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Clinical Years / Progress Test > MSK Orthopaedics > Flashcards

MSK Orthopaedics Flashcards

1
Q

Haversian system of bones

A

central Haversian canal surrounded by concentric rings of lamellar bone with embedded osteocytes

canaliculi within the lamellar bone supply blood and allow communication between osteocytes

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2
Q

macroscopic organisation of bone

A

outer region of compact bone where muscles attach and provides strength and protection

inner trabecular bone which contains bone marrow

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3
Q

assessing a fracture on xray

A

Describe the qualities of the x-ray (patient details correct? appropriate penetration and view?)

Site of fracture (which bone and which part of the bone? Examine entire cortex for any breaks)

Type of fracture (Transverse, oblique, spiral)

Simple or comminuted?

Displaced or not?

Angulated or not?

Is the bone of normal consistency or not?

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4
Q

general management of fractures

A

in simple fractures compression can improve bone healing

management options include casts/ splints, intramedullary devices, plates and screws, tension band wires, K-wires and external fixators

in more complicated fractures if the bone is salvageable surgical fixation can be performed; Open Reduction Internal Fixation is the most common method usually with plates and screws
Closed Reduction Internal Fixation can also be done

if bone not salvageable i.e. due to lack of blood supply then joint replacement needed

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5
Q

management of hip fractures

A

depends on intracapsular or extra capsular

intracapsular fractures can have compromised blood supply so usually need arthroplasty

extra capsular fractures can be fixed with a DHS or IM Nail

management also depends on severity of fracture (graded 1-4) where 1 and 2 can usually be done with screws and 3 and 4 would need a hip replacement

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6
Q

who is considered for a total hip replacement after a fracture

A

no cognitive impairment and are independently mobile

otherwise a hemi-arthroplasty is done instead just replacing the femoral component and femoral head

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7
Q

osteoarthritis x ray features

A

Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis

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8
Q

primary osteoarthritis

A

wear and tear” of the joint
the breaking down and rebuilding the joint tissues starts to become less efficient and joint integrity and function starts to gradually decline

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9
Q

secondary osteoarthritis

A

arthritis is due to an underlying cause such as rheumatological disease, trauma or infection

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10
Q

basis of management in osteoarthritis

A

Long term regular exercise and physiotherapy can help combat this with simple analgesia.

If this progresses, this can require orthopaedic intervention for joint replacement

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11
Q

what is septic arthritis
how does it present

A

infection in the joint fluid or tissues

presents with a single hot, red, swollen joint - needs a low index of suspicion and fast action - can lead to septic shock

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12
Q

management of septic arthritis

A

rapid referral to orthopaedics

joint aspiration needed and send sample for culture

then start empirical antibiotic treatment flucloxacillin for 4-6 weeks IV. If MRSA suspected, use vancomycin instead and if penicillin allergy, use clindamycin

prosthetic joints should only be aspirated in theatre

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13
Q

osteomyelitis presentation and management

A

can present similarly to septic arthritis but can also have a more subacute presentation on a background of a local infection

flucloxacillin +/- rifampicin for the first 2 weeks (duration about 6 weeks IV abx) (if penicillin allergic, clindamycin +/- rifampicin)

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14
Q

how should all acute swollen joints be managed

A

aspirate can be a form of treatment and also needs sending for culture, gram stain, cytology, and microscopy which will cover most causes of an acutely swollen joint

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15
Q

differentials acutely swollen joint

A

septic arthritis
osteomyelitis
crystal arthropathy
inflammatory process

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16
Q

treatment if swollen joint suspected inflammatory cause

A

intra-articular steroids - but must be avoided if patient unwell/septic

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17
Q

antibody tests useful in synovitis

A

anti-CCP

rheumatoid factor

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18
Q

typical appearance of the lower limb in a neck of femur fracture

A

Shortened and externally rotated

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19
Q

gold standard imaging in osteomyelitis

A

MRI

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20
Q

management of an open fracture

A

-gross contamination removed
-photograph the wound
-wound should be covered in a saline soaked gauze and the limb should be splinted, usually in a backslab
-IV antibiotics within 1 hour of injury then every 8 hours
-theatre for a wound washout and debridement, and stabilization of the fracture within 24 hours (unless highly contaminated or neuromuscular compromise which need urgent surgery)

