Trauma & Orthopaedic Surgery for the MRCS

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Trauma & Orthopaedic Surgery for the MRCS

  1. 1. Trauma & Orthopaedic Surgery for the Intercollegiate MRCS
  2. 2. Instructions <ul><li>Here are some slides to illustrate some of the more important concepts of the orthopaedic and trauma content of the Intercollegiate MRCS Exam. </li></ul>
  3. 3. What is the structure of bone? <ul><li>Cortical bone </li></ul><ul><li>Cancellous bone </li></ul><ul><li>Haversion System </li></ul><ul><ul><li>Blood Supply </li></ul></ul><ul><ul><li>Osteoblast </li></ul></ul><ul><ul><li>Osteoclast </li></ul></ul><ul><ul><li>Osteocyte </li></ul></ul>
  4. 4. How do bones fracture? <ul><li>Mechanism of injury </li></ul><ul><ul><li>Traumatic </li></ul></ul><ul><ul><li>Pathological </li></ul></ul><ul><ul><li>Stress </li></ul></ul><ul><ul><li>Pathological sieve </li></ul></ul><ul><li>Describe the fracture </li></ul><ul><ul><li>Open - Closed </li></ul></ul><ul><ul><li>Undisplaced - Displaced </li></ul></ul><ul><ul><li>Angulations </li></ul></ul><ul><ul><ul><li>Varus/valgus </li></ul></ul></ul><ul><ul><ul><li>Procurvartum - Recurvatum </li></ul></ul></ul><ul><ul><ul><li>Rotation – internal/External </li></ul></ul></ul><ul><ul><ul><li>Translation </li></ul></ul></ul><ul><ul><ul><li>Shortening </li></ul></ul></ul>
  5. 5. Where do bones fracture? <ul><li>Position in the bone </li></ul><ul><ul><li>Metaphysis </li></ul></ul><ul><ul><li>Diaphysis </li></ul></ul><ul><ul><li>Intra-articular </li></ul></ul><ul><li>Describe the fracture </li></ul><ul><ul><li>Transverse </li></ul></ul><ul><ul><li>Spiral </li></ul></ul><ul><ul><li>Comminuted </li></ul></ul>
  6. 6. How do fractures heal? <ul><li>Inflammation 0 – 5 days </li></ul><ul><li>Haematoma </li></ul><ul><li>Necrotic material </li></ul><ul><li>Phagocytosis </li></ul><ul><li>Repair: 5 – 42 days </li></ul><ul><li>Granulation tissue </li></ul><ul><li>Acid environment </li></ul><ul><li>Periosteum – osteogenic cells </li></ul><ul><li>Cortical osteoclasis </li></ul><ul><li>Remodelling </li></ul><ul><li>years </li></ul>
  7. 7. What is the difference between direct and indirect bone healing? <ul><li>INDIRECT BONE HEALING </li></ul><ul><li>Unstable situation </li></ul><ul><li>As in nature </li></ul><ul><li>External Fixator / Cast </li></ul><ul><li>Callus stabilises # </li></ul><ul><li>Direct healing between cortices </li></ul><ul><li>Periosteal New Bone Formation </li></ul><ul><li>DIRECT BONE HEALING </li></ul><ul><li>The response to rigid fixation </li></ul><ul><li>Plates Fixation </li></ul><ul><li>Temporary acceleration of Haversian remodelling </li></ul><ul><li>Only occurs in absolute stability of the fracture </li></ul><ul><li>Does not involve callus formation </li></ul><ul><li>Requires good blood supply </li></ul>
  8. 8. How do You Treat Fractures? <ul><li>REDUCE </li></ul><ul><li>HOLD </li></ul><ul><li>REHABILITATE </li></ul>
  9. 9. What are the aims of fracture treatment? <ul><li>Restore the patient to optimal functional state </li></ul><ul><li>Prevent fracture and soft-tissue complications </li></ul><ul><li>Get the fracture to heal, and in a position which will produce optimal functional recovery </li></ul><ul><li>Rehabilitate the patient as early as possible </li></ul>
  10. 10. What factors effect fracture healing? <ul><li>The energy transfer of the injury </li></ul><ul><li>The tissue response </li></ul><ul><ul><li>Two bone ends in opposition or compression </li></ul></ul><ul><ul><li>Micro-movement or no movement </li></ul></ul><ul><ul><li>Blood Supply (scaphoid, talus, femoral and humeral head) </li></ul></ul><ul><ul><li>Nerve Supply </li></ul></ul><ul><ul><li>No infection </li></ul></ul><ul><li>The patient </li></ul><ul><ul><li>Smoking </li></ul></ul><ul><ul><li>Nutrition </li></ul></ul><ul><li>The method of treatment </li></ul>
