)Ulnar deviation AP needed for visualization of scaphoid Immobilization of scaphoid fractures difficultManagementNon-displaced fractures- Casts or splints- Percutaneous scaphoid fixationDisplaced fractureSurgical fixation, usually with a screwComplicationsNon union of scaphoid Avascular necrosis of the scaphoid Scapholunate disruption and wrist collapseDegenerative changes of the adjacent jointTheme: Paediatric orthopaedicsA.Musculoskeletal painB.Congenital dysplasia of the hipC.Slipped upper femoral epiphysisD.Transient synovitisE.Septic arthritisF.Perthes diseaseG.Tibial fracturePlease select the most likely diagnosis for the scenario given. Each option may be used once, more than once or not at all.23. A 4 year boy presents with an abnormal gait. He has a history of recent viral illness. His WCC is 11 and ESR is 30.Transient synovitisViral illnesses can be associated with transient synovitis. The WCC should ideally be > 12 and the ESR > 40 to suggest septic arthritis.24. A 6 year old boy presents with an groin pain. He is known to be disruptive in class. He reports that he is bullied for being short. On examination he has an antalgic gait and pain on internal rotation of the right hip.Perthes diseaseThis child is short, has hyperactivity (disruptive behaviour) and is within the age range for Perthes disease. Hyperactivity and short stature are associated with Perthes disease.25. An obese 12 year old boy is referred with pain in the left knee and hip. On examination he has an antaglic gait and limitation of internal rotation. His knee has normal range of passive and active movement.Slipped upper femoral epiphysisSimilar theme to September 2012 ExamSlipped upper femoral epiphysis is commonest in obese adolescent males. The x-ray will show displacement of the femoral epiphysis inferolaterally. Treatment is usually with rest and non weight bearing crutches. Beware of attributing gait disorders to benign processes in young children without careful clinical and radiological assessment.Paediatric orthopaedicsDiagnosisMode of presentationTreatmentRadiologyDevelopmental dysplasia of the hip Usually diagnosed in infancy by screening tests. May be bilateral, when disease is unilateral there may be leg length inequality. As disease progresses child may limp and then early onset arthritis. More common in extended breech babies.Splints and harnesses or traction. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revisionInitially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arcPerthes DiseaseHip pain (may be referred to the knee) usually occurring between 5 and 12 years of age. Bilateral disease in 20%. Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly. X-rays will show flattened femoral head. Eventually in untreated cases the femoral head will fragment.Slipped upper femoral epiphysis Typically seen in obese male adolescents. Pain is often referred to the knee. Limitation to internal rotation is usually seen. Knee pain is usually present 2 months prior to hip slipping. Bilateral in 20%. Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required.X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severityTheme: Eponymous fracturesA.Smith'sB.Bennett'sC.Monteggia'sD.Colle'sE.GaleazziF.Pott'sG.Barton'sLink the most appropriate eponymously named fracture to the scenario described. Each scenario may be used once, more than once or not at all.26. A 28 year old man falls on the back of his hand. On x-ray the he has a fractured distal radius demonstrating volar displacement of the fracture.Smith'sThis is a Smith fracture (reverse Colle's fracture); unlike a Colle's this is a high velocity injury and may require surgical correction. Note that Colles fractures are usually dorsally displaced 27. A 38 year old window cleaner falls from his ladder. He lands on his left arm and notices an obvious injury. An x-ray and clinical examination demonstrate that has a fracture of the proximal ulna and associated radial dislocationMonteggia'sThis constellation of injuries is referred to as a Monteggia's fracture28. A 32 year old man falls from scaffolding and sustains an injury to his forearm. Clinical examination and x-ray shows that he has sustained a radial fracture with dislocation of the inferior radio-ulna jointGaleazziIsolated fracture of the radius alone can occur but is rare. Always check for associated injuryEponymous fracturesColles' fracture (dinner fork deformity)Fall onto extended outstretched handClassical Colles' fractures have the following 3 features:1. Transverse fracture of the radius 2. 1 inch proximal to the radio-carpal joint 3. Dorsal displacement and angulationSmith's fracture (reverse Colles' fracture)Volar angulation of distal radius fragment (Garden spade deformity)Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexedBennett's fractureIntra-articular fracture of the first carpometacarpal jointImpact on flexed metacarpal, caused by fist fightsX-ray: triangular fragment at ulnar base of metacarpalImage sourced from Wikipedia Monteggia's fractureDislocation of the proximal radioulnar joint in association with an ulna fractureFall on outstretched hand with forced pronationNeeds prompt diagnosis to avoid disabilityImage sourced from Wikipedia Galeazzi fractureRadial shaft fracture with associated dislocation of the distal radioulnar jointDirect blowPott's fractureBimalleolar ankle fractureForced foot eversionBarton's fractureDistal radius fracture (Colles'/Smith's) with associated radiocarpal dislocationFall onto extended and pronated wristA 54-year-old man presents to the Emergency Department with a 2 day history of a swollen, painful left knee. You aspirate the joint to avoid admission to the orthopaedic wards. Aspirated joint fluid shows calcium pyrophosphate crystals. Which of the following blood tests is most useful in revealing an underlying cause?A.Transferrin saturationB.ACTHC.ANAD.Serum ferritinE.LDHThis is a typical presentation of pseudogout. An elevated transferrin saturation may indicate haemochromatosis, a recognised cause of pseudogout.A high ferritin level is also seen in haemochromatosis but can be raised in a variety of infective and inflammatory processes, including pseudogout, as part of an acute phase response.PseudogoutPseudogout is a form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate in the synoviumRisk factorshyperparathyroidismhypothyroidismhaemochromatosisacromegalylow magnesium, low phosphateWilson's diseaseFeaturesknee, wrist and shoulders most commonly affectedjoint aspiration: weakly-positively birefringent rhomboid shaped crystalsx-ray: chondrocalcinosisManagementaspiration of joint fluid, to exclude septic arthritisNSAIDs or intra-articular, intra-muscular or oral steroids as for goutA 65-year-old Asian female presents with an extracapsular neck of femur fracture. Investigations show:Calcium2.07 mmol/l (2.20-2.60 mmol/l)Phosphate0.66 mmol/l (0.8-1.40 mmol/l)ALP256 IU/l (44-147 IU/l)What is the most likely diagnosis?A.Bone tuberculosisB.HypoparathyroidismC.MyelomaD.OsteomalaciaE.Paget's diseaseOsteomalacialow: calcium, phosphateraised: alkaline phosphataseThe low calcium and phosphate combined with the raised alkaline phosphatase point towards osteomalacia.OsteomalaciaBasicsnormal bony tissue but decreased mineral contentrickets if when growingosteomalacia if after epiphysis fusionTypesvitamin D deficiency e.g. malabsorption, lack of sunlight, dietrenal failuredrug induced e.g. anticonvulsantsvitamin D resistant; inheritedliver disease, e.g. cirrhosisFeaturesrickets: knock-knee, bow leg, features of hypocalcaemiaosteomalacia: bone pain, fractures, muscle tenderness, proximal myopathyInvestigationlow calcium, phosphate, 25(OH) vitamin D raised alkaline phosphatase x-ray: children - cupped, ragged metaphyseal surfaces; adults - translucent bands (Looser's zones or pseudofractures) Treatmentcalcium with vitamin D tabletsA 78-year-old woman is discharged following a fractured neck of femur. On review she is making good progress but consideration is given to secondary prevention of further fractures. Unfortunately the orthogeriatricians are all on annual leave and the consultant has asked you to arrange suitable management. Which is the best option?A.AlendronateB.Alendronate, calcium and vitamin D supplementationC.StrontiumD.Arrange a DEXA scanE.Hormone replacement therapyA bisphosphonate, calcium and vitamin D supplementation should be given to all patients aged over 75 years after having a fracture. A DEXA scan is only needed of the patient is aged below 75 years. Hormone replacement therpay has been shown to reduce vertebral and non vertebral fractures, however the risks of cardiovascular disease and breast malignancy make this a less favourable option.Osteoporosis: secondary preventionNICE guidelines were updated in 2008 on the secondary prevention of osteoporotic fractures in postmenopausal women.Key points includeTreatment is indicated following osteoporotic fragility fractures in postmenopausal women who are confirmed to have osteoporosis (a T-score of - 2.5 SD or below).In women aged 75 years or older, a DEXA scan may not be required 'if the responsible clinician considers it to be clinically inappropriate or unfeasible'Vitamin D and calcium supplementation should be offered to all women unless the clinician