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21
Q

neurovascular importance in knee dislocations

A

high rate of peroneal nerve and popliteal artery injuries as well as ligament injuries

consider CT angiogram to assess for artery involvement

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22
Q

how are soft tissues around joints assessed in injury

A

MRI

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23
Q

what is a pathological fracture

A

a fracture of abnormal bone i..e weakened or damaged already

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24
Q

general management of soft tissue injuries

A

conservative management - splinting and physiotherapy

direct surgical repair

some injuries need reconstruction with new tissue e.g. ACL tears

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25
Q

steps of the WHO analgesic ladder

A

principles; move up if pain not controlled, move down if signs of toxicity or severe side effects

step 1; non-opioid with or without adjunctive analgesic

step 2; mild to moderate pain opioid with non-opioid

step 3; moderate to severe pain opioid with non-opioid and can adder adjuncts

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26
Q

morphine administration in patient controlled analgesia

A

usual concentration of morphine is 2mg/ml and the lock-out time is 5 minutes. This means that once the patient has given himself a bolus of 1 mg (or 0.5ml), he/she will not be able to administer a further dose for the duration of the lock-out period

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27
Q

compartment syndrome

A

pressure within a fascial compartment exceeds the perfusion pressure within the compartment, causing ischaemia of the tissues within the compartment

severe pain after a fracture that’s not controlled by analgesia should raise suspicion

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28
Q

management in severe cases of compartment syndrome

A

surgical fasciotomy

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29
Q

what is delayed union

what factors contribute

A

failure to reach bony union at 6 months post injury

Local factors include location (scaphoid, distal tibia and base of 5th metatarsal are at risk due to the blood supply), stability, infection and pattern (segmental fractures are at higher risk)

Systemic factors include diet, Diabetes Mellitus, smoking, HIV and medications such as corticosteroids and NSAIDs.

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30
Q

classification of nerve injuries

A

Neuropraxia (reversible conduction block due to injury to the axon sheath)

Axonotmesis (disruption to the myelin sheath and the axon)

Neurotmesis (complete nerve division and disruption of the endoneurium)

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31
Q

nerve supply of the muscles of the anterior leg

A

common peroneal nerve divides into the superficial and deep peroneal nerves.
deep supplies the anterior compartment muscles.

The superficial peroneal nerve is a sensory nerve.

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32
Q

definition of
- osteopenia
- osteoporosis

A

osteopaenia- bone mineral density one standard deviation below that of an average young subject from the same race and sex

osteoporosis - bone density 2.5 standard deviations below that of a young subject from the same race and sex

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33
Q

fragility fracture

A

fracture that results from a fall from standing height or less

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34
Q

what is the most accurate clinical sign for diagnosing compartment syndrome

A

pain exacerbated by passive stretch

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35
Q

what compartment is most commonly affected in compartment syndrome

A

anterior compartment

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36
Q

fracture of the upper limb with pallor and no pulse in the hand?

A

suspect brachial artery may be trapped, kinked or torn

if doesn’t resolve after fracture surgically fixed then urgent surgical exploration by vascular of the brachial artery needed

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37
Q

surgery of supracondylar fracture

A

under GA fracture reduced and held using K wires and a plaster cast

K wires removed in clinic at 4 weeks along with plaster cast and mobilisation now encouraged

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38
Q

immobilisation in paediatric fractures

A

4 weeks upper limb
6-8 weeks lower limb

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39
Q

what is the growth plate

A

An area of cartilage which proliferate or enlarges, effectively growing, the leading edge calcifies

