Flashcards in Clinical (Weeks 3, 4 +5) Deck (166)
What are risk factors for childhood hip disorders (Developmental Dysplasia of the Hip [DDH])?
Other MSK abnormalities:
- Club foot
What populations are most commonly affected by childhood hip disorders?
What hip is more commonly affected?
What should you look for on examination of a suspected DDH?
- Leg position
- Leg length
- Thigh creases
Feel for click
What special instability tests are useful in diagnosing hip disorders?
- Attempt to dislocate/sublux
- By flexion adduction
- Relocate dislocated by abduction
In a 2 month old child what is the best imaging technique for a suspected hip problem?
In a 6 month old child what is the best imaging technique for a suspected hip problem and why?
Epiphysis has calcified
What is the most successful treatment for DDH?
Pavlik harness (95% success)
What surgical options for treatment are available for DDH at the following ages:
- Age > 3/12
- Age > 9/12
- Age > 2 years
- Closed reduction
- Open reduction
> 2 years:
- Bony surgery (?Femoral/?Pelvic Osteotomy)
A preschool child presents with a limp. What questions are important to ask?
Painful or painless?
History of injury?
Generally well or ill?
What questions may help include/exclude infection?
Pain at rest/movement?
Resistance to movement?
Susceptibility to infection?
If there is a joint effusion what investigation might we carry out?
How would a late DDH present?
Asymmetric creases - Xray
A 7 year old boy is brought to the GP with a painful right hip and limp. His mother informs you he enjoys playing football regularly. On examination he is in the 5th height centile for his age (short) and has a positive Trendellenburg gait.
What is Perthes disease?
Idiopathic AVN of the femoral head
How is Perthes treated?
Influencing the shape of the recovering femoral head:
- Ensure it is contained in acetabulum
A 14 year old African-American boy is brought to you with the inability to bear weight on his left leg, with associated knee pain. On examination he is obese, pre-pubescent and his hip cannot be internally rotated
Slipped Upper Femoral Epiphysis (SUFE)
What is seen on x-ray of a SUFE?
Trethowans sign (AP)
Lateral view is imperative
What ages is transient synovitis most common in?
2-5 year olds
What typically precedes transient synovitis?
An URTI (viral)
What is the commonest cause of hip pain in kids? What conditions must be excluded?
- Septic arthritis
- Juvenile OA
What must you prevent in a patient who cannot bear weight?
Any weight bearing - Assume SUFE until it is excluded
What are red flag symptoms in back pain?
- No variation with exercise
- Night pain
Major, new neurological defect
- Painless urinary retention
- Bowel incontinence
What signs might be seen on observation of a patient presenting with back pain?
What neurological symptoms can be present in back pain?
What myotomes should be tested in the presentation of back pain?
- Hip flexion
- Knee extension
- Foot dorsiflexion and EHL
- Ankle plantarflexion
What is the sciatic stretch test?
Straight leg raise with foot extension
(Testing for nerve irritation)
What is the bowstring test?
Straight leg raise with pressure behind knee
(Testing for nerve irritation)
When will an x-ray be useful in back pain?
If spinal stenosis:
- Degenerate + hypertrophic spine
- Narrow interpedicular distance
- Obliteration of IV foraminae
What signs may be seen on a spinal MRI?
- Annular tear
- Disc inflammation
- White patches either side in vertebral bodies
What are features of sciatica?
Buttock and/or leg pain
A patient presents with episodic back pain with new onset of leg pain and weakness. The leg pain has become the dominant pain.
When is surgery considered in disc prolapse?
Cauda equina syndrome
No resolval in 3 months
Back pain patients should get long-term bed rest. True or false?
They need early return to normal activity and physical therapy
What symptoms may suggest a behavioural problem?
Pain at coccyx
Whole leg pain/numbness
Absence of pain free spells
A 59 year old man presents to the GP with back pain. He notes that he has been unable to walk very far. He also informs you that he used to be a builder. He says that his symptoms get better on sitting and leaning forward. On examination he is obese.
How is spinal stenosis treated?
Step 1. Decompression -> Destabilises spine
Step 2. Stabilisation:
- Fusion and Fixation
What pattern of pain does disc degeneration follow?
