ORTHOPAEDICS FOR FINAL YEAR Kahoot https://kahoot.it/ Google - - PowerPoint PPT Presentation

ORTHOPAEDICS FOR FINAL YEAR

https://kahoot.it/ Google “Kahoot” → First link

Kahoot

CONGRATULATIONS

• PACES
• Knee
• Hip
• Shoulder
• Trauma

OVERVIEW

Unique Examined by Orthopaedic Surgeons Highly variable (any joint in the body) Knee → Hip → Shoulder → Hand → Spine

PACES - Orthopaedics

Knee Examination (4.5 minutes) Interpretation of plain radiographs (2 minutes)

• Osteoarthritis (medial compartment)
• Knee prosthesis

Viva (3.5 minutes)

My Experience

Surgical Shorts:

• Bilateral amputation
• Groin examination
• Viva on anatomy

Subjective exam You are in control → what you do / say → future Revise viva

Top Tips for PACES

Osteoarthritis: medial, lateral, both Knee prosthesis ACL injuries

PACES - Knee

Knee Osteoarthritis

Take a short history Examine the relevant joint Interpret relevant images Viva 3–4 minutes

Knee Osteoarthritis

Examine the joint (LOOK FEEL MOVE) History: Pain (SOCRATES), previous trauma/operations, functional status, mobility, employment Plain radiographs of joint ?Joint aspirate MRI if diagnostic uncertainty

Which of the following is not a radiographic feature of osteoarthritis? a) Osteophytes b) Reduced cortical density c) Subchondral sclerosis d) Loss of joint space

QUESTION 1

Osteoarthritis

Knee Hip Fingers

Loss of joint space Osteophytes Subchondral sclerosis Subchondral cysts

Loss of Joint Space

LOSS

LOSS

Osteoarthritis O/E

Examine the joint (LOOK FEEL MOVE) History: Pain (SOCRATES), functional status, mobility, employment Plain radiographs of joint ?Joint aspirate MRI if diagnostic uncertainty

Osteoarthritis Mx

Analgesia – WHO analgesic ladder (Paracetamol, NSAIDs +PPI, Weak → Strong) Modification of activities of daily living

• Stop doing whatever you’re doing that brings on pain
• Occupational adjustments
• Home adjustments

Rehabilitation: Occupational and physiotherapy Injections: corticosteroid, hyaluronic acid Correction of deformity

Knee Osteoarthritis

Lateral Medial Both Why???

What does this plain radiograph show? a) Tibial plateau fracture repair b) Intramedullary plate after cancer resection c) High tibial

• steotomy with

cortical plate d) Some screws to heel a poorly knee

Knee Osteoarthritis

What is the term to describe this deformity? a) Varus with medial compression b) Varus with lateral compression c) Valgus with medial compression d) Valgus with lateral compression

Knee Osteoarthritis

Osteoarthritis O/E

Varus deformity: medical compartment compressed Valgus deformity: lateral compartment compressed

Operative Mx Knee Osteoarthritis

Arthroscopic washout Correction of deformity → high-tibia osteotomies –

• pening vs closing wedges

Partial knee replacement Total knee replacement

Anterior Cruciate Ligament

Anterior Cruciate Ligament

• Stability to prevent anterior translation of the tibia

relative to the femur

• Secondary restraint to tibial rotation and

varus/valgus movement

• Anteromedial bundle tightest (most tension) during

flexion

• Supplied by the middle geniculate artery

ACL Injuries

• Non-contact pivoting injury
• Lateral meniscal tears in 54% of acute ACL tears
• 4x more common in female athletes
• Present with pop and pain
• Symptoms of buckling and instability

O/E: Lachman’s +ve, swollen, tender

ACL Tear Mx

Physiotherapy & modifications of ADLs

• Low demand patients

→loss of meniscal integrity →buckling episodes ACL reconstruction

• Younger patients + children
• Older active patients
• Prior reconstructive failure

ACL Tear Mx

Bone-Patellar-Bone Hamstring (gracillis and semitendinosis tendon)

ACL Tear Mx

Osteoarthritis of the hip Hip prosthesis Fractures of the lower extremity PACES - Hip

Gait

Stance phase: foot is in contact with the ground

• ~60% of one gait cycle
• Leg accepts body weight and provides single limb

support Swing phase: foot is off the ground moving forward

• ~40% of one gait cycle
• Limb advances through space

Shortened stance phase → Antalgic gait = pain

Gait

Antalgic gait = pain (ankle, knee or hip)

• Ankle: reduced stride length (heel / toe WB)
• Knee: flexion during stance
• Hip: reduced stance phase

