O&T: CCT Notes Flashcards
- Septic arthritis
Investigations:
1. Blood
- WBC
- ESR, CRP
- Culture
- X-ray (First few days: normal (only Soft tissue swelling))
- **Shenton’s line: Broken
- **Slight subluxation
- **Bone density: Osteopenia
- **Soft tissue swelling
- ***Widening of joint space - Arthrocentesis
- Colour, appearance
- WBC, %PMN
- Gram stain, Culture + sensitivity (Bacteria, AFB, Fungal)
- Crystal
- Protein (High), Glucose (Low)
Treatment:
1. **IV Broad spectrum antibiotics
2. **Emergency arthroscopic / Open arthrotomy debridement + lavage
Complications:
1. **Systemic sepsis
2. **Premature arthritis (OA)
3. Joint stiffness
4. Effusion compress Circumflex femoral artery —> **Avascular necrosis of proximal femur (can lead to total loss of femoral neck), **Physeal closure, growth disturbance
5. **Chronic infection
6. **Pathological fracture
- Shoulder exam
Causes of impingement syndrome (from Dex Wu):
1. **Supraspinatus Tendonitis
2. Reactive **Subacromial Bursitis
3. **Acromion Osteophytes
4. Degenerative **Coracoacromial Ligament Hypertrophy
5. Osteoarthritis of Acromioclavicular Joint
6. Dialysis-related Amyloidosis (according to McRae)
7. Biceps Tendonitis
- Colles fracture
How to reduce:
- Traction to disimpact fracture
- Exaggerate the deformity
- Reverse the deformity
Principles of management:
1. Reduction if necessary
2. Immobilisation if necessary
- Dorsal plaster slab
- Short / Long arm cast should be avoided immediately after reduction, especially if limb is swollen = risk of compartment syndrome
3. Rehabilitation always
Other treatment:
- Fall prevention
- Osteoporosis treatment
Complications:
- Nerve impingement (Median nerve)
- Skin impingement
- **Tendon impingement (*EPL)
- Pain
- Unstable
- Loss of reduction
(- Premature OA?
- Deformity)
- Carpal tunnel syndrome
- Test sensation of BOTH hands at the same time
- Sensation: Cover respective areas for ALL 3 nerves
Causes:
1. **Idiopathic / Overuse CTS
2. **Secondary CTS
- **Trauma (e.g. **Distal radius fracture, Carpal injury, **Supracondylar humerus fracture: **AIN palsy) —> Acute CTS
- **Inflammatory joint disease (e.g. RA, Gout, Pseudogout)
- **Systemic (e.g. Myxedema, Amyloidosis)
- **SOL within carpal tunnel (e.g. Ganglion cyst, gouty tophi)
- Tenosynovitis
(- **Pregnancy
- ***Acromegaly
- Diabetic neuropathy)
Look:
- Thenar wasting
- Adducted thumb
Feel (Sensation):
- Radial 3.5 fingers
- Thenar sensation
Move (Power):
- Thumb abduction (Weak APB)
- Failure to do OK sign (AIN palsy)
- Benediction sign
Special tests:
1. Phalen test (30s)
2. Tinel’s sign (percuss from distal to proximal)
3. Durkan’s test (direct compression test)
Investigations:
- NCV
- X-ray carpal tunnel
Treatment:
Conservative:
- Night splint
- Analgesic
- Steroid injection
Surgery:
- Endoscopic / Open release of flexor retinaculum
- Sciatica
NORMAL side first
Causes:
Intraspinal:
- PIVD
- Spondylolisthesis
- Facet joint degeneration / hypertrophy
Extraspinal:
- Piriformis syndrome (examiner sometimes ask: what is piriformis syndrome…)
- Pregnancy, PID (but this patient is male)
- Pelvic mass (e.g. tumour) in male
Differentiate location of prolapse:
- Axilla / posteromedial: cross tension test positive
- Shoulder / far lateral: cross tension test negative
What nerve is compressed in bowstring test:
- Tibial Nerve
Branches of Sciatic nerve:
- Tibial nerve
- Common peroneal nerve
Supply the first dorsal web space of the foot:
- Deep peroneal nerve
- Thomas test + ROM
NORMAL side first
Other tests:
- Gait
- Trendelenburg test
Fixed flexion contracture causes:
- Joint contracture (RA, AS, OA)