is confident they have adequate calcium intake and are vitamin D repleteAlendronate is first-lineAround 25% of patients cannot tolerate alendronate, usually due to upper gastrointestinal problems. These patients should be offered risedronate or etidronate (see treatment criteria below)Strontium ranelate and raloxifene are recommended if patients cannot tolerate bisphosphonates (see treatment criteria below)Supplementary notes on treatmentBisphosphonatesAlendronate, risedronate and etidronate are all licensed for the prevention and treatment of post-menopausal and glucocorticoid-induced osteoporosis All three have been shown to reduce the risk of both vertebral and non-vertebral fractures although alendronate, risedronate may be superior to etidronate in preventing hip fracturesIbandronate is a once-monthly oral bisphosphonateVitamin D and calciumPoor evidence base to suggest reduced fracture rates in the general population at risk of osteoporotic fractures - may reduce rates in frail, housebound patientsRaloxifene - selective oestrogen receptor modulator (SERM)Has been shown to prevent bone loss and to reduce the risk of vertebral fractures, but has not yet been shown to reduce the risk of non-vertebral fracturesHas been shown to increase bone density in the spine and proximal femurMay worsen menopausal symptomsIncreased risk of thromboembolic eventsMay decrease risk of breast cancerStrontium ranelate'Dual action bone agent' - increases deposition of new bone by osteoblasts and reduces the resorption of bone by osteoclastsStrong evidence base, may be second-line treatment in near futureIncreased risk of thromboembolic eventsWhich of the following statements relating to avascular necrosis is false?A.When associated with fracture may occur despite the radiological evidence of fracture union.B.Pain and stiffness will typically precede radiological evidence of the condition.C.Drilling of affected bony fragments may be used to facilitate angiogenesis where arthroplasty is not warranted.D.The earliest detectable radiological evidence is a radiolucency of the affected area coupled with subchondral collapse.E.It is less likely when prompt anatomical alignment of fracture fragments is achieved.Avascular necrosis- radiological changes occur late.Radiolucency and subchondral collapse are late changes. The earliest evidence on plain films is the affected area appearing as being more radio-opaque due to hyperaemia and resorption of the neighboring area. It may be diagnosed earlier using bone scans and MRI.Avascular necrosisCellular death of bone components due to interruption of the blood supply, causing bone destructionMain joints affected are hip, scaphoid, lunate and the talus.It is not the same as non union. The fracture has usually united.Radiological evidence is slow to appear.Vascular ingrowth into the affected bone may occur. However, many joints will develop secondary osteoarthritis.CausesP ancreatitis L upus A lcohol S teroids T rauma I diopathic, infection C aisson disease, collagen vascular disease R adiation, rheumatoid arthritis A myloid G aucher disease S ickle cell diseasePresentationUsually pain. Often despite apparent fracture union.InvestigationMRI scanning will show changes earlier than plain films.TreatmentIn fractures at high risk sites anticipation is key. Early prompt and accurate reduction is essential.Non weight bearing may help to facilitate vascular regeneration.Joint replacement may be necessary, or even the preferred option (e.g. Hip in the elderly).Which of the following statements relating to avascular necrosis is false?A.When associated with fracture may occur despite the radiological evidence of fracture union.B.Pain and stiffness will typically precede radiological evidence of the condition.C.Drilling of affected bony fragments may be used to facilitate angiogenesis where arthroplasty is not warranted.D.The earliest detectable radiological evidence is a radiolucency of the affected area coupled with subchondral collapse.E.It is less likely when prompt anatomical alignment of fracture fragments is achieved.Avascular necrosis- radiological changes occur late.Radiolucency and subchondral collapse are late changes. The earliest evidence on plain films is the affected area appearing as being more radio-opaque due to hyperaemia and resorption of the neighboring area. It may be diagnosed earlier using bone scans and MRI.Avascular necrosisCellular death of bone components due to interruption of the blood supply, causing bone destructionMain joints affected are hip, scaphoid, lunate and the talus.It is not the same as non union. The fracture has usually united.Radiological evidence is slow to appear.Vascular ingrowth into the affected bone may occur. However, many joints will develop secondary osteoarthritis.CausesP ancreatitis L upus A lcohol S teroids T rauma I diopathic, infection C aisson disease, collagen vascular disease R adiation, rheumatoid arthritis A myloid G aucher disease S ickle cell diseasePresentationUsually pain. Often despite apparent fracture union.InvestigationMRI scanning will show changes earlier than plain films.TreatmentIn fractures at high risk sites anticipation is key. Early prompt and accurate reduction is essential.Non weight bearing may help to facilitate vascular regeneration.Joint replacement may be necessary, or even the preferred option (e.g. Hip in the elderly)Theme: Diseases affecting the spineA.SpondylolysisB.Spina bifida occultaC.SpondylolisthesisD.MeningomyeloceleE.MeningoceleF.Scoliosis - non structuralG.ScoliosisH.Ankylosing spondylitisI.Scheuermann's diseasePlease select the most likely underlying diagnosis for the condition described. Each condition may be used once, more than once or not at all.33. A 19 year old female is involved in an athletics event. She has just completed the high jump when she suddenly develops severe back pain and weakness affecting both her legs. on examination she has a prominent sacrum and her lower back is painful.SpondylolisthesisTheme from September 2012 ExamYoung athletic females are the group most frequently affected by spondylolythesis who have a background of spondylolysis. Whilst the latter condition is a risk factor for spondylolythesis the former condition is most likely in a young athletic female who presents with sudden pain.34. A 15 year old boy is brought to the clinic by his mother who is concerned that he has a mark overlying his lower spine. On examination the boy has a patch of hair overlying his lower lumbar spine and a birth mark at the same location. Lower limb neurological examination is normal.Spina bifida occultaSpina bifida occulta is a common condition and may affect up to 10% of the population. The more severe types of spina bifida have more characteristic skin changes. Occasionally the unwary surgeon is persuaded to operate on these "cutaneous" changes and we would advocate performing an MRI scan prior to any such surgical procedure in this region.35. A 19 year old female presents to the clinic with progressive pain in her neck and back. The condition has been progressively worsening over the past 6 months. She has not presented previously because she was an inpatient with a disease flare of ulcerative colitis. On examination she has a stiff back with limited spinal extension on bending forwards.Ankylosing spondylitisAnkylosing spondylitis is associated with HLA B27, there is a strong association with ulcerative colitis in such individuals. The clinical findings are usually of a kyphosis affecting the cervical and thoracic spine. Considerable symptomatic benefit may be obtained using non steroidal anti inflammatory drugs. These should be used carefully in patients with inflammatory bowel disease who may be taking steroids.Diseases affecting the vertebral columnAnkylosing spondylitisChronic inflammatory disorder affecting the axial skeletonSacro-ilitis is a usually visible in plain filmsUp to 20% of those who are HLA B27 positive will develop the conditionAffected articulations develop bony or fibrous changesTypical spinal features include loss of the lumbar lordosis and progressive kyphosis of the cervico-thoracic spineScheuermann's diseaseEpiphysitis of the vertebral joints is the main pathological processPredominantly affects adolescents Symptoms include back pain and stiffnessX-ray changes include epiphyseal plate disturbance and anterior wedgingClinical features include progressive kyphosis (at least 3 vertebrae must be involved)Minor cases may be managed with physiotherapy and analgesia, more severe cases may require bracing or surgical stabilisationScoliosisConsists of curvature of the spine in the coronal planeDivisible into structural and non structural, the latter being commonest in adolescent females who develop minor postural changes only. Postural scoliosis will typically disappear on manoeuvres such as bending forwards Structural scoliosis affects > 1 vertebral body and is divisible into idiopathic, congential and neuromuscular in origin. It is not correctable by alterations in postureWithin structural scoliosis, idiopathic is the most common typeSevere, or progressive structural disease is often managed surgically with bilateral rod stabilisation of the spineSpina bifidaNon fusion of the vertebral arches during embryonic developmentThree