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40
Q

significance of a growth plate injury

A

Growth may cease, the limb is shortened. If asymmetrical with growth on one side deformity and angulation may occur

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41
Q

common paediatric fractures

A

Wrist, buckle; Clavicle; distal humerus and supracondylar fracture

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42
Q

back pain history

A

SOCRATES
variation in the day ?inflammatory
acute or insidious onset
duration
cauda equina symptoms?
systemic features ?malignancy

pain from other origin ?renal ?leaking AAA or other abdominal pathology

?immunosuppressed
?occupation and functional impairment
?PMH inc malignancy and trauma
?FHx inc IA
?patient concerns

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43
Q

back pain red flags

A
  • fever
  • night sweats
  • age <20 or >50
  • night pain, constant pain or pain lying flat
  • trauma
  • weight loss
  • reduced appetite
  • weakness or numbness
  • bladder or bowel involvement
  • history of cancer
44
Q

what is the schober test

A

test of lumbar flexion for ankylosing spondylitis - pen mark above and below L5 and when patient flexes back (touches toes) fingers should move apart when placed on pen marks

45
Q

what signs suggest psychological or socioeconomic contributions to back pain

A

superificial tenderness esp over a wide area

pain on movements that shouldn’t be painful

distraction; able to perform a movement when distracted

regionalisation; symptoms that don’t fit with neuroanatomy

overreaction

46
Q

non-invasive treatments for mechanical or musculoskeletal back pain

A

Education warn about red flags
Return to normal activities and avoid bed rest
Avoid precipitants
Physiotherapy and advised to mobilise

47
Q

what features indicate musculoskeletal or mechanical back pain

A

lack of red flags

no nerve root tension signs

48
Q

features of sciatica
most common cause

A

positive nerve tension signs; i.e. positive straight leg stretch test (can’t raise leg to 90degrees)

shooting pain down leg

most likely due to a prolapsed disc

49
Q

what patient age are disc herniations more common

A

<50

in those >60 spinal stenosis is more common

50
Q

imaging for lumbar disc disease

A

MRI is imaging of choice - but ensure to match with clincial signs as some can have abnormalities on MRI but no symptoms

X-rays not particularly useful, may show may show degenerative changes such as narrow joint spaces and osteophyte formation but not clinically useful

51
Q

management for chronic lower back pain

A

MDT pain management clinic; physio, OT, psychotherapy
can prescribe topical treatments such as capsaicin and lidocaine and also pain modifying treatments such gabapentin and amitriptyline

52
Q

how does capsaicin work to reduce pain

A

reduces substance P in small nociceptors

53
Q

what injections can be given in chronic lower back pain

A

corticosteroid injections for facet joint pain

epidural injections for radicular symptoms (nerve root)

54
Q

what is TENS?
how is it used in back pain

A

Transcutaneous Electrical Nerve Stimulation

via superficial skin electrodes; stimulates large unmyelinated fibres on the basis that this inhibits transmission of pain via small myelinated fibres

55
Q

what kind of discomfort do osteoporotic fractures cause

A

can be minimal even if multiple present

56
Q

special tests in shoulder examination

A

empty can test (abduction to 70-80degress in 15 degrees forward flexion and examiner attempts to depress arms) - supraspinatus

lift off test (palms on lower back then lift them off unaided) - subscapularis

scarf test (touch opposite shoulder with hand) - acromioclavicular joint pathology

Hawkins-Kennedy test (at 90 degrees abduciton and elbow flexed then internally rotate shoulder) - supraspinatus impingement

57
Q

predominant features of rotator cuff disease

A

pain (esp on abudction between 60 and 120 degrees)
weakness
history of trauma but can also be degenerative

tears can be full or partial and more likely to be full in older age

only symptomatic tears should be treatment and treatment depends on the degree of symptoms