- Muscle contracture (Tight iliopsoas, Cerebral palsy)
- Skin contracture (Scarring)
- X-ray hip
- Shenton’s line
- Medial border of proximal femur to Inferior border of superior pubic ramus - OA
- AVN
- Sclerosis, Cyst, Crescent sign
- Causes: STARS (Steroid, Trauma, Alcohol, Radiation, Scuba / Sickle cell disease)
OA vs AVN:
OA:
- Joint space: Narrowed
- Femoral head: Preserved
- Involvement: Femoral head + Acetabulum
- Osteophyte: Present
AVN:
- Joint space: Preserved
- Femoral head: Collapsed
- Involvement: Only Femoral head
- Osteophyte: Only in Ficat stage 4
- NOF fracture
- Garden’s classification:
Undisplaced:
Class 1: **valgus impacted, undisplaced fracture
Class 2: **complete but **undisplaced fracture
Displaced:
Class 3: complete fracture, **partial displacement indicated by **change in angle of trabeculae
Class 4: complete fracture, **complete displacement leading to ***parallel orientation of trabeculae
- Knee exam
NORMAL side first
Posterior sag test of both LL (palpation for tibial step-off)
—> Posterior drawer test of normal LL
—> Anterior drawer test of normal LL
—> Posterior drawer test of affected LL
—> Anterior drawer test of affected LL
—> Lachman test of normal LL
—> Lachman test of affected LL
Posterior sagging:
- Sagging of tibia in relation to medial femoral condyle
- Tibial stepping: Between medial tibial plateau and medial femoral condyle
- X-ray tumour
Past paper:
- Radiolucency (i.e. osteolytic)
- Border ill-defined
- Periosteum elevated
- Expansile lesion
- No soft tissue involvement
- No pathological fractures
DDx:
- Primary / Secondary bone tumour (Multiple myeloma)
- **Infection: **Osteomyelitis (TB)
- **Metabolic disorders: **Gout, Paget’s disease, **Renal osteodystrophy
- **Endocrine disorders: **Hyperparathyroidism (Brown’s tumor (Osteitis fibrosa cystica)), **Cushing’s disease
P/E:
- Search for primary
1. Local examination
2. **Region LN
- think about leukaemia / lymphoma
3. **Liver / Spleen
Investigations:
1. Blood test
- CBC, ESR, CRP
- Bone profile (Ca, PO4, ALP)
- Tumour markers (LDH, AFP, Beta-HCG, CEA, SEP, PSA)
2. X-ray
- Local
- CXR
3. CT, PET
4. Biopsy
- FNA
- Tru-cut
- Open (Incisional / Excisional)
Complications:
- Pain
- **Pathological fracture
- **Spinal cord compression
- **Hypercalcemia
(- **Marrow failure)
Treat complications:
- **Pain: Analgesia
- **Spinal cord compression: Spine stabilisation + spinal cord decompression
- **HyperCa: Bisphosphonate
- **Pathological fracture: Fixation —> **Mirel’s score >9 —> **Prophylactic fixation (Prophylactic IM nailing with screws)
- C1/2 subluxation
Flexion + Extension view:
- ABCDEF
- Soft tissue
- AADI: 4mm (children: larger, <5mm)
- PADI: 11mm
P/E:
- Look, Feel, Move
1. Neurological
- Sensory
- Power
- **Proprioception
- **Gait
- **Sphincter
2. **Lhermitte sign
- flexion of neck —> cervical instability (e.g. C1/2 subluxation) —> **cord compression —> sharp radiating symptoms down all 4 limbs
3. **Cervical myelopathy signs
- Upper limb: ***Myelopathic hand signs (Hoffman’s, 10 second test, Finger escape, Inverted supinator reflex, Scapulohumeral reflex)
- Lower limb: Spasticity, Clonus, Brisk jerks, Babinski upgoing, Romberg’s test, Gait
Investigations:
- MRI spine
Causes:
1. Degenerative
2. Trauma
3. RA, AS
4. C1/2 rotatory subluxation
5. Syndromal (Down’s)
Treatment:
- Surgery (Decompression by Anterior / Posterior approach)
Other presentations related to cervical spine due to RA:
- Atlantoaxial instability
- Cranial settling
- Subaxial subluxation
- DDH
Underdevelopment of hip joint
- Shallow acetabulum
- Reduced coverage of femoral neck
