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Clinical Years / Progress Test > MSK Orthopaedics > Flashcards

MSK Orthopaedics Flashcards

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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
steps of the WHO analgesic ladder
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
26
morphine administration in patient controlled analgesia
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
27
compartment syndrome
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
28
management in severe cases of compartment syndrome
surgical fasciotomy
29
what is delayed union what factors contribute
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.
30
classification of nerve injuries
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)
31
nerve supply of the muscles of the anterior leg
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.
32
definition of - osteopenia - osteoporosis
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
33
fragility fracture
fracture that results from a fall from standing height or less
34
what is the most accurate clinical sign for diagnosing compartment syndrome
pain exacerbated by passive stretch
35
what compartment is most commonly affected in compartment syndrome
anterior compartment
36
fracture of the upper limb with pallor and no pulse in the hand?
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
37
surgery of supracondylar fracture
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
38
immobilisation in paediatric fractures
4 weeks upper limb 6-8 weeks lower limb
39
what is the growth plate
An area of cartilage which proliferate or enlarges, effectively growing, the leading edge calcifies
40
significance of a growth plate injury
Growth may cease, the limb is shortened. If asymmetrical with growth on one side deformity and angulation may occur
41
common paediatric fractures
Wrist, buckle; Clavicle; distal humerus and supracondylar fracture
42
back pain history
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
43
back pain red flags
- 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
what is the schober test
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
what signs suggest psychological or socioeconomic contributions to back pain
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
non-invasive treatments for mechanical or musculoskeletal back pain
Education warn about red flags Return to normal activities and avoid bed rest Avoid precipitants Physiotherapy and advised to mobilise
47
what features indicate musculoskeletal or mechanical back pain
lack of red flags no nerve root tension signs
48
features of sciatica most common cause
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
what patient age are disc herniations more common
<50 in those >60 spinal stenosis is more common
50
imaging for lumbar disc disease
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
management for chronic lower back pain
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
how does capsaicin work to reduce pain
reduces substance P in small nociceptors
53
what injections can be given in chronic lower back pain
corticosteroid injections for facet joint pain epidural injections for radicular symptoms (nerve root)
54
what is TENS? how is it used in back pain
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
what kind of discomfort do osteoporotic fractures cause
can be minimal even if multiple present
56
special tests in shoulder examination
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
predominant features of rotator cuff disease
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
shoulder pain referred from the neck
cervical disc disease or cervical spine stenosis can present with shoulder pain
59
frozen shoulder
predominant symptom of stiffness particularly of external rotation initially may have pain but this usually settles
60
muscles of the rotator cuff
supraspinatus infraspinatus subscapularis teres minor
61
supraspinatus action and innervation
action - abduction innervation - suprascapular nerve
62
infraspinatus action and innervation
external rotation supra scapular nerve
63
teres minor action and innervation
external rotation axillary nerve
64
subscapularis action and innervation
internal rotation upper and lower subscapular nerves
65
USS as a shoulder investigation
not first line but can demonstrate rotator cuff injuries, bursitis and fluid in the joint space can show movements while assessing
66
first line investigation in shoulder pathology
plan film xray - rule out bone pathology
67
MRI in joint pathology
not first line but will demonstrate any soft tissue injury disadvantage of not being dynamic - i.e. only shows still image
68
what is cuff arthropathy
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
rotator cuff injury conservative management
analgesia physiotherapy to help the deltoid muscle achieve abduction
70
rotator cuff injury medical management
injection with steroid and local anaesthetic into the subacromial space will act as both analgesia and anti-inflammatory + physiotherapy
71
rotator cuff injury surgical management
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
what factors to consider if giving injections into joints
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
how does injecting a joint affect opportunity for surgical intervention
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
what large muscles cross the shoulder joint
deltoid pectoralis major biceps triceps latissimus dorsi
75
what symptom is caused by a tendon rubbing against nearby tissue
impingement - very painful
76
what diseases increase risk of a frozen shoulder
diabetes or thyroid disease
77
what nerve is most commonly injured in shoulder dislocation
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
what type of shoulder dislocation is more common
anterior dislocation
79
features of fibromyalgia
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
differential diagnoses in symptoms of fibromyalgia
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
what examination is most useful in diagnosis fibromyalgia
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
what two scales are used in fibromyalgia diagnosis what must the scores be
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
what investigations are useful in fibromyalgia
TSH Vit D level B12 level Iron studies Magnesium ESR/CRP CK level - determine if muscle breakdown
84
management of fibromyalgia
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
prognosis of fibromyalgia
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
fibromyalgia risk factors
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
theories of pathophysiology in fibromyalgia
central sensitisation - increased excitability and efficacy of central nociceptor pathways parallel processing - psychosocial factors interfering with pain perception
88
Colle's fracture
fracture of the distal radius
89
pathological fracture underlying causes
tumour (primary or metastasis) osteoporosis Paget's disease of the bone
90
T scores osteopenia/osteoporosis
> -1 normal -1 to -2.5 osteopenia < -2.5 osteoporosis < -2.5 + fracture ; severe osteoporosis
91
how to achieve alignment of a fracture
closed reduction - mechanical manipulation of the limb open reduction - via surgery
92
principles of fracture management
mechanical alignment of the bones provide relative stability for healing to occur
93
head of femur blood supply
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
what is replaced in a hemiarthroplasty compared to a full hip replacement
hemi - only femoral head replaced full - head of the femur and the socket replaced
95
non displaced intracapsular fracture management
internal fixation
96
types of extra capsular hip fracture and management
Intertrochanteric fracture - dynamic hip screw subtrochanteric fracture - intramedullary nail
97
non surgical hip fracture management
analgesia investigations to establish diagnosis and underlying conditions/causes VTE prophylaxis preoperative assessment of fitness for surgery - bloods, ECG involve orthogeris
98
most common cause of osteomyelitis
staphylococcus aureus
99
imaging for osteomyelitis
MRI
99
osteomyelitis management
surgical debridement and antibiotics
100
Baker's cyst
swelling behind the knee in the popliteal fossa in children self resolving in adults the underlying cause should be treated e.g. osteoarthritis
101
Paget's disease of bone - presentation - management
often asymptomatic with isolated raised ALP may have headaches and bone pain typically older male treated with bisphosphonates if pain or fractures
102
what are tendons made up of
predominantly type I collagen fibres arranged in bundles
103
how do tendons heal
3 phases: inflammation, proliferation, and remodelling, where type III collagen replaced with type I
104
how can tendonitis develop
either from acute overloading or via a degenerative process
105
what is Tredelenburg's test
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
what is Thomas' test
tests for fixed flexion deformity of the hip

Clinical Years / Progress Test (24 decks)

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