categories; myelomeningocele, spina bifida occulta and meningoceleMyelomeningocele is the most severe type with associated neurological defects that may persist in spite of anatomical closure of the defectUp to 10% of the population may have spina bifida occulta, in this condition the skin and tissues (but not not bones) may develop over the distal cord. The site may be identifiable by a birth mark or hair patchThe incidence of the condition is reduced by use of folic acid supplements during pregnancySpondylolysisCongenital or acquired deficiency of the pars interarticularis of the neural arch of a particular vertebral body, usually affects L4/ L5May be asymptomatic and affects up to 5% of the populationSpondylolysis is the commonest cause of spondylolisthesis in childrenAsymptomatic cases do not require treatmentSpondylolisthesisThis occurs when one vertebra is displaced relative to its immediate inferior vertebral bodyMay occur as a result of stress fracture or spondylolysisTraumatic cases may show the classic "Scotty Dog" appearance on plain filmsTreatment depends upon the extent of deformity and associated neurological symptoms, minor cases may be actively monitored. Individuals with radicular symptoms or signs will usually require spinal decompression and stabilisationTheme: Management of fracturesA.Discharge home with arm sling and fracture clinic appointmentB.Discharge home with futura splint and fracture clinic appointmentC.Admit for open reduction and fixationD.FasciotomyE.Active observation for progression of neurovascular compromiseF.Reduction of fracture in casualty and application of plaster backslab, followed by discharge home.Please select the most appropriate immediate management for the fracture scenarios given. Each option may be used once, more than once or not at all.36. A 22 year old rugby player falls onto an outstretched hand and sustains a fracture of the distal radius. The x-ray shows a dorsally angulated comminuted fracture.You answered Reduction of fracture in casualty and application of plaster backslab, followed by discharge home. The correct answer is Admit for open reduction and fixationUnlike an osteoporotic fracture in an elderly lady this is a high velocity injury and will require surgical fixation.37. A 10 year old boy undergoes a delayed open reduction and fixation of a significantly displaced supracondylar fracture. On the ward he complains of significant forearm pain and paraesthesia of the hand. Radial pulse is normal.You answered Active observation for progression of neurovascular compromise The correct answer is FasciotomyThe delay is the significant factor here. These injuries often have neurovascular compromise and inactivity now places him at risk of developing complications. In compartment syndrome the loss of arterial pulsation occurs late.38. A 28 year old man falls onto an outstretched hand. On examination there is tenderness of the anatomical snuffbox. However, forearm and hand x-rays are normal.Discharge home with futura splint and fracture clinic appointmentThis could well be a scaphoid fracture and should be temporarily immobilised pending further review. A futura splint will immobilise better than an arm sling for this problem.Fracture managementBony injury resulting in a fracture may arise from trauma (excessive forces applied to bone), stress related (repetitive low velocity injury) or pathological (abnormal bone which fractures during normal use of following minimal trauma)Diagnosis involves not just evaluating the fracture ; such as site and type of injury but also other associated injuries and distal neurovascular deficits. This may entail not just clinical examination but radiographs of proximal and distal joints. When assessing x-rays it is important to assess for changes in length of the bone, the angulation of the distal bone, rotational effects, presence of material such as glass.Fracture typesFracture typeDescriptionOblique fracture Fracture lies obliquely to long axis of boneComminuted fracture >2 fragmentsSegmental fracture More than one fracture along a boneTransverse fracturePerpendicular to long axis of boneSpiral fractureSevere oblique fracture with rotation along long axis of boneOpen Vs ClosedIt is also important to distinguish open from closed injuries. The most common classification system for open fractures is the Gustilo and Anderson classification system (given below):GradeInjury1 Low energy wound <1cm2 Greater than 1cm wound with moderate soft tissue damage3 High energy wound > 1cm with extensive soft tissue damage3 A (sub group of 3) Adequate soft tissue coverage3 B (sub group of 3) Inadequate soft tissue coverage3 C (sub group of 3) Associated arterial injuryKey points in management of fracturesImmobilise the fracture including the proximal and distal jointsCarefully monitor and document neurovascular status, particularly following reduction and immobilisationManage infection including tetanus prophylaxisIV broad spectrum antibiotics for open injuriesAs a general principle all open fractures should be thoroughly debrided ( and internal fixation devices avoided or used with extreme caution) Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injuryA 4 year old boy falls and sustains a fracture to the growth plate of his right wrist. Which of the following systems is used to classify the injury?A.Salter - Harris systemB.Weber systemC.Gustilo - Anderson systemD.Garden systemE.None of the aboveThe Salter - Harris system is most commonly used. The radiological signs in Type 1 and 5 injuries may be identical. Which is unfortunate as type 5 injuries do not do well (and may be missed!)Paediatric fracturesPaediatric fracture typesTypeInjury patternComplete fracture Both sides of cortex are breachedToddlers fracture Oblique tibial fracture in infantsPlastic deformityStress on bone resulting in deformity without cortical disruptionGreenstick fracture Unilateral cortical breach onlyBuckle fracture Incomplete cortical disruption resulting in periosteal haematoma onlyGrowth plate fracturesIn paediatric practice fractures may also involve the growth plate and these injuries are classified according to the Salter- Harris system (given below):TypeInjury patternI Fracture through the physis only (x-ray often normal)II Fracture through the physis and metaphysisIIIFracture through the physis and epiphyisis to include the jointIV Fracture involving the physis, metaphysis and epiphysisV Crush injury involving the physis (x-ray may resemble type I, and appear normal)As a general rule it is safer to assume that growth plate tenderness is indicative of an underlying fracture even if the x-ray appears normal. Injuries of Types III, IV and V will usually require surgery. Type V injuries are often associated with disruption to growth.Non accidental injuryDelayed presentationDelay in attaining milestonesLack of concordance between proposed and actual mechanism of injuryMultiple injuriesInjuries at sites not commonly exposed to traumaChildren on the at risk registerPathological fracturesGenetic conditions, such as osteogenesis imperfecta, may cause pathological fractures. Osteogenesis imperfectaDefective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine.Failure of maturation of collagen in all the connective tissues.Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.SubtypesType I The collagen is normal quality but insufficient quantity.Type II- Poor collagen quantity and quality.Type III- Collagen poorly formed. Normal quantity.Type IV- Sufficient collagen quantity but poor quality.OsteopetrosisBones become harder and more dense. Autosomal recessive condition. It is commonest in young adults. Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone. Theme: Bone diseaseA.Osteogenesis imperfectaB.OsteoporosisC.RicketsD.Pagets diseaseE.ChondrosarcomaF.Metastatic breast cancerPlease select the most likely diagnosis for the scenario given. Each option may be used once, more than once or not at all.40. A 66 year old lady presents with pain in her right hip. It has been increasing over the previous three weeks and waking her from sleep. On examination she is tender on internal rotation. Blood tests reveal a mildly elevated serum calcium and alkaline phosphatase levels.Metastatic breast cancerIncreasing pain at rest, together with increased serum calcium and alkaline phosphatase are most likely to represent metastatic tumour to bone. Chondrosarcomas do occur in the pelvis but are not associated with increased serum calcium and typically have a longer history.41. A 73 year old man presents with pain in the right leg. It is most uncomfortable on walking. On examination he has a deformity of his right femur, which on x-ray is thickened and sclerotic. His serum alkaline phosphatase is elevated, but calcium is within normal limits.You answered Osteoporosis The correct answer is Pagets diseaseThis is a typical scenario for Pagets disease.42. A 73 year old lady presents with pain in her left hip. She was walking around the house when she tripped over a rug and fell over. Apart from temporal arteritis which is well controlled with prednisolone she is otherwise well. On examination he leg is shorted and externally rotated.Her serum alkaline phosphatase and calcium are normal.OsteoporosisThe combination of age, female