Epidemiology:
- 0.87/1000
Risk factors:
- **Breech presentation 3rd trimester (need USG screening of hip joint)
- **Female
- **Positive family history
- **First born
- ***Oligohydramnios
- Torticollis, Metatarsus adductus (mechanical effect)
(- Left hip (from SpC bedside))
Clinical features:
Neonatal:
1. **Groin skin crease asymmetry (extra groin skin fold due to lateral femur displacement causing shortening of limb, in dislocated hip, can occur in normal baby as well)
2. **Decrease hip abduction
(3. **LLD (from SpC bedside): **Galeazzi’s sign)
Toddler:
1. Waddling gait (Bilateral trendelenburg gait: unable to abduct hip during swing phase to clear the ground —> walk like a duck)
2. Short limb unilaterally
Clinical features:
1. **Pain-free usually
2. Reduce **spontaneously
P/E:
1. **Barlow’s test (dislocatability: Flex hip 90o, Adduct hip + Posterior force to try to posteriorly dislocate hip)
2. **Ortolani’s test (reducibility: Flex hip 90o, Abduct hip + Traction force to try to reduce dislocated hip)
3. Leg length discrepancy
4. Decreased Abduction
Investigations:
1. USG (***<6 months)
- Able to image the cartilage + associated soft tissues of the hip
- More sensitive than X-ray + P/E but false positive causing overdiagnosis + overtreatment
- Operator dependent
- Static: Alpha / Beta angle —> Coverage
- Dynamic: stress test —> Hip stability
- X-ray (**>=6 months)
- Not for <6 months (∵ Ossific nucleus not ossified —> capital femoral epiphysis only starts to ossify after **5 months)
- Difficult to interpret for mild cases
X-ray description:
1. **Displacement of the capital femoral epiphysis (i.e. dislocated)
2. **Shenton’s line broken (draw from medial proximal femur back to pubic rami)
3. **Hilgenreiner’s line (line traversing triradiate cartilage) + **Perkin’s line (most lateral aspect of acetabulum, perpendicular to Hilgenreiner’s line)
- Medial beak of proximal femur should be within **inferior + **medial quadrant (if within —> still cannot rule out since subluxation can produce “normal” image)
4. **Acetabulum dysplasia: Increased **Acetabular index (>30o) (~ Tonnis angle in adults)
- angle between Hilgenreiner’s line and line tangentially connecting inferior margin of iliac bone and superolateral part of acetabular bony rim
- indicate Acetabulum dysplasia
5. ***Delayed ossification of femoral head (Size of ossific nucleus smaller)
6. Lateral edge of acetabulum
(Aim of treatment (from SpC Bedside):
- Obtain + Maintain hip reduction
- Allow normal development of hip
- Obtain joint congruence)
Treatment:
1. **Pavlik Harness
- **<6 months
- Keep hip in flexion + abduction (to help reduction of hip)
- Size + compliance are more important
- May cause AVN of femoral head (excessive abduction cause compression of medial circumflex artery by acetabulum in posterior side of femur neck), (Femoral nerve palsy —> baby cannot kick leg (from SpC bedside))
- ***Serial USG to confirm reduction of hip joint
-
**Hip Spica immobilisation (Close reduction)
- **6-18 months (Pavlik Harness not strong enough)
- **Arthrogram (confirm presence of **concentric reduction) —> minimal medial pooling of contrast (contrast should smoothly distribute throughout hip joint and outline acetabulum + epiphysis)
- +/- Adductor tenotomy
10% of cases still is irreducible despite above measures (∵ extra-articular + intra-articular obstacles)
-
**Open reduction (Medial / Anterior approach) +/- **Femoral or ***Acetabular osteotomy (to reconstruct acetabulum)
- Remove possible obstacles to reduction (e.g. ligamentum teres)