  11. 11. How do you manage a polytrauma patient? <ul><li>Life saving measures </li></ul><ul><ul><li>Diagnose and treat life threatening injuries - ATLS </li></ul></ul><ul><ul><li>Emergency orthopaedic involvement </li></ul></ul><ul><ul><ul><li>Life saving </li></ul></ul></ul><ul><ul><ul><li>Limb saving </li></ul></ul></ul><ul><ul><ul><li>Complication saving </li></ul></ul></ul><ul><li>Emergency orthopaedic management (Day 1) </li></ul><ul><li>Monitoring of fracture (Days to weeks) </li></ul><ul><li>Rehabilitation + treatment of complications (weeks to months) </li></ul>
  12. 12. What is ATLS? <ul><li>A - Airway and cervical spine immobilisation </li></ul><ul><li>B - Breathing </li></ul><ul><li>C - Circulation (treatment and diagnosis of cause) </li></ul><ul><li>D - Disability (head injury) </li></ul><ul><li>E - Exposure (musculo-skeletal injury) </li></ul>
  13. 13. Why is treating the soft tissues so important? <ul><li>Open fractures </li></ul><ul><ul><li>degloving injuries and ischaemic necrosis </li></ul></ul><ul><li>Muscles </li></ul><ul><ul><li>Crush and compartment syndromes </li></ul></ul><ul><li>Blood vessels </li></ul><ul><ul><li>Vasospasm and arterial laceration </li></ul></ul><ul><li>Nerves </li></ul><ul><ul><li>Neurapraxias, axonotmesis, neurotmesis </li></ul></ul><ul><li>Ligaments </li></ul><ul><ul><li>Joint instability and dislocation </li></ul></ul>
  14. 14. How do you classify soft tissue injury? <ul><li>GRADE </li></ul><ul><li>I Clean, <1cm </li></ul><ul><li>Simple # </li></ul><ul><li>II Clean, >1cm </li></ul><ul><li>Simple # </li></ul><ul><li>III Extensive </li></ul><ul><li>High energy # </li></ul>
  15. 15. How do you treat soft tissue injury? <ul><li>All severe soft tissue injuries require urgent treatment </li></ul><ul><ul><li>Prevent infection/tetanus/antibiotics </li></ul></ul><ul><ul><li>Wound debridement/irrigation </li></ul></ul><ul><ul><li>Look for open fractures, Vascular injuries, Nerve injuries, Compartment syndromes, Fracture/dislocations </li></ul></ul><ul><ul><li>After the treatment of the soft tissue injury the fracture requires rigid fixation </li></ul></ul><ul><ul><li>A severe soft-tissue injury will delay fracture healing </li></ul></ul>
  16. 16. What are the indications for the operative treatment of fractures? <ul><li>General trend toward operative treatment last 30 yrs </li></ul><ul><ul><ul><li>Improved implants and antibiotic prophylaxis, </li></ul></ul></ul><ul><ul><ul><li>Use of closed and minimally invasive methods </li></ul></ul></ul><ul><li>Current absolute indications:- </li></ul><ul><ul><ul><li>Polytrauma </li></ul></ul></ul><ul><ul><ul><li>Displaced intra-articular fractures </li></ul></ul></ul><ul><ul><ul><li>Open #’s </li></ul></ul></ul><ul><ul><ul><li>#’s with vascular injury or compartment syndrome </li></ul></ul></ul><ul><ul><ul><li>Pathological #’s </li></ul></ul></ul><ul><ul><ul><li>Non-unions </li></ul></ul></ul><ul><li>Current relative indications:- </li></ul><ul><ul><ul><li>Loss of position with closed method, Poor functional result with non-anatomical reduction, Displaced fractures with poor blood supply, Economic and medical indications </li></ul></ul></ul>
  17. 17. When is a fracture healed? <ul><li>Clinically </li></ul><ul><ul><ul><li>Upper limb Lower limb </li></ul></ul></ul><ul><ul><ul><li>Adult 6-8 weeks 12-16 weeks </li></ul></ul></ul><ul><ul><ul><li>Child 3-4 weeks 6-8 weeks </li></ul></ul></ul><ul><li>Radiologically </li></ul><ul><ul><ul><li>Bridging callus formation </li></ul></ul></ul><ul><ul><ul><li>Remodelling </li></ul></ul></ul><ul><li>Biomechanically </li></ul>
  18. 18. What are the complications of fractures? <ul><li>Early Late </li></ul><ul><li>General Other injuries Chest infection </li></ul><ul><li>PE UTI </li></ul><ul><li>FES/ARDS Bed sores </li></ul><ul><li>Bone Infection Non- union/Malunion AVN </li></ul><ul><li>Soft-tissues Plaster sores/WI Tendon rupture N/V injury Nerve compression </li></ul><ul><li>Compartment syn. Volkmann contracture </li></ul>