gender and steroids coupled with hip pain on minor trauma are strongly suggestive of osteoporosis. Bone diseaseDiseaseFeaturesTreatmentPagetsFocal bone resorption followed by excessive and chaotic bone depositionAffects (in order): spine, skull, pelvis and femurSerum alkaline phosphatase raised (other parameters normal)Abnormal thickened, sclerotic bone on x-raysRisk of cardiac failure with >15% bony involvementSmall risk of sarcomatous changeBisphosphonatesOsteoporosisExcessive bone resorption resulting in demineralised boneCommoner in old ageIncreased risk of pathological fracture, otherwise asymptomaticAlkaline phosphatase normal, calcium normalBisphosphonates, calcium and vitamin DSecondary bone tumoursBone destruction and tumour infiltrationMirel scoring used to predict risk of fractureAppearances depend on primary (e.g.sclerotic - prostate, lytic - breast)Elevated serum calcium and alkaline phosphatase may be seenRadiotherapy, prophylactic fixation and analgesiaTheme: Shoulder painA.Impingement syndromeB.Rotator cuff tearC.Adhesive capsulitisD.Calcific tendonitisE.Biceps tendon ruptureF.Parsonage - Turner syndromeG.Labral tearPlease select the most likely cause for shoulder pain from the list. Each option may be used once, more than once or not at all.43. A 63 year old lady undergoes an axillary clearance for breast cancer. She makes steady progress. However, 8 weeks post operatively she still suffers from severe shoulder pain. On examination she has reduced active movements in all planes and loss of passive external rotation.You answered Calcific tendonitis The correct answer is Adhesive capsulitisFrozen shoulder passes through an initial painful stage followed by a period of joint stiffness. With physiotherapy the problem will usually resolve although it may take up to 2 years to do so.44. A 78 year old man complains of a long history of shoulder pain and more recently weakness. On examination active attempts at abduction are impaired. Passive movements are normal.Rotator cuff tearRotator cuff tears are common in elderly people and may occur following minor trauma or as a result of long standing impingement. Tears greater than 2cm should generally be repaired surgically.45. A 28 year old man complains of pain and weakness in the shoulder. He has recently been unwell with glandular fever from which he is fully recovered. On examination there is some evidence of muscle wasting and a degree of winging of the scapula. Power during active movements is impaired.You answered Impingement syndrome The correct answer is Parsonage - Turner syndromeThis is a peripheral neuropathy that may complicate viral illnesses and usually resolves spontaneously.Deep seated pain in the proximal forearm especially during the night and at rest may be due to tumour, especially metastatic lesions.Shoulder disordersProximal humerus fracturesVery common. Usually through the surgical neck. Number of classification systems though for practical purposes describing the number of fracture fragments is probably easier. Some key points:It is rare to have fractures through the anatomical neck.Anatomical neck fractures which are displaced by >1cm carry a risk of avascular necrosis to the humeral head.In children the commonest injury pattern is a greenstick fracture through the surgical neck.Impacted fractures of the surgical neck are usually managed with a collar and cuff for 3 weeks followed by physiotherapy.More significant displaced fractures may require open reduction and fixation or use of an intramedullary device.Types of shoulder dislocationGlenohumeral dislocation (commonest): anterior shoulder dislocation most commonAcromioclavicular dislocation (12%): clavicle loses all attachment with the scapulaSternoclavicular dislocation (uncommon)Types of glenohumeral dislocation:Anterior shoulder dislocationExternal rotation and abduction35-40% recurrent (it is the commonest disorder)Assocociated with greater tuberosity fracture, Bankart lesion, Hill-Sachs defectInferior shoulder dislocationLuxatio erectaPosterior shoulder dislocationProportion misdiagnosed.Rim's sign, light bulb sign.Assocociated with Trough signSuperior shoulder dislocationRare and usually follow major trauma.TreatmentPrompt reduction is the mainstay of treatment and is usually performed in the emergency department. Neurovascular status must be checked pre and post reduction and x-rays should be performed again post reduction to ensure no fracture has occurred. In recurrent anterior dislocation there is usually a Bankart lesion and this may be repaired surgically. Recurrent posterior dislocations may be repaired in a similar manner to anterior lesions but using a posterior (or arthroscopic) approach.Theme: Knee injuriesA.Anterior cruciate ligament ruptureB.Posterior cruciate ligament ruptureC.Medial collateral ligament tearD.Lateral collateral ligament tearE.Torn meniscusF.Chondromalacia patellaeG.Dislocated patellaH.Fractured patellaI.Tibial plateau fractureWhat is the most likely injury for scenario given? Each option may be used once, more than once or not at all.46. A 38 year old man is playing football when he slips over during a tackle. His knee is painful immediately following the fall. Several hours later he notices that the knee has become swollen. Following a course of non steroidal anti inflammatory drugs and rest the situation improves. However, complains of recurrent pain. On assessment in clinic you notice that it is impossible to fully extend the knee, although the patient is able to do so when asked.Torn meniscusTheme from September 2012 ExamTwisting sporting injuries followed by delayed onset of knee swelling and locking are strongly suggestive of a menisceal tear. Arthroscopic menisectomy is the usual treatment.47. A 34 year old woman is a passenger in a car during an accident. Her knee hits the dashboard. On examination the tibia looks posterior compared to the non injured knee.Posterior cruciate ligament ruptureIn ruptured posterior cruciate ligament the tibia lies back on the femur and can be drawn forward during a paradoxical draw test.48. A 28 year old professional footballer is admitted to the emergency department. During a tackle he is twisted with his knee flexed. He hears a loud crack and his knee rapidly becomes swollen.Anterior cruciate ligament ruptureThis is common in footballers as the football boot studs stick to the ground and high twisting force is applied to a flexed knee. Rapid joint swelling also supports the diagnosis.Knee injuryTypes of injuryRuptured anterior cruciate ligamentSport injuryMechanism: high twisting force applied to a bent kneeTypically presents with: loud crack, pain and RAPID swelling knee (haemoarthrosis)Poor healingManagement: intense physiotherapy or surgeryRuptured posterior cruciate ligamentMechanism: hyperextension injuriesTibia lies back on the femurParadoxical anterior draw testRupture of medial collateral ligamentMechanism: leg forced into valgus via force outside the legKnee unstable when put into valgus positionMenisceal tearRotational sporting injuriesDelayed knee swellingJoint locking (Patient may develop skills to "unlock" the kneeRecurrent episodes of pain and effusions are common, often following minor traumaChondromalacia patellaeTeenage girls, following an injury to knee e.g. Dislocation patellaTypical history of pain on going downstairs or at restTenderness, quadriceps wastingDislocation of the patellaMost commonly occurs as a traumatic primary event, either through direct trauma or through severe contraction of quadriceps with knee streched in valgus and external rotationGenu valgum, tibial torsion and high riding patella are risk factorsSkyline x-ray views of patella are required, although displaced patella may be clinically obviousAn osteochondral fracture is present in 5%The condition has a 20% recurrence rateFractured patella2 types: i. Direct blow to patella causing undisplaced fragments ii. Avulsion fractureTibial plateau fractureOccur in the elderly (or following significant trauma in young)Mechanism: knee forced into valgus or varus, but the knee fractures before the ligaments ruptureVarus injury affects medial plateau and if valgus injury, lateral plateau depressed fracture occursClassified using the Schatzker system (see below)Schatzker Classification system for tibial plateau fracturesTypeFeatures1- vertical split of lateral condyleFracture through dense bone, usually in the young. It may be virtually undisplaced, or the condylar fragment may be pushed inferiorly and tilted2- a vertical split of the lateral condyle combined with an adjacent loadbearing part of the condyleThe wedge fragement (which may be of variable size), is displaced laterally; the joint is widened. Untreated, a valgus deformity may develop3- depression of the articular surface with intact condylar rimThe split does not extend to the edge of the plateau. Depressed fragments may be firmly embedded in subchondral bone, the joint is stable4- fragment of the medial tibial condyleTwo injuries are seen in this category; (1) a depressed fracture of osteoporotic bone in the elderly. (2) a high energy fracture resulting in a condylar split that runs from the intercondylar eminence to the medial cortex. Associated ligamentous injury may be severe5-fracture of both condylesBoth