- For severe dysplastic acetabulum, excessive femoral anteversion (in chronic dysplasia)
Complications:
1. **AVN —> Proximal growth disturbance
2. **Re-dislocation
3. ***Residual dysplasia
- Ulnar nerve palsy
Causes:
1. **Entrapment neuropathy (e.g. **Cubital tunnel syndrome, **Guyon’s canal)
2. **Tardive ulnar nerve palsy (valgus deformity of elbow stretching ulnar nerve)
3. **Elbow arthritis (e.g. OA / RA elbow)
4. **Subluxable ulnar nerve with frictional injury
Look:
- Claw hand deformity (Hyperextension of MCPJ, flexion of both IPJs)
- Hypothenar atrophy (Masse sign)
- Web space muscle atrophy
- Wartenberg sign
Feel (Sensation):
- Cover respective areas for ALL 3 nerves
- Dorsal sensation: Dorsal cutaneous branch (High palsy, branches off proximal to wrist)
Move (Power):
- Froment’s sign
- Little finger abduction
Special test:
- Tinel sign for ulnar nerve (+ve at cubital tunnel)
Treatment:
- **Surgery mainly (not much room for Conservative)
—> **Decompression (open / endoscopic)
—> **Anterior transposition of ulnar nerve (move ulnar nerve to volar side of elbow joint to decrease tension + release compression)
—> **Medial epicondylectomy
- Spine X-ray
Common causes of collapse:
- Osteoporosis
- Infection
- Malignancy (Primary / Secondary)
- Trauma
- Supracondylar fracture
Ossification centres in elbow (temporal appearance sequence: ***CRITOE)
—> Capitellum (1 yo)
—> Radial head (3 yo)
—> Internal (Medial) epicondyle (5 yo)
—> Trochlea (7 yo)
—> Olecranon (9 yo)
—> External (Lateral) epicondyle (11 yo)
Physeal injury:
- Salter-Harris classification
- Resting zone damaged (Type 3-5: injury extending to epiphysis)
Management:
1. ABCDE (beware of differences in vitals in different age group: faster HR, lower BP, higher RR)
2. Investigations
3. Fracture assessment
- Adequate exposure of fracture site
- Look out for associated soft tissue injuries
—> Rule out **open fracture / open wound
—> Skin blistering / abrasions / necrosis
—> **Skin impingement by bone ends
—> Subcutaneous swelling
—> **Neurovascular injury
—> **Compartment syndrome
- Reduction if necessary (Pain control + Anaesthesia)
- Open / Closed reduction
- Failed CR: Interposition of soft tissue, Difficulty handling fragments, Swelling, Instability, No X-ray control - Immobilisation if necessary
- Cast / External / Internal fixation - Rehabilitation always
Complications:
1. **Vascular injuries
2. **Neurologic deficits (esp. **Anterior interosseous nerve)
3. **Cubitus varus / Recurvatum
4. **Volkmann’s contracture
5. **Compartment syndrome
Classification:
1. Extension (95%)
- **Gartland classification
—> **Undisplaced (type 1): Conservative with cast
—> **Displaced with intact posterior cortex (Type 2): Surgery needed
—> **Displaced with no cortical contact (Type 3): Surgery needed
- Flexion
Assessing whether fracture is displace or not:
1. **Baumann angle (~10o)
2. **Anterior humeral line
P/E:
1. Swelling + Tenderness of forearm compartments (potential site of compartment syndrome)
2. **“Dimple sign”
3. **Neurovascular injuries (Radial pulse)
4. ***Compartment syndrome
5. Associated injury
X-ray:
1. ***Fat pad sign (swelling around fracture site)
Post-op care:
1. Haemodynamic status
2. Respiratory status
3. **Neurovascular monitoring
4. **Exclude compartment syndrome
5. Swelling control (Limb elevation)
6. **Avoid pressure / plaster sores
7. **Pain control
8. Psychological support to parents
- Neurofibromatosis
Signs:
- Orthopaedic: Scoliosis, Tibial pseudoarthrosis
- Eyes: Lisch nodules (Iris hamartoma), Optic glioma
- Skin: Axillary freckling (Crowe’s sign), Neurofibroma, Cafe-au-lait spot
