11 - Orthopaedic Assessment Flashcards
Which of the following are especially susceptible to osteomyelitis? (tick all correct answers)
Patient with an open fracture of the tibia
Patients who are an intravenous drug abusers
Patients aged 30-45 years old
Patients who have had a renal transplant
Patients with cardiac disease
Correct: Patient with an open fracture of the tibia
Correct answer
Correct: Patients who are an intravenous drug abusers
Correct answer
Incorrect: Patients aged 30-45 years old
Incorrect: Patients who have had a renal transplant
Incorrect: Patients with cardiac disease
The commonest mechanism of spread is haematogenous, so those with open fractures and iv drug abusers are more susceptible. The age distribution is bimodal – under 20 or over 50. Those with renal disease who are receiving dialysis are more susceptible, but once they have had a renal transplant that risk reduces. Cardiac disease does not increase the susceptibility.
An otherwise healthy 45 year-old man presents with osteomyelitis. Which is the commonest organism that will most likely be the causative organism?
Candida albicans
Escherichia coli
Haemophilus influenzae
Staphyloccocus aureus
Streptococcus pyogenes
The commonest causative organism of osteomyelitis is staphylococcus aureus; other organisms are much less commonly implicated.
What are the likely clinical signs that you will find in osteomyelitis? (tick all that apply)
Abscess formation
Erythema over site of infection
Reduced pulse volume and vascularity
Reduced range of movement of adjacent joint
Tenderness over whole length of bone
The usual clinical signs of an acute osteomyelitis are erythema, localised bony tenderness, oedema and possibly limited range of movement of adjacent joints.
What is the initial treatment that that should be given for osteomyelitis? (tick all that apply)
Analgesia
Intravenous antibiotics
Intravenous fluids
Oral antibiotics
Plaster cast to immobilise the limb
Correct: Analgesia
Correct: Intravenous antibiotics
If treatment is started promptly, then early high dose antibiotics are the best and most crucial initial treatment, but if there is delay, then surgical exploration, debridement and irrigation is often needed. Analgesia is invariably needed and intravenous fluids are also useful adjuncts in some patients as is occasionally immobilisation of the limb is indicated.
Which of the following are risk factors for the development of osteoarthritis of the hip? (tick all correct answers)
Osteoporosis of the hip
Obesity
Sedentary occupation
Rheumatoid arthritis of the hip
Avascular necrosis of the femoral head
Osteoarthritis is associated with LACK of osteoporosis (it is rare to find the two together in the hip, osteoarthritic joints have hard, sclerotic bone rather than porotic bone), obesity (more load on the joint), manual occupations and especially those with high impact on the lower limb, inflammatory arthritis causes joint destruction and can predispose to osteoarthritis, avascular necrosis leads to progressive femoral head collapse and deformity that then leads to osteoarthritis.
A total hip replacement is typically indicated in which of the following scenarios? (tick all that apply)
A 55 year-old female teacher with hip pain of 5/10 only when she plays tennis for more than 3 hours, but not during other daily activities
A 70 year-old male with no comorbidities other than hip pain after he walks a mile
A 45 year-old obese man with uncontrolled type 2 diabetes mellitus and ipsilateral chronic lower leg ulceration with hip pain at night
A 65 year-old woman with a previous myocardial infarction with shortness of breath when walking more than 50 metres with hip pain of severity 4/10
A 67 year-old woman with controlled hypertension with difficulty walking upstairs due to hip pain
Correct: A 67 year-old woman with controlled hypertension with difficulty walking upstairs due to hip pain
All of the answers could be correct or incorrect, dependent upon analgesic usage, the severity of the pain, the effects of the comorbidities on the individual’s lifestyle and the patient preference and attitude to the risks and benefits associated with a total hip replacement. However, hip replaceement is unlikely to be indicated in:
a. as the pain does not affect the life other than after prolonged tennis
c. as the risk of infection is very high with ipsilateral chronic diabetic ulceration and the diabetes mellitus is not controlled
d. since the shortness of breath is the limiting factor in mobility rather than the hip pain
Which of the following are yellow flags for back pain? (tick all that apply)
Hide answer choices
Clinical depression
Night pain
Weight loss
Previous longstanding back problems
History of RTC and compensation claim
Correct: Clinical depression
Correct answer
Correct: Previous longstanding back problems
Correct answer
Correct: History of RTC and compensation claim
The purpose of this question is to discuss the significance of yellow flags and to ensure that you can differentiate them from red flags (see below). Clinical depression, previous longstanding back problems and a history of RTC with a compensation claim are all yellow flags. Night pain and weight loss are red flags. Clearly the presence of yellow flags does not exclude the possibility of genuine significant pathology in the back.
Which of the following are red flags for back pain? (tick all that apply)
Generalised pain
Progressive loss of sensation in the foot
Urinary incontinence
Pain not affected by movement
Radiation of pain into the thigh
Correct: Progressive loss of sensation in the foot
Correct answer
Correct: Urinary incontinence
Correct answer
Correct: Pain not affected by movement
Generalised pain is a yellow flag. Progressive neurological deficits, loss of urinary continence, pain not affected by movement are all red flags. Loss of urinary continence is usually part of cauda equina syndrome and is an orthopaedic emergency. Radiation of pain into the thigh is common in many types of back pathology and not a red or a yellow flag.
Arthroplasty of the big toe MTPJ in a 55 year-old female teacher with a painful big toe MTPJ limiting her ability to perform her job as a cleaner
Osteotomy of the proximal tibia in a 75 year-old male with pain at night and limited walking distance due to severe medial compartment osteoarthritis of the knee
Excision arthroplasty of the subtalar joint in a 68 year-old diabetic lady with a neuropathic subtalar joint with arthritic changes
Hip resurfacing in a 65 year-old woman with a previous myocardial infarction with hip pain when walking more than 300 metres
Total knee replacement in a 67 year-old woman with difficulty walking upstairs and pain at night due to knee pain
Correct: Total knee replacement in a 67 year-old woman with difficulty walking upstairs and pain at night due to knee pain
Osteoarthritis of the 1st MTPJ is common and may often severely limit the joint movement to such an extent that it becomes so stiff it becomes known as hallux rigidus. Arthroplasty of this joint is not commonly performed, but the alternative procedure of arthrodesis is usually preferred. Rarely in very elderly frail patients, an excision arthroplasty has been used in the past.
Osteotomy of the proximal tibia is not commonly performed, and would not usually be considered in a 75 year-old man even if it was thought that the lateral and patella-femoral compartments were well preserved. A total knee replacement would usually be the treatment of choice.
A neuropathic subtalar joint is usually seen in those with diabetic neuropathy (or neuropathy from other causes) and the management is often very challenging. Excision arthroplasty of the subtalar joint is not usually performed, but arthrodesis to give a plantigrade stable foot is often considered. If ulceration is present the management is even more challenging and amputation is not unknown in such challenging cases.
Hip resurfacing is usually offered for active, young patients with osteoarthritis of the hip but would not normally be considered in a 65 year-old patient. The presence of a previous myocardial infarction would need to be carefully considered and the cardiac function assessed prior to any thoughts of musculoskeletal surgery to determine anaesthetic risk and likely success of the operation in improving the quality of life of the patient.
Total knee replacement is the gold standard for relief of night pain and limited mobility in a 67 year-old with osteoarthritis of their knee, assuming no extenuating circumstances.