Worse as day goes on
Worse on flexion
Worse on activity
Central, lower back pain
A patient presents with morning stiffness. They explain how they have a 'loosening up' routine. They have difficulty sitting and standing. They note the pain is better on exercise. Sometimes it radiates to the buttocks. On examination the pain is worsened on back extension.
Between 6-9 months what should a child be able to do?
Sit alone and crawl
Between 8-12 months what should a child be able to do?
Stand (holding furniture)
Between 14-17 months what should a child be able to do?
At what age should a child be able to run/jump?
At what age should a child be able to climb up and down stairs?
Up - 3 years
Down - 4 years
How does the foot arch develop?
As we walk the muscles strengthen
What are the types of flat foot?
What is Jack's test in terms of a flat foot?
Great toe dorsiflexion:
- Arch will form in a mobile flat foot
- Due to tight tibialis anterior
What are some causes of in-toeing?
Femoral neck anteversion
Internal tibial torsion
How do we diagnose femoral neck anteversion?
Measure hip rotational range
What features are present in patients with femoral neck anteversion?
Age > 4 years
What do we measure in suspected internal tibial torsion?
What features are present in patients with internal tibial torsion?
When are bow legs physiological? What causes this?
Medial tibial torsion
When should bow legs be referred?
What is the medical term for bow legs?
What is the normal intermalleolar distance at 11 years?
When do you refer for knock knees?
> 8cm distance at 11
What is the medical term for knock knees?
What is the commonest cause of adolescent knee pain in girls?
What are some of the risk factors for adolescent knee pain?
- Wide hips
- Femoral neck anteversion
What is chondromalacia patellae and what can it be seen in?
Softening of patella's hyaline cartilage
Adolescent knee pain
What must you examine in an adolescent presenting with anterior knee pain?
Abnormalities in what bones causes clubfoot?
What soft tissue contractures can result from clubfoot?
Ankle equinus (plantarflex)
What are some risk factors for clubfoot?
Oligohydramnios (reduced amniotic fluid)
How is clubfoot treated?
- Splintage after birth
- Weekly casts (5-6 weeks)
- 80% have Achilles tenotomy
- Braced (23 hours/day for 3 months)
What are the National Institute for Health Criteria for NF1?
6 or more cafe au lait spots:
- > 5mm pre-puberty
- > 15mm post-puberty
>= 2 neurofibromas or 1 PFN
>= 2 Lisch nodules (Iris hamartomas)
1st degree relative
(2/7 of these)
How does a NF1-type 'rash' look?
Soft, subcutaneous, pedunculated lumps
A child presents with frontal bossing, midface hypoplasia and rhizomelic disproportion
What is the pathogenesis resulting in bone deformities in cerebral palsy?
Brain injury -> Increased tone -> Abnormal posture -> Contracture
What is the pathology that results in spastic cerebral palsy?
1. Periventricular leukomalacia (white matter injury)
2. Loss of inhibition of LMN
3. Positive features of UMN syndrome
How do benzodiazepines reduce spasticity?
1. Bind to GABAa receptors
2. Increased GABA affinity for receptor
3. Reduce neurone excitability
What is baclofen's mode of action?
GABAb receptor agonist
How is Baclofen administered?
How does Botox work?
Cleaves SNARE receptor proteins reduce neurotransmitter release
What is a surgical treatment for spasticity?
Selective Dorsal Rhizotomy
What are causes of tip-toe walking?
2-3 months while child learns to walk
What inheritance is Duchenne Muscular Dystrophy?
What gender is DMD presented in and at what age?
2-5 years old
Mutations in what gene cause DMD?
What clinical and biochemical features help diagnose DMD?
- Using hands/arms to 'walk up' from kneeling
Increased serum CK
What disease can cause pes cavus?
A patient presents with local, nocturnal pain in their shin. On x-ray there is a 1cm round lucency surrounded by sclerosis.
What are the two most common causes of acute osteomyelitis?
What is the pathogenesis of acute osteomyelitis in children and the immunosuppressed?
1. Haematogenous spread
3. Thromboses sinusoidal vessel
4. Bacterial colonisation
What is the most common infective agent in acute osteomyelitis?