Trendelenburg gait

• Gluteus medius and gluteus minimus
• Abductors of the lower limb

Gait

Which nerves supplies the gluteus medius and gluteus minimus? a) Sciatic nerve b) Superior gluteal nerve c) Phrenic nerve d) Common peroneal nerve

Gait

• Gluteus medius and

gluteus minimus

• Superior gluteal nerve
• Pelvic drop on

contralateral side to lesion

• Lateral (Hardinge)

approach to the hip

Trendelenburg gait

Trendelenburg gait

• Antalgic (or Trendelenberg) gait
• Pain (standing, walking)
• Fixed flexion deformity (inability to obliterate

lumbar lordosis)

• Lack of ROM – check at two points of flexion
• Muscle wasting (quadriceps, gluteal muscles)
• Reduced power around the hip joint

PACES – Hip Osteoarthritis

Osteoarthritis Mx

Analgesia – WHO analgesic ladder (Paracetamol, NSAIDs +PPI, Weak → Strong) Modification of activities of daily living

• Occupational & physiotherapy
• Stick / mobility aids (contralateral)

Physiotherapy + Rehabilitation Correction of deformity Joint replacement

Operative Mx Hip Osteoarthritis

Periacetabular osteotomy +/- femoral osteotomy Hip resurfacing Total hip arthroplasty (THA)

Hip Replacement

Hemi-arthroplasty

• Unipolar
• Bipolar

Total hip replacement

Fixation of Prosthesis

Cement fixation: Polymethylmethacrylate (PMMA)

• Elderly patients → osteopenia
• Irradiated bone

Biologic fixation (cementless fixation)

• Bone in-growth
• Bone on-growth

What does this plain radiograph show? a) Unipolar hemi b) Bipolar hemi c) THR d) Hip-resurfacing

Subacromial impingement Rotator cuff tears Frozen shoulder

PACES - Shoulder

Impingement and rotator cuff disease are a continuum of disease including

• Subacromial impingement
• Subcoracoid impingement
• Calcific tendonitis
• Rotator cuff tears

PACES - Shoulder

Shoulder

What does this AP plain radiograph show?

a) Dislocation of humeral head b) Avascular necrosis

• f humeral head

c) Distal fracture of clavicle d) Superior migration

• f humeral head

Extrinsic compression - Rotator cuff between the humeral head and

• Acromion
• Coracoacromial ligaments
• Acromioclavicular joint

Intrinsic degeneration

• Attrition of the supraspinatus → superior migration

and narrowing of the subacromial space

Subacromial Impingement

Acromion types: Type I - flat Type II - curved Type III - hooked

Subacromial Impingement

Which of the following ligaments is resected in a subacromial decompression? a) Inferior glenohumeral ligament b) Coracoclavicular ligament c) Coracoacromial ligament d) Acromioclavicular ligament

Subacromial Impingement

Presentation:

• Pain in deltoid region (worse with overhead activity)
• Night pain → poor indicator for conservative management
• Weakness

Investigations:

• Radiographs: AP, AP in rotation, outlet view
• USS
• MRI

Subacromial Impingement

Management:

• Modification of ADLs
• Analgesia
• Conservative
• Corticosteroid injection

Operative:

• Subacromial decompression and rotator cuff debridement

alone

• Rotator cuff repair (arthroscopic or mini-open)
• Tendon transfer

Subacromial Impingement

Subacromial Impingement

Rotator Cuff Muscles

Chronic degenerative tear

• Older patients
• Supraspinatus, infraspinatus, teres minor

Chronic impingement Acute avulsion injuries

• Acute subscapularis tears seen in younger patients

following a fall

• Acute SIT tears seen in patients > 40 yrs with a

shoulder dislocation

Rotator Cuff Tears

Previous management listed Indications for surgical repair:

• Symptoms >6 -12 months
• Tear (more than 3 cm)
• Significant weakness and loss of function
• Acute tear/ injury

Rotator Cuff Tears

= pain and loss of ROM in shoulder with no

• ther cause

Soft tissue scarring and contracture Involves the coracohumeral ligament O/E: Pain and reduced ROM (external rotation)

Frozen Shoulder

Diabetes (I and II) Thyroid disorders (autoimmune) Previous surgery (lung and breast) Prolonged immobilization Extended hospitalization

Frozen Shoulder

Stages:

Frozen Shoulder

Painful Gradual onset of diffuse pain (6 weeks – 4 months) Stiff Decreased ROM affecting activities of daily living (4 - 9 months) Thawing Gradual return of motion (up to 2 years)