58
Q

shoulder pain referred from the neck

A

cervical disc disease or cervical spine stenosis can present with shoulder pain

59
Q

frozen shoulder

A

predominant symptom of stiffness particularly of external rotation

initially may have pain but this usually settles

60
Q

muscles of the rotator cuff

A

supraspinatus
infraspinatus
subscapularis
teres minor

61
Q

supraspinatus action and innervation

A

action - abduction

innervation - suprascapular nerve

62
Q

infraspinatus action and innervation

A

external rotation

supra scapular nerve

63
Q

teres minor action and innervation

A

external rotation

axillary nerve

64
Q

subscapularis action and innervation

A

internal rotation

upper and lower subscapular nerves

65
Q

USS as a shoulder investigation

A

not first line but can demonstrate rotator cuff injuries, bursitis and fluid in the joint space
can show movements while assessing

66
Q

first line investigation in shoulder pathology

A

plan film xray - rule out bone pathology

67
Q

MRI in joint pathology

A

not first line but will demonstrate any soft tissue injury
disadvantage of not being dynamic - i.e. only shows still image

68
Q

what is cuff arthropathy

A

torn rotator cuff tendon/muscle pathology means joint not held in place correctly and movements restricted
bone and surrounding tissue not held in place correctly causes pain

69
Q

rotator cuff injury conservative management

A

analgesia
physiotherapy to help the deltoid muscle achieve abduction

70
Q

rotator cuff injury medical management

A

injection with steroid and local anaesthetic into the subacromial space will act as both analgesia and anti-inflammatory
+ physiotherapy

71
Q

rotator cuff injury surgical management

A

repair using sutures and bone anchors to re-attached the torn cuff to the greater tuberosity
subacromial decompression is also usually performed

arthroplasty (shoulder replacement) is sometimes required especially in cases of rotator cuff arthopathy but risks associated and outcome not same as a normal shoulder

72
Q

what factors to consider if giving injections into joints

A

Anticoagulation, diabetes (injection could increase blood sugars, higher risk of infection) check systemically well i.e. not on antibiotics, check allergies

also counsel patient:
Failure to work
Infection (1 in 10,000)
Pain
Worsening of symptoms temporarily
Bruising, bleeding, skin dimpling

73
Q

how does injecting a joint affect opportunity for surgical intervention

A

precludes surgical intervention with implants for a period of 3 months minimum due to the risk of infection

need to be clear that you definitely don’t want to pursue a surgical option in the near future prior to administering an injection

74
Q

what large muscles cross the shoulder joint

A

deltoid
pectoralis major
biceps
triceps
latissimus dorsi

75
Q

what symptom is caused by a tendon rubbing against nearby tissue

A

impingement - very painful

76
Q

what diseases increase risk of a frozen shoulder

A

diabetes or thyroid disease

77
Q

what nerve is most commonly injured in shoulder dislocation

A

axillary nerve - wraps around humerus

test with sensation in the regimental badge area and through deltoid contraction - before and after reduction of a dislocated shoulder

78
Q

what type of shoulder dislocation is more common

A

anterior dislocation

79
Q

features of fibromyalgia

A

chronic widespread pain; >3 months, found on both sides of the body, above and below the waist and along the axial spine

sleep difficulties and poor concentration/memory are other common features

80
Q

differential diagnoses in symptoms of fibromyalgia

A

Endocrine; Addison’s, hyperparathyroid, hypothyroid, vit D def

Infection; HIV, Hep C

Rheum; RA, SLE, polymyalgia reumatica

Malignancy esp lymphoma

also need to exclude synovitis and myositis/muscle weakness

81
Q

what examination is most useful in diagnosis fibromyalgia

A

examine 18 recognised ‘tender points’ which exist an 9 pairs spread over the anterior and posterior body

palpate each with the amount of pressure that the thumb nail goes white

tenderness at 11 or more out of 18 is in keeping with fibromyalgia

82
Q

what two scales are used in fibromyalgia diagnosis

what must the scores be

A

Widespread Pain Index; number if areas of pain in last week out of 19

Symptom Severity Scale; rates fatigue, waking unrefreshed, cognitive symptoms, headaches, abdominal pain and depression

