Ortho Flashcards by S B

Tx cascade for OA

1st line = topical analgesia i.e. topical NSAID (diclofenac)

2nd line = paracetamol + local analgesia

3rd line = NSAID + paracetamol + local analgesia (+PPI)

4th line = Opioid (e.g. oxycodone) + paracetamol + NSAID + local analgesia

Adjunct = IA Corticosteroid injection

Surgical options = arthrodesis, THR/TKR

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what is mnemonic for OA on x-ray

L – loss of joint space
O – osteophytes
S – sclerosis
S - subchondral cysts

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what are the Ix results for RA (antibodies)

Auto-Ab – Rheumatoid factor, Anti-CCP

Bloods – CRP raised

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how does RA present

swelling,
morning stiffness, 
pain, 
deformity, 
loss of function, 
nodules

affects small joints and c-spine

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what might be seen in hands in RA

Boutonniere deformity
Ulnar deviation
Swan-Neck deformity

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Mx of RA

DMARD monotherapy +/-bridging prednisolone
= Methotrexate

TNF inhibitors
- infliximab

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side effects of methotrexate

myelosuppression – monitor FBC + LFTs

pneumonitis

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what are the seronegative/HLA B27 arthritis

AS
Psoriatic arthritis
Reactive arthritis
Inflammatory Bowel Disease arthritis

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how does AS present

Chronic inflammation – spine and sacroiliac joints  fusion of joints
Young males
Symptoms – pain, stiffness, hip/knee arthritis

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Ix of AS

X-Ray

Key Buzzwords = ‘sacroiliitis’ ‘bamboo spine’, ’squaring of lumbar vertebrae’

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Mx of AS

- important

1st line = NSAIDs, physio, EXERCISE [gets much better w/ exercise]
2nd line = Anti-TNF therapy = etanercept/adalumumab

DMARDS only useful if peripheral joint disease

Adjunct = IA corticosteroids

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how does psoriatic arthritis present

30% skin psoriasis

Asymmetrical, oligoarthritis, sacroiliitis, spondylitis, dactylitis and enthesitis

nail changes: pitting, onycholysis, arthritis DIP joints

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Ix of psoriatic arthritis

x-ray

- pencil-in-cup appearance

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what are common causative organisms for reactive arthritis

GI - campylobacter, shigella, salmonella, yersinia

GU - chlamydia, gonorrhoea

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Sx of reactive arthritis

urethritis, uveitis, arthritis

“can’t see, can’t pee, can’t climb a tree”

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Mx of reactive arthritis

Rx underlying infection, symptomatic relief, +/- DMARDS

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what is gout and what causes it

Urate crystals in joints – hyperuricaemia

Renal underexcretion or excessive intake of alcohol, red meat, seafood

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how does gout present

Classic site – 1st MTP joint, ‘podagra’

CF – intensely painful, hot, swollen joint, tophi

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Ix for gout

1st line = joint aspiration

- Synovial fluid with needle shaped, negative birefringence

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Mx of gout

Acute = NSAIDS, colchicine, intra-articular corticosteroid

Long term = allopurinol

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what can allopurinol interact with and what can it cause

Azathioprine

- can cause pancytopenia

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what is pseudogout

1 - Calcium pyrophosphate crystals – causing acute arthritis

2 - Chondrocalcinosis - deposits in cartilage/soft tissue, but no inflammation

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Ix of pseudogout

joint aspirate

= Synovial fluid w/ positively birefringent crystals

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Mx of pseudogout

NSAIDS, corticosteroids, +/- colchicine

hydroxychloroquinine

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causes of septic arthritis by age = adults/ivdu, children, young adult

Staphylococcus aureus – adults/IVDU Haemophilus influenza – children Neisseria gonorrhea – young adults

Mx of septic arthritis

Ix – urgent joint aspirate BEFORE giving Abx Tx – Abx, surgical washout

SLE antibodies

anti-dsDNA. Remember C3/C4 low in active disease

sjogrens antibodies

anti RO/anti LA

systemic sclerosis antibodies

limited = anti-centromere diffuse = anti-scl-70

polymyositis antibodies

anti-Jo-1

mixed connective antibodies

anti-RNP

Sx of Anti-Phospholipid Syndrome

CLOT ``` Coagulation defect Levido reticularis Obstetric problems (miscarriages) Thrombocytopenia ```

what is surgery reserved for in back pain

nerve root compression single level disc degeneration/prolapse

?Sudden shooting pain while performing heavy lifting

prolapsed disc

?Lowgrade fever, local tenderness at L3

discitis

?Lorry driver, stiff, tender

mechanical back pain

?Person with sciatica and back pain and wants something to be done . They are also obese

weight loss programme + physiotherapy 1st line

what causes radiculopathy and how does it present

Gelatinous nucleus pulposis can ‘herniate’ or ‘prolapse’ = impinge on nerve Neuralgic burn, severe tingling

what does an L3/4 prolapse cause and what are the Sx

L4 root entrapment - pain to medial ankle, loss of quad power, reduced knee jerk

what does an L4/5 prolapse cause and what are the Sx

L5 root entrapment - pain to dorsum of foot, reduced power on dorsiflexion

what does an L5/S1 prolapse cause and what are the Sx

S1 root entrapment - pain to sole of foot, reduced foot plantar flexion, reduced ankle jerks

what are Sx of Cauda Equina

Bilateral leg pain Paraesthesia Saddle anaesthesia Urinary retention / faecal incontinence