  19. 19. What is compartment Syndrome? <ul><li>Increased Pressure </li></ul><ul><li>in a </li></ul><ul><li>closed tissue compartment </li></ul><ul><li>resulting in </li></ul><ul><li>local ischaemia </li></ul><ul><li>Needs urgent Fasciotomy </li></ul>
  20. 20. How do classify hip fractures? <ul><li>Intracapsular – involving the femoral neck. </li></ul><ul><li>Extracapsular – involving the intertrochanteric or pertrochanteric region. </li></ul><ul><li>Subtrochanteric – involving the proximal femoral diaphysis. </li></ul>
  21. 21. How do displaced hip fractures fail? <ul><li>30% fixation failure/loss of reduction </li></ul><ul><li>Avascular necrosis </li></ul><ul><li>Non-union </li></ul>
  22. 22. Who is suitable for a uncemented Hemiarthropasty? <ul><li>Frail </li></ul><ul><li>Demented </li></ul><ul><li>Very elderly </li></ul>
  23. 23. What is this hip fracture system? <ul><li>Sliding Hip Screw for Intertrochanteric fractures </li></ul>
  24. 24. What is a Ganglia ? <ul><li>Cystic Swelling in vicinity of tendon or joint </li></ul><ul><li>Excise with wide base only if symptomatic </li></ul><ul><li>High rate of recurrence </li></ul>
  25. 25. What is carpal tunnel syndrome? <ul><li>The entrapment of the median nerve at the fibro osseous tunnel of the carpus </li></ul><ul><li>Weakness of abductor pollicis brevis </li></ul><ul><li>Dysaesthesiae in median nerve distribution </li></ul><ul><li>Decrease in the size of the canal </li></ul><ul><li>osteoarthritis </li></ul><ul><li>trauma </li></ul><ul><li>acromegaly </li></ul><ul><li>Increase in the size of its contents </li></ul><ul><li>pregnancy </li></ul><ul><li>rheumatoid arthritis </li></ul><ul><li>alcoholism </li></ul><ul><li>tumour </li></ul><ul><li>idiopathic </li></ul>
  26. 26. What is DeQuervain’s Disease? <ul><li>Stenosing tenovaginitis of the first dorsal extensor compartment wrist </li></ul><ul><li>Extensor pollicis brevis and abductor pollicis longus tendons </li></ul><ul><li>Steroid injection – rarely surgery </li></ul>
  27. 27. What is trigger finger? <ul><li>Stenosing tenovaginitis of the flexor tendon sheath - A1 pulley </li></ul><ul><li>Steroid injection </li></ul><ul><li>Rarely excsion of A1 pulley </li></ul>
  28. 28. What is Dupuytren’s Contracture <ul><li>nodular hypertrophy and contracture of the palmar fascia </li></ul><ul><li>Genetic </li></ul><ul><li>Fasciectomy if Fixed Flexion Deformity at MCPJ greater than 40 degrees </li></ul>
  29. 29. What are the types of Arthritis <ul><li>Rheumatoid arthritis (RA) </li></ul><ul><li>Osteoarthritis (OA) </li></ul><ul><li>Sero-negative arthritis </li></ul><ul><li>Ankylosing spondylitis </li></ul><ul><li>Reiter’s disease </li></ul><ul><li>Crystal arthropathies </li></ul>
  30. 30. What is the epidemiology of Rheumatoid Arthritis? <ul><li>affects 3% population </li></ul><ul><li>female> male (3:1) </li></ul><ul><li>80% RF </li></ul><ul><li>30% ANF </li></ul><ul><li>HLA DR4 (chr 6) </li></ul>
  31. 31. What is the Pathology of Rhuenmatoid Arthritis? <ul><li>Synovitis </li></ul><ul><li>chronic inflammation, synovial hypertrophy, effusion </li></ul><ul><li>Destruction </li></ul><ul><li>proteolytic enzymes, pannus </li></ul><ul><li>Deformity </li></ul><ul><li>articular destruction, capsular stretching, tendon rupture </li></ul>
  32. 32. What are the extra-articular features of Rheumatoid Arthritis? <ul><li>tendon sheath thickening </li></ul><ul><li>nodules </li></ul><ul><li>vasculitis </li></ul><ul><li>myopathy </li></ul><ul><li>neuropathy </li></ul><ul><li>reticulo-endothelial system - spleen </li></ul><ul><li>visceral - lungs, heart, kidneys, brain, GI </li></ul>