condyles fractured but the column of the metaphysis remains in continuity with the tibial shaft6-combined condylar and subcondylar fracturesHigh energy fracture with marked comminutionA 10 year old boy is referred to the orthopaedic clinic with symptoms of right knee pain. He has suffered pain for the past 3 months and the pain typically lasts for several hours. On examination he walks with an antalgic gait and has apparent right leg shortening. The right knee is normal but the right hip reveals pain on internal and external rotation. Imaging shows flattening of the femoral head. Which of the following is the most likely underlying diagnosis?A.Osteogenesis imperfectaB.Child abuseC.OsteosarcomaD.OsteopetrosisE.Perthes diseaseThis is a typical description of Perthes disease. Management involves keeping the femoral head in the acetabulum by braces, casts or surgery.Perthes diseasePerthes diseaseIdiopathic avascular necrosis of the femoral epiphysis of the femoral headImpaired blood supply to femoral head, causing bone infarction. New vessels develop and ossification occurs. The bone either heals or a subchondral fracture occurs.Clinical featuresMales 4x's greater than femalesAge between 2-12 years (the younger the age of onset, the better the prognosis)LimpHip painBilateral in 20%DiagnosisPlain x-ray, Technetium bone scan or magnetic resonance imaging if normal x-ray and symptoms persist.Catterall stagingStageFeaturesStage 1Clinical and histological features onlyStage 2Sclerosis with or without cystic changes and preservation of the articular surfaceStage 3Loss of structural integrity of the femoral headStage 4Loss of acetabular integrityManagementTo keep the femoral head within the acetabulum: cast, bracesIf less than 6 years: observationOlder: surgical management with moderate resultsOperate on severe deformitiesPrognosisMost cases will resolve with conservative management. Early diagnosis improves outcomes.Which statement relating to talipes equinovarus is untrue?A.It has an annual incidence of around 1 in 1000 in the UK.B.The muscles involved in the disorder are intrinsically abnormal.C.The cuboid is classically displaced medially.D.All cases should be treated with an Ilizarov frame initially unless there is minor deformity.E.The talocalcaneal angle is typically less than 20 degrees in club foot.In most cases of Club Foot conservative measures should be tried first. The Ponsetti method is a popular approach. Severe cases may benefit from Ilizarov frame re-aligment.Talipes EquinovarusCongenital talipes equinovarus.Features:Equinus of the hindfoot.Adduction and varus of the midfoot.High arch.Most cases in developing countries. Incidence in UK is 1 per 1000 live births. It is more common in males and is bilateral in 50% cases. There is a strong familial link(1). It may also be associated with other developmental disorders such as Down's syndrome. Key anatomical deformities (2):Adducted and inverted calcaneusWedge shaped distal calcaneal articular surfaceSevere Tibio-talar plantar flexion.Medial Talar neck inclinationDisplacement of the navicular bone (medially)Wedge shaped head of talusDisplacement of the cuboid (medially)ManagementConservative first, the Ponseti method is best described and gives comparable results to surgery. It consists of serial casting to mold the foot into correct shape. Following casting around 90% will require a Achilles tenotomy. This is then followed by a phase of walking braces to maintain the correction. Surgical correction is reserved for those cases that fail to respond to conservative measures. The procedures involve multiple tenotomies and lengthening procedures. In patients who fail to respond surgically an Ilizarov frame reconstruction may be attempted and gives good results.References1. Wynne-Davies R, Littlejohn A, Gormley J. Aetiology and interrelationship of some common skeletal deformities. (Talipes equinovarus and calcaneovalgus, metatarsus varus, congenital dislocation of the hip, and infantile idiopathic scoliosis). J Med Genet. 1982 Oct;19(5):321-8.2. Horn BD, Davidson RS. Current treatment of clubfoot in infancy and childhood. Foot Ankle Clin. 2010 Jun;15(2):235-43.3. Clarke NM, Uglow MG, Valentine KM. Comparison of Ponseti Versus Surgical Treatment in Congenital Talipes Equinovarus. J Foot Ankle Surg. 2011 Jun 14.Which of the following is least likely to impair bone fracture healing?A.RadiotherapyB.OsteoporosisC.Administration of non steroidal anti inflammatory drugsD.Preservation of periosteumE.Presence of osteomyelitic sequestraPeriosteal preservation helps fractures to heal.Fracture healingBone fracture- Bleeding vessels in the bone and periosteum- Clot and haematoma formation- The clot organises over a week (improved structure and collagen)- The periosteum contains osteoblasts which produce new bone- Mesenchymal cells produce cartilage (fibrocartilage and hyaline cartilage) in the soft tissue around the fracture- Connective tissue + hyaline cartilage = callus- As the new bone approaches the new cartilage, endochondral ossification occurs to bridge the gap- Trabecular bone forms- Trabecular bone is resorbed by osteoclasts and replaced with compact boneFactors Affecting Fracture HealingAgeMalnutritionBone disorders: osteoporosisSystemic disorders: diabetes, Marfan's syndrome and Ehlers-Danlos syndrome cause abnormal musculoskeletal healing. Drugs: steroids, non steroidal anti inflammatory agents.Type of bone: Cancellous (spongy) bone fractures are usually more stable, involve greater surface areas, and have a better blood supply than cortical (compact) bone fractures. Degree of Trauma: The more extensive the injury to bone and surrounding soft tissue, the poorer the outcome. Vascular Injury: Especially the femoral head, talus, and scaphoid bones. Degree of ImmobilizationIntra-articular Fractures: These fractures communicate with synovial fluid, which contains collagenases that retard bone healing. Separation of Bone Ends: Normal apposition of fracture fragments is needed for union to occur. Inadequate reduction, excessive traction, or interposition of soft tissue will prevent healing. InfectionTheme: Disorders of the hipA.Perthes diseaseB.Developmental dysplasia of the hipC.OsteoarthritisD.Slipped upper femoral epiphysisE.Septic arthritisF.Rheumatoid arthritisG.Intra capsular fracture of the femoral neckH.Extra capsular fracture of the femoral neckPlease select the most likely diagnosis for the scenario given. Each option may be used once, more than once or not at all.52. An obese 14 year old boy presents with difficulty running and mild knee and hip pain. There is no antecedent history of trauma. On examination internal rotation is restricted but the knee is normal with full range of passive movement possible and no evidence of effusions. Both the C-reactive protein and white cell count are normal.Slipped upper femoral epiphysisSlipped upper femoral epiphysis is the commonest adolescent hip disorder. It occurs most commonly in obese males. It may often present as knee pain which is usually referred from the ipsilateral hip. The knee itself is normal. The hip often limits internal rotation. The diagnosis is easily missed. X-rays will show displacement of the femoral epiphysis and the degree of its displacement may be calculated using the Southwick angle. Treatment is directed at preventing further slippage which may result in avascular necrosis of the femoral head.53. A 6 year old boy presents with pain in the hip it is present on activity and has been worsening over the past few weeks. There is no history of trauma. He was born by normal vaginal delivery at 38 weeks gestation On examination he has an antalgic gait and limitation of active and passive movement of the hip joint in all directions. C-reactive protein is mildly elevated at 10 but the white cell count is normal.Perthes diseaseThis is a typical presentation for Perthes disease. X-ray may show flattening of the femoral head or fragmentation in more advanced cases.54. A 30 year old man presents with severe pain in the left hip it has been present on and off for many years. He was born at 39 weeks gestation by emergency caesarean section after a long obstructed breech delivery. He was slow to walk and as a child was noted to have an antalgic gait. He was a frequent attender at the primary care centre and the pains dismissed as growing pains. X-rays show almost complete destruction of the femoral head and a narrow acetabulum.Developmental dysplasia of the hipDevelopmental dysplasia of the hip. Usually diagnosed by Barlow and Ortolani tests in early childhood. Most Breech deliveries are also routinely subjected to USS of the hip joint. At this young age an arthrodesis may be preferable to hip replacement.Early plain x-ray changes in Perthes Disease:Widening of the joint space.Sub chondral linear lucency.Paediatric orthopaedicsDiagnosisMode of presentationTreatmentRadiologyDevelopmental dysplasia of the hip Usually diagnosed in infancy by screening tests. May be bilateral, when disease is unilateral there may be leg length inequality. As disease progresses child may limp and then early onset arthritis. More common in extended breech babies.Splints and harnesses or traction. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revisionInitially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arcPerthes DiseaseHip pain (may be referred to the knee) usually occurring between 5 and 12 years of age. Bilateral disease in 20%. Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly. X-rays will show flattened femoral head. Eventually in untreated cases the femoral head will fragment.Slipped upper femoral epiphysis Typically seen in obese male adolescents. Pain is often referred to the knee. Limitation to internal rotation is usually seen. Knee pain is usually present 2 months prior to hip slipping. Bilateral in 20%. Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required.X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severityTheme: Paediatric fracturesA.Non accidental injuryB.Accidental fractureC.RicketsD.Metabolic bone disease of prematurityE.Hypophosphataemic ricketsF.OsteopetrosisG.Osteogenesis imperfectaH.HypoparathyroidismI.OsteoporosisPlease select the most likely explanation for each of the following injury scenarios. Each option may be used once, more than once or not at all.55. A toddler aged 3 years presents to the Emergency Department with swelling of his leg and is found to have a spiral fracture of the tibia. His mother reports that he had tripped and fallen the previous day but she had not noticed any sign of injury at the time. She is a single parent with little family support. The child is not on the child protection register.You answered Rickets The correct answer is Non accidental injuryDelayed presentation is unusual and should raise concern. In addition spiral fractures are usually the result of rotational injury which is not compatible with the mechanism proposed by the parent.56. A 5 month baby boy presents with swelling of his right arm and is found to have a spiral fracture of the humerus. He had been in the care of her mother's boyfriend who reported that he had nearly dropped her that day when reaching for his bottle and had inadvertently pulled on his arm to save him. He was immediately taken to the Emergency Department.Accidental fractureThe mechanism fits with the fracture pattern and the presentation is not delayed.57. An infant is admitted with symptoms and signs of respiratory infection and is found to have several posterior rib fractures on chest radiograph. He was born prematurely at 37 weeks' gestation and was observed overnight on the special care baby unit for tachypnoea which settled by the following day. On assessment it is also apparent that his head circumference has increased at an excessive rate and has crossed 3 centiles since birth.You answered Metabolic bone disease of prematurity The correct answer is Non accidental injuryPosterior rib fractures are extremely unusual in neonates. The change in head size may be accounted for by hydrocephalus which may occur as a sequelae from head injury.Paediatric fracturesPaediatric fracture typesTypeInjury patternComplete fracture Both sides of cortex are breachedToddlers fracture Oblique tibial fracture in infantsPlastic deformityStress on bone resulting in deformity without cortical disruptionGreenstick fracture Unilateral cortical breach onlyBuckle fracture Incomplete cortical disruption resulting in periosteal haematoma onlyGrowth plate fracturesIn paediatric practice fractures may also involve the growth plate and these injuries are classified according to the Salter- Harris system (given below):TypeInjury patternI Fracture through the physis only (x-ray often normal)II Fracture through the physis and metaphysisIIIFracture through the physis and epiphyisis to include the jointIV Fracture involving the physis, metaphysis and epiphysisV Crush injury involving the physis (x-ray may resemble type I, and appear normal)As a general rule it is safer to assume that growth plate tenderness is indicative of an underlying fracture even if the x-ray appears normal. Injuries of Types III, IV and V will usually require surgery. Type V injuries are often associated with disruption to growth.Non accidental injuryDelayed presentationDelay in attaining milestonesLack of concordance between proposed and actual mechanism of injuryMultiple injuriesInjuries at sites not commonly exposed to traumaChildren on the at risk registerPathological fracturesGenetic conditions, such as osteogenesis imperfecta, may cause pathological fractures. Osteogenesis imperfectaDefective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine.Failure of maturation of collagen in all the connective tissues.Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.SubtypesType I The collagen is normal quality but insufficient quantity.Type II- Poor collagen quantity and quality.Type III- Collagen poorly formed. Normal quantity.Type IV- Sufficient collagen quantity but poor quality.OsteopetrosisBones become harder and more dense. Autosomal recessive condition. It is commonest in young adults. Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone. In paediatric orthopaedic surgery, which of the following does not fulfill the Kocher criteria for septic arthritis?A.ESR > 40mm/hB.Positive blood cultureC.FeverD.White cell count > 12, 000E.Non weight bearing on the affected sideKocher criteria 1. Non weight bearing on affected side2. ESR > 40 mm/hr3. Fever4. WBC count of >12,000 mm3- When 4/4 criteria are met, there is a 99% chance that the child has septic arthritisThe Kocher criteria do not consider blood culture results.Septic arthritis- PaediatricSeptic arthritisStaph aureus commonest organismUrgent washout and antibiotics otherwise high risk of joint destructionDiagnosisPlain x-raysConsider aspirationKocher criteria: 1. Non weight bearing on affected side2. ESR > 40 mm/hr3. Fever4. WBC count of >12,000 mm3- when 4/4 criteria are met, there is a 99% chance that the child has septic arthritisTheme: Ankle fracturesA.Surgical fixationB.Below knee amputationC.Aircast bootD.Application of full leg plaster cast to include midfootE.Application of below knee plaster cast to include the midfootF.Application of external fixation deviceG.Application of compression bandage and physiotherapy.Please select the most appropriate management for the injury type described. Each option may be used once, more than once or not at all.59. A 24 year old man falls sustaining an inversion injury to his ankle. On examination he is tender over the lateral malleolus only. On x-ray there is a fibular fracture that is distal to the syndesmosis.Application of below knee plaster cast to include the midfootTheme from 2008 ExamThese distal injuries are generally managed conservatively. Conservative management will involve a below knee cast, this will need to extend to the midfoot. It can be substituted for an aircast boot once radiological union is achieved.60. An 86 year old lady stumbles and falls whilst opening her front door. On examination her ankle is swollen with both medial and lateral tenderness. X rays demonstrate a fibular fracture at the level of the syndesmosis.You answered Application of external fixation device The correct answer is Application of below knee plaster cast to include the midfootAlthough, this is a potentially unstable injury operative fixation in this age group generally gives poor results owing to poor quality bone. A below knee cast should be applied in the first instance. If this fails to provide adequate control it can be extended above the knee.61. A 25 year old man suffers an injury whilst playing rugby involving a violent twist to his left lower leg. On examination both malleoli are tender and the ankle joint is very swollen. On x-ray there is a spiral fracture of the fibula and widening of the ankle mortise.Surgical fixationThis is a variant of the Weber C fracture in which disruption of the tibio-fibular syndesmosis occurs leading to joint disruption. Surgical repair is warranted.Ankle injuriesAnkle fractures are a common cause of admission to casualty. Clinical examination is facilitated by the Ottawa ankle rules to try and minimise the unnecessary use of x-rays. These state that x-rays are only necessary if there is pain in the malleolar zone and:1. Inability to weight bear for 4 steps2. Tenderness over the distal tibia3. Bone tenderness over the distal fibulaA number of classification systems exist for describing ankle fractures, these include the Potts, Weber and AO systems. For simplicity the Weber system is outlined here.Weber classificationRelated to the level of the fibular fracture. Type A is below the syndesmosisType B fractures start at the level of the tibial plafond and may extend proximally to involve the syndesmosisType C is above the syndesmosis which may itself be damagedA subtype known as a Maisonneuve fracture may occur with spiral tibial fracture that leads to disruption of the syndesmosis with widening of the ankle joint, surgery is required. ManagementDepends upon stability of ankle joint and patient co-morbidites.All ankle fractures should be promptly reduced to remove pressure on the overlying skin and subsequent necrosis.Young patients, with unstable, high velocity or proximal injuries will usually require surgical repair. Often using a compression plate.Elderly patients, even with potentially unstable injuries usually fare better with attempts at conservative management as their thin bone does not hold metalwork well.Theme: Management of hip