WPI 7 or more and SSS 5 or more
OR
WPI 4-6 and SSS 9 or more

83
Q

what investigations are useful in fibromyalgia

A

TSH
Vit D level
B12 level
Iron studies
Magnesium
ESR/CRP
CK level - determine if muscle breakdown

84
Q

management of fibromyalgia

A

biopsychosocial approach

  • patient education
  • exercise (strongest evidence)
  • CBT
  • screen for psychiatric conditions and treat if present
  • pharmacological in severe pain/sleep disturbance; can use medications such as gabapentin, amitriptyline, duloxetine, tramadol (note NSAIDs harmful in FM)

if severe multimodal rehab programme

85
Q

prognosis of fibromyalgia

A

no cure but many patients can reduce symptoms and the impact of them on their life

there are ‘yellow flags’ that indicate progression to long term distress
including biological, psychological and social factors

86
Q

fibromyalgia risk factors

A

low household income
lack of further education
female sex
family history of fibromyalgia
having been through a traumatic event (e.g. a car crash)
having certain conditions such as Rheumatoid arthritis.

87
Q

theories of pathophysiology in fibromyalgia

A

central sensitisation - increased excitability and efficacy of central nociceptor pathways

parallel processing - psychosocial factors interfering with pain perception

88
Q

Colle’s fracture

A

fracture of the distal radius

89
Q

pathological fracture underlying causes

A

tumour (primary or metastasis)
osteoporosis
Paget’s disease of the bone

90
Q

T scores osteopenia/osteoporosis

A

> -1 normal
-1 to -2.5 osteopenia
< -2.5 osteoporosis
< -2.5 + fracture ; severe osteoporosis

91
Q

how to achieve alignment of a fracture

A

closed reduction - mechanical manipulation of the limb

open reduction - via surgery

92
Q

principles of fracture management

A

mechanical alignment of the bones

provide relative stability for healing to occur

93
Q

head of femur blood supply

A

retrograde from the medial and lateral femoral circumflex arteries
if damaged lead to avascular necrosis of the femoral head - this happens in a displaced intracapsular fracture - needs a total or semi arthroplasty

94
Q

what is replaced in a hemiarthroplasty compared to a full hip replacement

A

hemi - only femoral head replaced

full - head of the femur and the socket replaced

95
Q

non displaced intracapsular fracture management

A

internal fixation

96
Q

types of extra capsular hip fracture and management

A

Intertrochanteric fracture - dynamic hip screw

subtrochanteric fracture - intramedullary nail

97
Q

non surgical hip fracture management

A

analgesia

investigations to establish diagnosis and underlying conditions/causes

VTE prophylaxis

preoperative assessment of fitness for surgery - bloods, ECG

involve orthogeris

98
Q

most common cause of osteomyelitis

A

staphylococcus aureus

99
Q

imaging for osteomyelitis

A

MRI

99
Q

osteomyelitis management

A

surgical debridement and antibiotics

100
Q

Baker’s cyst

A

swelling behind the knee in the popliteal fossa

in children self resolving

in adults the underlying cause should be treated e.g. osteoarthritis

101
Q

Paget’s disease of bone
- presentation
- management

A

often asymptomatic with isolated raised ALP
may have headaches and bone pain
typically older male

treated with bisphosphonates
if pain or fractures

102
Q

what are tendons made up of

A

predominantly type I collagen fibres arranged in bundles

103
Q

how do tendons heal

A

3 phases: inflammation, proliferation, and remodelling, where type III collagen replaced with type I

104
Q

how can tendonitis develop

A

either from acute overloading or via a degenerative process

105
Q

what is Tredelenburg’s test

A

stand on one leg at a time - tests for weak hip abduction
pt leans away from their painful side to compensate for weak hip abductors

106
Q

what is Thomas’ test

A

tests for fixed flexion deformity of the hip

Clinical Years / Progress Test (24 decks)

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