Haem. influenzae in kids
If there's pus...
...Let it out
What is the pathogenesis of chronic osteomyelitis?
1. Bone abscess -> Dead bone (Sequestrum)
2. Pus seeps out under periosteum
3. Bone forms from the periosteum (Involucrum)
4. Bone remodelling (Wolff's Law)
What is Wolff's Law?
Bone will remodel and shape due to the pressures it is placed under
What investigations are useful in chronic osteomyelitis?
Where is the most common affected site of chronic osteomyelitis?
How can septic arthritis be acquired?
Inoculation (penetrating injury)
Direct haematogenous spread
What is the biggest feature of septic arthritis?
Total loss of function due to pus filling joint space and forcing bones apart
Treatment of septic arthritis
Replacement of joint
How do we treat cellulitis and why?
Flucloxacillin and Benzylpenicillin
(Staph and Strep most common causes)
Black specs on x-ray suggest what?
When is a bone infection operated upon?
What is the most likely diagnosis of a teen with back pain and how would we treat?
What investigations would we carry out in a suspected infected arthroplasty?
Technetium 99 Bone Scan
What can cause a biofilm-producing infection?
What is important in determining the degree of pain a patient is experiencing in a joint?
How it affects their QoL
What knee ligament is most commonly injured?
A patient presents with a painful lump on their left leg. They explain that they are a cyclist and cut their leg about 2 weeks ago. On examination the lump is very red, well defined and fluctuant.
A patient presents with a severely swollen right knee. The knee is very swollen and absolutely impossible to move, even passively. The patient has felt very tired, suffered night sweats and has a fever of 39.
What investigations need done into septic arthritis?
How do we treat septic arthritis?
Urgent open/arthroscopic washout (6L) and debridement
A patient presents with a 12mm swelling on their left anterior wrist. On examination it is round and discrete. It is non-tender. The skin is freely mobile over it. The patient presented because it tends to catch on his watch.
What is a ganglion?
How do you treat a ganglion?
DO NOT ASPIRATE
What is a Baker's cyst?
Popliteal fossa ganglion
What is a Baker's cyst associated with?
A patient presents with a painful right hip. It is worse when they are lying on that side. On examination there is tenderness on the anterolateral aspect of their right hip.
How is bursitis treated?
If abscess -> Drain
What are rheumatoid nodules associated with?
What joints are commonly affected by Dupuytren's contractures?
What causes Dupuytren's?
Excess myofibroblast prolifetation and altered collagen matrix (Collagen iii instead of i)
What happens to the palmar fascia in Dupuytren's?
Is Dupuytren's vascular or avascular?
Avascular (O2 free radicals)
Management of Dupuytren's
- Needle fasciotomy
- Collagenase injection
Limited fasciectomy (Band removal)
If skin involved:
- Skin grafting after
What genetics can be involved in Dupuytren's?
Autosomal dominant condition
Risk factors for Dupuytren's?
A patient presents with a firm, discrete swelling on the back of their middle finger. It is painful/
Giant cell tumour of the tendon sheath
What are diffuse giant cells tendon sheath tumours associated with?
Pigmented Villonodular synovitis
In regard to lipomas, which are the following are true and which are false?
1. They grow quickly
2. They are painless
3. Have a firm feeling
4. Tend to cause skin changes
5. They move under your skin on palpation
2. True (Usually)
3. False (Feel 'fatty')
A 15 year old boy presents with a 2 month history of a lump just beneath his knee. He says it is usually painless, but can catch on clothes when walking. On examination there is a hard lump on his proximal tibia.
What is the histology of an osteochondroma?
Cartilage-capped ossified pedicle derived from aberrant cartilage from perichondral ring
What are the two forms of osteochondromas? What is the difference?
Multiple Hereditary Exostosis:
- Numerous tumours
- Increased risk of malignant transformation
What is a Ewing's sarcoma derived from?
Marrow endothelial cells
A 13 year old patient presents with night pain in his left leg. He has a fever. His bloods show anaemia, increased CRP and ESR.
What do sebaceous cysts fill with?
How do sebaceous cysts present?