fracturesA.Hemiarthroplasty cemented prosthesisB.Hemiarthroplasty non cemented prosthesisC.Percutaneous pinningD.Conservative managementE.Dynamic hip screwF.Intramedullary deviceG.Hip arthrodesisH.Total hip replacementFor each fracture scenario please select the most appropriate management option from the list. Each option may be used once, more than once or not at all.62. A 72 year old retired teacher is admitted to A&E with a fall and hip pain. He is normally fit and well. He lives with his son in a detached, 2 storey house. A hip x-ray confirms an extracapsular fracture.You answered Conservative management The correct answer is Dynamic hip screwExtracapsular fractures should be treated surgically. Since the blood supply to the femoral head is not compromised joint replacement is not usually warranted.63. A 72 year old retired teacher is admitted to A&E with a fall and hip pain. He is normally fit and well. He lives with his son in a detached, 2 storey house. A hip x-ray confirms an subtrochanteric fracture.You answered Dynamic hip screw The correct answer is Intramedullary deviceIntramedullary device is normally recommended for reverse oblique, transverse or subtrochanteric fractures.64. An 86 year old retired pharmacist is admitted to A&E following a fall. She complains of right hip pain. She is known to have hypertension and is currently on bendrofluazide. She lives alone and does not mobilise. Her right leg is shortened and externally rotated. A hip x-ray confirms a displaced intracapsular fracture.You answered Total hip replacement The correct answer is Hemiarthroplasty non cemented prosthesisThis patient warrants a hemiarthroplasty due to reduced mobility and older age. The anterolateral approach is recommended in the SIGN guidelines. In this case most surgeons would not use a cemented prosthesis.Hip fracturesThe hip is a common site of fracture especially in osteoporotic, elderly females. The blood supply to the femoral head runs up the neck and thus avascular necrosis is a risk in displaced fractures.ClassificationThe Garden system is one classification system in common use.Type I: Stable fracture with impaction in valgus.Type II: Complete fracture but undisplaced.Type III: Displaced fracture, usually rotated and angulated, but still has bony contact.Type IV: Complete bony disruption.Blood supply disruption is most common following Types III and IV.Management of hip fractures in older adultsSIGN GuidelinesFracture typePatient co-morbiditiesManagementUndisplaced intracapsular fractureNilInternal fixation (especially if young)Undisplaced intracapsular fractureMajor illness or advanced organ specific diseaseHemiarthroplastyDisplaced intracapsular fractureNilIf age <70 then internal fixation (if possible), hip arthroplasty if notDisplaced intracapsular fractureNilAge >70 total hip arthroplastyDisplaced intracapsular fractureMajor/ immobileHemiarthroplastyExtracapsular fracture (non special type)Only major co-morbidities affect managementDynamic hip screwExtracapsular fracture (reverse oblique, transverse or sub trochanteric)Only major co-morbidities affect managementUsually intramedullary deviceA typical image of an intracapsular fracture occurring in an elderly osteoporotic ladyImage sourced from Wikipedia Referencessign.ac.uk/guidelines/fulltext/111/index.htmlTheme: Paediatric orthopaedicsA.USS hipB.Hip x-rayC.Anteroposterior pelvic x-rayD.CT scanE.MRI scanF.Technetium bone scanG.USS kneeH.X-ray kneeI.Discharge and reassureFor each of the following scenarios which is the most appropriate investigation? Each option may be used once, more than once or not at all.65. An obese 12 year old boy presents with knee pain. On examination he has pain on internal rotation of the hip. His knee is clinically normal.Hip x-rayThe main differential diagnosis in a boy over 10 years old is of slipped upper femoral epiphysis. Knee pain is a common presenting feature. An anteroposterior pelvic x-ray may miss a minor slip, therefore request a hip film.66. A baby is delivered in the breech position. Barlows and Ortolani tests are normalYou answered Discharge and reassure The correct answer is USS hipThis child is at risk of developmental dysplasia of the hip (up to 20% will have DDH), so should have the hip joints scanned to exclude this.67. A 5 year old boy presents with a painful limp. The symptoms have been present for 8 weeks. Two hip x-rays have been performed and appear normal.You answered USS hip The correct answer is Technetium bone scanPerthes disease should be suspected in boys over 4 years old presenting with a limp. Early disease can be missed on x-ray, therefore a bone scan should be performed. MRI is less sensitive than the bone scan.Paediatric orthopaedicsDiagnosisMode of presentationTreatmentRadiologyDevelopmental dysplasia of the hip Usually diagnosed in infancy by screening tests. May be bilateral, when disease is unilateral there may be leg length inequality. As disease progresses child may limp and then early onset arthritis. More common in extended breech babies.Splints and harnesses or traction. In later years osteotomy and hip realignment procedures may be needed. In arthritis a joint replacement may be needed. However, this is best deferred if possible as it will almost certainly require revisionInitially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arcPerthes DiseaseHip pain (may be referred to the knee) usually occurring between 5 and 12 years of age. Bilateral disease in 20%. Remove pressure from joint to allow normal development. Physiotherapy. Usually self-limiting if diagnosed and treated promptly. X-rays will show flattened femoral head. Eventually in untreated cases the femoral head will fragment.Slipped upper femoral epiphysis Typically seen in obese male adolescents. Pain is often referred to the knee. Limitation to internal rotation is usually seen. Knee pain is usually present 2 months prior to hip slipping. Bilateral in 20%. Bed rest and non-weight bearing. Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required.X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severityA 5 year old boy is playing in a tree when he falls and lands on his right forearm. He is brought to the emergency department by his parents. On examination he has bony tenderness and bruising. An X-ray is taken and shows unilateral cortical disruption is development of periosteal haematoma. Which of the following is the most likely diagnosis? A.Buckle fractureB.Greenstick fractureC.Toddlers plete fractureE.None of the aboveGreenstick fractures are common childhood injuries. Unilateral cortical disruption is the main radiological feature, since involvement of both cortices makes the injury a complete fracture. Buckle fractures will show periosteal haematoma formation only. Paediatric fracturesPaediatric fracture typesTypeInjury patternComplete fracture Both sides of cortex are breachedToddlers fracture Oblique tibial fracture in infantsPlastic deformityStress on bone resulting in deformity without cortical disruptionGreenstick fracture Unilateral cortical breach onlyBuckle fracture Incomplete cortical disruption resulting in periosteal haematoma onlyGrowth plate fracturesIn paediatric practice fractures may also involve the growth plate and these injuries are classified according to the Salter- Harris system (given below):TypeInjury patternI Fracture through the physis only (x-ray often normal)II Fracture through the physis and metaphysisIIIFracture through the physis and epiphyisis to include the jointIV Fracture involving the physis, metaphysis and epiphysisV Crush injury involving the physis (x-ray may resemble type I, and appear normal)As a general rule it is safer to assume that growth plate tenderness is indicative of an underlying fracture even if the x-ray appears normal. Injuries of Types III, IV and V will usually require surgery. Type V injuries are often associated with disruption to growth.Non accidental injuryDelayed presentationDelay in attaining milestonesLack of concordance between proposed and actual mechanism of injuryMultiple injuriesInjuries at sites not commonly exposed to traumaChildren on the at risk registerPathological fracturesGenetic conditions, such as osteogenesis imperfecta, may cause pathological fractures. Osteogenesis imperfectaDefective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine.Failure of maturation of collagen in all the connective tissues.Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.SubtypesType I The collagen is normal quality but insufficient quantity.Type II- Poor collagen quantity and quality.Type III- Collagen poorly formed. Normal quantity.Type IV- Sufficient collagen quantity but poor quality.OsteopetrosisBones become harder and more dense. Autosomal recessive condition. It is commonest in young adults. Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone. Theme: Eponymous fracturesA.Smith'sB.Bennett'sC.Monteggia'sD.Colle'sE.GaleazziF.Pott'sG.Barton'sWhich is the most likely eponymous fracture for the scenario given. Each option may be used once, more than once or not at all.69. A 14 year old boy jumps off a 10 foot wall and lands on both feet. An x-ray shows a bimalleolar fracture of the right ankle.Pott's70. A 22 year old drunk man is involved in a fight. He hurts his thumb when he punches his opponent.Bennett's71. A 63 year nurse falls on an extended and pronated wrist. An x-ray shows a distal radial fracture with radiocarpal dislocation.Barton'sEponymous fracturesColles' fracture (dinner fork deformity)Fall onto extended outstretched handClassical Colles' fractures have the following 3 features:1. Transverse fracture of the radius 2. 