Conservative

• NSAIDs
• Physiotherapy including heat therapy
• Joint injections

Surgical

• Manipulation under anesthesia (MUA)
• Arthroscopic surgical release

Frozen Shoulder Mx

TRAUMA

Orthopaedics

You are working as surgical F1 at night and you are fast- bleeped to a major trauma call arriving into A&E. The A&E registrar is undertaking the primary survey and you begin to

• help. The patient is hypotensive. What should your next act
• f management be:

A. Take some blood and order an FBC, U+Es, LFTs, CRP and a Lactate B. Perform a 12-lead ECG, the patient has a tachycardia C. Request Pan-CT trauma series D. Establish IV access with a wide-bore cannula and start crystalloids

Question 1

• Resuscitation
• Reduction
• Restriction
• Rehabilitation

THE FOUR Rs

• Resuscitation = A→ E
• Reduction = pulling on it / traction
• Restriction = plates, screws, casts
• Rehabilitation = physio, occupational therapy, and analgesia

THE FOUR Rs

• Resuscitation = A→ E

Primary Survey +/- 3-point C-Spine Immobilisation IV access, VBG, Set of bloods inc G+S for blood Crystalloids 500ml → 1L (+/- DAMAGE CONTROL SURGERY) Secondary Survey + Pan CT

Resuscitation

• Reduction = Pull on it

Requires adequate analgesia: Opioids / neural blockade / General anaesthesia Pre-hospital / Ward-based / Intra-operative Intra or post-reduction imaging May require on-going traction until intra-operative fixation is established

Reduction

• Restriction = pin it / screw it / plate it / nail it

Casting, usually ward-based unless reduction under GA Fixation: internal OR external monoplane OR multiplane K-wires, metal plates, cannulated screws, dynamic screw, intramedullary nails, Taylor Spatial Frame, Lizarov Apparatus

Restriction

Restriction

Restriction

• Rehabilitation

Adequate analgesia → Allows early rehabilitation

• WHO analgesic ladder +/- PPI
• Complimentary analgesics

Physiotherapy (graded, progressive) Occupational therapy

Rehabilitation

#NOF #Long bones Shoulder dislocations

Trauma

Shortened leg Externally rotated Unable to weight-bare Tenderness over greater trochanter Discrepancy in leg length

#NOF

Intracapsular:

• subcapital (through the junction of the head and

neck)

• basocervical fracture (through the base of femoral

neck) Extracapsular:

• intertrochanteric (between the two trochanters)
• subtrochanteric (<5cm distal to the lesser

trochanter)

Hip Fractures

Hip Fractures

Hip Fractures

• 1. Incomplete #, undisplaced
• 2. Complete #, undisplaced
• 3. Complete #, partially displaced
• 4. Complete #, completely displaced

Garden Classification

Management

What kind

• f fixation is

this?

a) Internal fixation with short gamma nail b) Internal fixation with dynamic hip screw c) External fixation with femoral plate + screw d) Screws to fix poorly leg

Types of Fixation

Types of Fixation

Kirschner wires “K wires”

Types of Fixation

Intracapsular:

• Subcapital --> DHS, Cannulated screws, THA
• Transcervical --> DHS, Cannulated screws,

THA Extracapsular:

• Intertrochanteric --> gamma nail
• Subtrochanteric --> femoral nail

Hip Fractures

Types of Fixation

Fracture Repair

• Mal-/non-union
• Osteomyelitis
• AVN – YOUNG VS ELDERLY
• Compartment syndrome

Hip Replacement

• Deep infection
• VTE
• Dislocation – AVOID FULL HIP FLEXION
• Nerve injury: sciatic, SGN
• Leg length discrepancy

Hip Fractures

Posterior

• most common
• does not violate hip abductors
• higher rate of dislocations

Anterolateral

• violates hip abductors
• lower rates of posterior dislocation

THR Approaches

Hip Fractures

=EMERGENCY

• Painful, hot, swollen, and restricted
• Diagnosis: clinical
• Joint should be aspirated
• Empirical antibiotic therapy should be commenced
• nce appropriate cultures have been taken e.g. IV

Flucloxacillin and BenPen

Septic Arthritis

END

SLAP Lesions

SLAP Lesions

I Labral and biceps fraying, anchor intact II Labral fraying with detached biceps tendon anchor III Bucket handle tear, intact biceps tendon anchor (biceps separates from bucket handle tear) IV Bucket handle tear with detached biceps tendon anchor (remains attached to bucket handle tear)

SLAP Lesions