  33. 33. What are early symptoms of rheumatoid arthritis ? <ul><li>myopathy, tiredness, weight loss, malaise </li></ul><ul><li>proximal finger joint swelling </li></ul><ul><li>start up pain </li></ul><ul><li>tendon crepitus </li></ul><ul><li>pain wrists, feet, knees, shoulders </li></ul>
  34. 34. What are the late symptoms of Rheumatoid Arthritis? <ul><li>joint destruction </li></ul><ul><li>pain </li></ul><ul><li>deformity </li></ul><ul><li>instability </li></ul>
  35. 35. What are Rheumatoid Arthritis X-ray findings <ul><li>joint space narrowing </li></ul><ul><li>peri-articular osteopenia </li></ul><ul><li>erosions </li></ul>
  36. 36. What is the treatment of rheumatoid Arthritis ? <ul><li>stop synovitis </li></ul><ul><li>prevent deformity </li></ul><ul><li>reconstruct </li></ul><ul><li>rehabilitate </li></ul>
  37. 37. What is Osteoarthritis? <ul><li>A chronic joint disorder in which there is progressive softening and disintegration of articular cartilage accompanied by new growth of cartilage and bone at the joint margins (osteophytes) and capsular fibrosis </li></ul>
  38. 38. What is the classification of Osteoarthritis ? <ul><li>Primary or idiopathic </li></ul><ul><li>Secondary - infection </li></ul><ul><ul><ul><ul><ul><li>- dysplasia </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>- Perthes’ </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>- SUFE </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>- trauma </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>- AVN </li></ul></ul></ul></ul></ul>
  39. 39. What is the aetiology of Osteoarthritis? <ul><li>Genetic </li></ul><ul><li>metabolic </li></ul><ul><li>hormonal </li></ul><ul><li>mechanical </li></ul><ul><li>ageing </li></ul>
  40. 40. What are Osteoarthritis X-ray changes? <ul><li>joint space narrowing </li></ul><ul><li>subchondral sclerosis </li></ul><ul><li>osteophytes </li></ul><ul><li>cysts </li></ul>
  41. 41. What is the non-surgical treatment of arthritis? <ul><li>analgesia </li></ul><ul><li>disease modifying drugs (RA) </li></ul><ul><li>altered activity </li></ul><ul><li>walking aids </li></ul><ul><li>physiotherapy </li></ul>
  42. 42. What is the Surgical treatment of osteoarthritis? <ul><li>arthroscopy </li></ul><ul><li>osteotomy </li></ul><ul><li>arthrodesis </li></ul><ul><li>excision arthroplasty </li></ul><ul><li>replacement arthroplasty </li></ul>
  43. 43. What are the indications for Joint Replacement? <ul><li>Disabling pain </li></ul><ul><li>Functional limitations </li></ul>
  44. 44. What is the ideal result from a Joint Replacement? <ul><li>painless joint </li></ul><ul><li>full range of movement </li></ul><ul><li>stable </li></ul><ul><li>permanent </li></ul>
  45. 45. Give some complications and there ideal relative incidence in THR? <ul><li>Deep vein thrombosis <10% </li></ul><ul><li>Fatal Pulmonary Embolus 1:1000 </li></ul><ul><li>Deep Infection < 1% </li></ul><ul><li>Dislocation < 5% </li></ul><ul><li>Loosening < 5% at 10 years </li></ul>
  46. 46. What is Ankylosing Spondylitis ? <ul><li>0.2% of population </li></ul><ul><li>mainly affects spine and SI joints </li></ul><ul><li>male > female </li></ul><ul><li>HLA B27 in 90% </li></ul><ul><li>synovitis </li></ul><ul><li>enthesopathy </li></ul>
  47. 47. Describe the MRC Muscle Power Testing Scale ? <ul><li>0 Total paralysis </li></ul><ul><li>1 Barely detectable contracture </li></ul><ul><li>2 Not enough to act against gravity </li></ul><ul><li>3 Strong enough to act against gravity </li></ul><ul><li>4 Still stronger but less than normal </li></ul><ul><li>5 Full power </li></ul>
  48. 48. What is Chronic low back pain ? <ul><li>Pain that persists after 3 months </li></ul><ul><li>< 5% of patients with L.B.P develop Ch.L.B.P </li></ul><ul><li>Multiple factors </li></ul><ul><ul><li>Disc, facet joints, annulus fibrosis, ligaments </li></ul></ul><ul><li>Psychosocial factors </li></ul><ul><li>Surgery is rarely helpful </li></ul><ul><li>Functional restoration programme </li></ul>