1 inch proximal to the radio-carpal joint 3. Dorsal displacement and angulationSmith's fracture (reverse Colles' fracture)Volar angulation of distal radius fragment (Garden spade deformity)Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexedBennett's fractureIntra-articular fracture of the first carpometacarpal jointImpact on flexed metacarpal, caused by fist fightsX-ray: triangular fragment at ulnar base of metacarpalImage sourced from Wikipedia Monteggia's fractureDislocation of the proximal radioulnar joint in association with an ulna fractureFall on outstretched hand with forced pronationNeeds prompt diagnosis to avoid disabilityImage sourced from Wikipedia Galeazzi fractureRadial shaft fracture with associated dislocation of the distal radioulnar jointDirect blowPott's fractureBimalleolar ankle fractureForced foot eversionBarton's fractureDistal radius fracture (Colles'/Smith's) with associated radiocarpal dislocationFall onto extended and pronated wristTheme: Fracture managementA.Application of external fixatorB.Open reduction and internal fixationC.FasciotomyD.Skeletal tractionFor the following upper limb injuries please select the most appropriate initial management. Each option may be used once, more than once or not at all.72. A 32 year old man falls from a ladder and sustains a fracture of his proximal radius. On examination he has severe pain in his forearm and diminished distal sensation. There is a single puncture wound present at the fracture site.FasciotomyTheme from April 2012 ExamPain and neurological symptoms in a tight fascial compartment coupled with a high velocity injury carry a high risk of compartment syndrome and prompt fasciotomy should be performed.73. A 32 year old man falls a sustains a fracture of his distal humerus. The fracture segment is markedly angulated and unstable. There is a puncture site overlying the fracture site.You answered Open reduction and internal fixation The correct answer is Application of external fixatorWide exposure to plate the humerus is generally inadvisable owing to its many important anatomical relations. Both intramedullary nailing and external fixation are reasonable treatments. However, in the presence of an open fracture application of an external fixator and appropriate tissue debridement would be most appropriate.74. A 24 year old man sustains a distal radius fracture during a game of rugby. Imaging shows a comminuted fracture with involvement of the articular surface.You answered Application of external fixator The correct answer is Open reduction and internal fixationMeticulous anatomical alignment of the fracture segments is crucial to avoid the development of osteoarthritis and risk of malunion.Fracture managementBony injury resulting in a fracture may arise from trauma (excessive forces applied to bone), stress related (repetitive low velocity injury) or pathological (abnormal bone which fractures during normal use of following minimal trauma)Diagnosis involves not just evaluating the fracture ; such as site and type of injury but also other associated injuries and distal neurovascular deficits. This may entail not just clinical examination but radiographs of proximal and distal joints. When assessing x-rays it is important to assess for changes in length of the bone, the angulation of the distal bone, rotational effects, presence of material such as glass.Fracture typesFracture typeDescriptionOblique fracture Fracture lies obliquely to long axis of boneComminuted fracture >2 fragmentsSegmental fracture More than one fracture along a boneTransverse fracturePerpendicular to long axis of boneSpiral fractureSevere oblique fracture with rotation along long axis of boneOpen Vs ClosedIt is also important to distinguish open from closed injuries. The most common classification system for open fractures is the Gustilo and Anderson classification system (given below):GradeInjury1 Low energy wound <1cm2 Greater than 1cm wound with moderate soft tissue damage3 High energy wound > 1cm with extensive soft tissue damage3 A (sub group of 3) Adequate soft tissue coverage3 B (sub group of 3) Inadequate soft tissue coverage3 C (sub group of 3) Associated arterial injuryKey points in management of fracturesImmobilise the fracture including the proximal and distal jointsCarefully monitor and document neurovascular status, particularly following reduction and immobilisationManage infection including tetanus prophylaxisIV broad spectrum antibiotics for open injuriesAs a general principle all open fractures should be thoroughly debrided ( and internal fixation devices avoided or used with extreme caution) Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injuryTheme: Fracture managementA.Copious lavage and generous surgical debridement, followed by external fixationB.Intramedullary nailC.Open reduction and internal fixationD.Immobilisation in plaster castE.External fixation using a frame deviceF.AmputationG.Application of external fixation deviceH.Primary closure of wound and application of plaster castPlease select the most appropriate management for the fractures described. Each option may be used once, more than once or not at all.75. A 55 year old motorcyclist is involved in a road traffic accident and sustained a Gustilo and Anderson IIIc type fracture to the distal tibia. He was trapped in the wreckage for 7 hours during which time he bled profusely from the fracture site. He has an established distal neurovascular deficit.You answered Copious lavage and generous surgical debridement, followed by external fixation The correct answer is AmputationThis man is unstable, and at 7 hours after extraction, the limb is not viable. The safest option is primary amputation.76. A 25 year old ski instructor who falls off a ski lift and sustains a spiral fracture of the mid shaft of the tibia. Attempts to achieve satisfactory position in plaster have failed. Overlying tissues are healthy.Intramedullary nailThis would be a good case for intramedullary nailing. Open reduction and external fixation would strip off otherwise healthy tissues and hence is unsuitable. In some units the injury may be managed with an Ilizarov frame device but the majority would treat with IM nailing.77. A 35 year old mechanic is hit by a fork lift truck. He sustains a Gustilo and Anderson type IIIA fracture of the shaft of the left femur.You answered External fixation using a frame device The correct answer is Copious lavage and generous surgical debridement, followed by external fixationAt the tissues are in better shape than in the first case and as there is no associated vascular injury the patient may be suitable for debridement of the area and external fixation. If debridement leaves a tissue defect then plastic surgical repair will be needed at a later stage.Delayed treatment of open fractures with significant vascular injury may be best treated by primary amputation.Fracture managementBony injury resulting in a fracture may arise from trauma (excessive forces applied to bone), stress related (repetitive low velocity injury) or pathological (abnormal bone which fractures during normal use of following minimal trauma)Diagnosis involves not just evaluating the fracture ; such as site and type of injury but also other associated injuries and distal neurovascular deficits. This may entail not just clinical examination but radiographs of proximal and distal joints. When assessing x-rays it is important to assess for changes in length of the bone, the angulation of the distal bone, rotational effects, presence of material such as glass.Fracture typesFracture typeDescriptionOblique fracture Fracture lies obliquely to long axis of boneComminuted fracture >2 fragmentsSegmental fracture More than one fracture along a boneTransverse fracturePerpendicular to long axis of boneSpiral fractureSevere oblique fracture with rotation along long axis of boneOpen Vs ClosedIt is also important to distinguish open from closed injuries. The most common classification system for open fractures is the Gustilo and Anderson classification system (given below):GradeInjury1 Low energy wound <1cm2 Greater than 1cm wound with moderate soft tissue damage3 High energy wound > 1cm with extensive soft tissue damage3 A (sub group of 3) Adequate soft tissue coverage3 B (sub group of 3) Inadequate soft tissue coverage3 C (sub group of 3) Associated arterial injuryKey points in management of fracturesImmobilise the fracture including the proximal and distal jointsCarefully monitor and document neurovascular status, particularly following reduction and immobilisationManage infection including tetanus prophylaxisIV broad spectrum antibiotics for open injuriesAs a general principle all open fractures should be thoroughly debrided ( and internal fixation devices avoided or used with extreme caution) Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injury ................
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