A patient was admitted to A&E 6 weeks ago following a sporting incident in which he suffered a large contusion to his right thigh. He recovered fully but initially noted some swelling a month ago but now his thigh feels 'hard'
What are some causes of 'shoulder impingement'?
Tendonitis (mostly supraspinatus)
Hooked rotator cuff tear
What is the grading system used to classify the shape of the acromial angle? How do these grades impact pathology?
Bigliani Acromial Grading
- Lowest risk of cuff tear
- Most common shape
- Highest risk of tear
A patient presents with sudden onset, severe shoulder pain. It is sometimes stiff. On x-ray there is a small opacified triangle proximal to the great humeral tuberosity. How can we treat this condition?
- Subacromial steroid injection
- Local anaesthetic
What is os acromiale?
Acromion remains a separate bone
What type of patients tend to present with rotator cuff tears?
Patients older than 40
Those with tendon degeneration
What is a classical history feature of a rotator cuff tear?
What is the most commonly affected rotator cuff muscle?
How does a rotator cuff tear present?
Weakness on abduction initiation
Poor internal and external rotation
How do we confirm a rotator cuff tear diagnosis?
What are the two types of shoulder instability and who gets them?
- Sporty people
- Older people
- Degenerative changes
What does TUBS stand for in terms of shoulder instability?
T - Traumatic
U - Unilateral
B - Bankart lesion:
- Injury to the anterior glenoid labrum of the shoulder
S - Surgery (Bankart repair)
What is a Hill-Sachs lesion and what causes it?
Cortical depression of the posterolateral humeral head
Anterior shoulder dislocation:
- (Soft) Humeral head impacts on anterior glenoid rim
What can a Hill-Sachs lesion contribute to?
What does AMBRI stand for in terms of shoulder instability?
A - Atraumatic
M - Multidirectional
B - Bilateral
R - Rehabilitation
I - Inferior capsular shift
What causes atraumatic instability?
- Minor trauma
What does the sulcus sign suggest?
Ligamentous laxity and potential ease of atruamatic shoulder dislocation
A 53 year old patient presents with stiffness in his shoulder for the past 6 months. He says that for the first couple of months there was a lot of pain, then pain and stiffness but now the pain has subsided as his shoulder has been almost totally immobile. He is diabetic and has Dupuytren's.
What can trigger adhesive capsulitis?
What nerve is affected in carpal tunnel syndrome?
What symptoms are present in carpal tunnel?
- Radial 2.5 fingers
Worse at night
Loss of sensation
What might be noted on examination of carpal tunnel syndrome?
Thenar muscle wasting
Tinel's test positive:
- Tapping over nerve causes symptoms
Phalen's test positive:
- Holding wrist hyper-flexed causes symptoms
How can we investigate carpal tunnel?
Nerve conduction studies
What nerve is affected in cubital tunnel syndrome?
What is the typical presentation of cubital tunnel syndrome?
Paraesthesia in ulnar 1.5 fingers
What might be noted on examination in a cubital tunnel patient?
Weakness in index finger abduction:
- 1st dorsal interossei weakness
Fromen'ts test positive:
- Weakness in adductor pollicis
- Ask patient to hold paper between 1st finger and thumb and pull paper away (in a positive test, the patient will have to flex their thumb's IP joint to maintain grip)
What three sites might cause compression of the ulnar nerve?
IM septum tightness above elbow
Flexor carpi ulnaris tightness
In what patients are pressure ulcers more likely?
Patients who aren't mobilised early
What pre-op analgesia was traditionally given before orthopaedic surgery?
What is the newer model for pre-op analgesia?
Local nerve blocks
What is the system for post-op analgesia?
1. Regular paracetamol (PO or IV) (Rarely enough)
2. Codeine - 15mg at first (Can be increased)
3. Morphine - Regular/As required
3. Oxycodone if confused on morphine
When are anti-resorptive agents commenced after a fragility fracture and what agents may we commence?
Oral alendronic acid
What features of a patient's history suggest a nerve root pain?
Unilateral leg pain
Paraesthesia in a dermatome
Leg pain worse than back pain
- Decreased reflexes
What ages might suggest a more serious spinal pathology?
55 years old