  49. 49. What is Lumbar Acute disc prolapse? <ul><li>Nerve root pain follows the dermatome of the involved nerve </li></ul><ul><li>Uncommon in very young and the very old </li></ul><ul><li>Pain is generally worse in the leg than in the back </li></ul><ul><li>Exacerbation of leg pain by straining, sneezing or coughing </li></ul><ul><li>Localised neurological signs </li></ul>
  50. 50. What is Cauda Equina Syndrome ? <ul><li>Large midline disc prolapse </li></ul><ul><li>Compresses several nerve roots </li></ul><ul><li>Sphincter disturbance </li></ul><ul><li>Saddle anaesthesia </li></ul><ul><li>Orthopaedic Emergency </li></ul><ul><li>Urgent MRI </li></ul><ul><li>Prompt surgical intervention </li></ul>
  51. 51. Describe Spinal Stenosis? <ul><li>Commonest cause of neurologic leg pain in older patients </li></ul><ul><li>Symptoms </li></ul><ul><li>Neurogenic claudication - Vascular claudication </li></ul><ul><li>Treatment ? decompress </li></ul>
  52. 52. What are Red flags for possible serious spinal pathology ? <ul><li>Presentation under age 20 or onset over 55 </li></ul><ul><li>Thoracic pain </li></ul><ul><li>Past history of carcinoma, steroids </li></ul><ul><li>Unwell, weight loss </li></ul><ul><li>Widespread neurology </li></ul><ul><li>Structural deformity </li></ul><ul><li>Abnormal blood parameters </li></ul><ul><li>Night pain </li></ul>
  53. 53. What are the common metastatic bone tumours ? <ul><li>The most common condition associated with pathologic fractures is osteoporosis </li></ul><ul><li>Prostate cancer, combined with breast cancer, contributes to 80% of all skeletal metastasis </li></ul><ul><li>Lung cancer has a relatively aggressive course and a short survival after bone metastasis </li></ul><ul><li>Consider thyroid, kidney </li></ul>
  54. 54. What are common primary bone tumours? <ul><li>Multiple Myeloma , the most common primary bone cancer, is a malignant tumour of bone marrow. Most cases are seen in patients aged 50 to 70 years old. Any bone can be involved. </li></ul><ul><li>Osteosarcoma is the second most common bone cancer. It occurs in two or three new people per million people each year. Most cases occur in teenagers. Most tumours occur around the knee. Other common locations include the hip and shoulder. </li></ul><ul><li>Ewing's sarcoma most commonly occurs between age 5 and 20. The most common locations are the upper and lower leg, pelvis, upper arm and ribs. </li></ul><ul><li>Chondrosarcoma occurs most commonly in patients 40 to 70 years of age. Most cases occur around the hip and pelvis or shoulder. </li></ul>
  55. 55. What is Osteomyelitis ? <ul><li>Infection of skin and other soft tissue can lead to infection of bones (osteomyelitis) and joints (septic arthritis). </li></ul><ul><li>Risks with HIV, rheumatoid arthritis, diabetes mellitus, haemophilia or sickle cell anaemia </li></ul><ul><li>MRI </li></ul><ul><li>Debridement/drainage/antibiotics </li></ul>
  56. 56. What are the common limb amputations? <ul><li>Minor amputations are amputations where only a toe or part of the foot is removed. </li></ul><ul><ul><li>A ray amputation is a particular form of minor amputation where a toe and part of the corresponding metatarsal bone is removed </li></ul></ul><ul><li>Major amputations are amputations where part of the limb is removed. </li></ul><ul><ul><li>Symes amputation – through ankle </li></ul></ul><ul><ul><li>Gritti-Stokes amputation – through knee </li></ul></ul><ul><ul><li>AKA/BKA </li></ul></ul><ul><li>Prosthetics – replaces part of limb </li></ul><ul><li>Orthotics – shoe inserts </li></ul><ul><li>PAM aid – pneumatic inflatable prosthesis </li></ul>

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