Ix and Tx for Cauda Equina

Ix – PR mandatory, urgent MRI Mx – surgical intervention

generally, what are the issues in shoulders related to young, middle age, and eldery

Young adult – instability Middle aged – rotator cuff tears, frozen shoulder Elderly – glenohumeral joint OA

how does frozen shoulder present, who is likely to get it, and what is buzzword clinical sign

Progressive pain and stiffness. Pain subsides, stiffness increased and then ‘thaws’ Affects aged 40-60. Diabetics. Loss of external rotation

how does RC tear present, who is likely to get it

Shoulder dislocation, degenerative changes in tendons ”Sudden jerk” = pain and weakness

what tendon is affected in painful arc syndrome

supraspinatus

broadly, what are the two classifications of hip fractures

intracapsular extracapsular

summary of intracapsular hip fractures

Affect arterial supply of femoral head Risk of avascular necrosis and non-union Replace femoral head – hemi-arthroplasty or THR

summary of extracapsular hip fractures

Not at risk of AVN and high union rate Fixed with Dynamic Hip Screw

how is a clavicle fracture managed

broad arm sling/ORIF

how is a proximal humerus fracture managed

collar + cuff/ORIF

how is an olecranon fracture managed

tension band wiring

how is an colles fracture managed

splintage/plaster cast

how is a femoral shaft fracture managed

IM nail

A 40-year-old man is investigated for back pain. For the past few months he has been troubled with pain in his lower back which is typically worse in the morning and better by the end of the day. There is some radiation of pain to the right buttock but no leg pains. What is the likely diagnosis?

Ankylosing Spondylitis

59-year-old man with a history of gout presents with a swollen and painful first metatarsophalangeal joint. He currently takes allopurinol 400mg od as gout prophylaxis. What should happen to his allopurinol therapy?

Continue at reduced dose

45-year-old lady presents with a 6 month history of pain in the joints of her right hand. On examination she has tenderness in the right distal interphalangeal joints. An X-ray shows erosions in the centre of the right distal interphalangeal joints, which are described as having a pencil in cup appearance.

Psoriatic arthritis

75-year-old woman presented to her GP with shoulder pain and discomfort. She had a full shoulder examination performed, during which she was unable to abduct her shoulder when it was flat against her body while standing. She was, however, able to fully abduct the shoulder after the doctor passively abducted it during the first 20 degrees. Which muscle is most likely to have been affected?

Supraspinatus

65-year-old lady presents to her GP complaining of sudden onset of pain and paraesthesia in her left leg. On further questioning, she reports that the pain radiates down to the dorsum of her foot. On examination, you identify sensory loss in the dorsum of her left foot and reduced power upon performing dorsiflexion of her left ankle. Her reflexes remain intact.

L5 radiculopathy

Treatment of necrotizing fasciitis

Surgical debridement | Iv Amox + clarithromycin + Gentamicin

? Rotator cuff – unable to initiate abduction

supraspinatus

hitting knee on dashboard

PCL injury

ankle jerk nerve roots

S1-S2

knee jerk nerve roots

L3-L4

Biceps jerk nerve roots

C5-C6

triceps jerk nerve roots

C7-8

brachioradialis/supinator jerk nerve roots

C5-C6

tx for Osteomyelitis - not pen allergic

Flucloxacillin IV 2g qds 2 weeks minimum IV followed by oral therapy Total course 4-6 weeks

Tx for osteomyelitis - pen allergic

Clindamycin IV 600mg qds Total Course 4-6 weeks

tx for Osteomyelitis - MRSA

Vancomycin IV

tx for septic arthritis

IV flucloxacillin 2g qds for 2 weeks then oral therapy Total course 4-6 weeks

1st line for mechanical back pain

NSAIDs

Mx of paget's disease

Biphosphonates

best imaging for achilles tendon

USS

what are the Ottawa rules for ankle injury and deciding if an x-ray is needed

x-ray is required only if there is any pain in the malleolar zone and any one of the following findings: - bony tenderness at the lateral malleolar zone - bony tenderness at the medial malleolar zone - inability to walk four weight bearing steps immediately after the injury and in the emergency department

tx for Intracapsular fracture, displaced, when person is mobile

THR

tx for Intracapsular fracture, displaced, when person is not mobile

Hemiarthroplasty

what fractures is compartment syndrome common in

supracondylar and tibial shaft fractures

what nerve roots make up the sciatic nerve

L4 to S3

left leg is shortened, adducted and internally rotated = ?

posterior hip dislocation = risk of sciatic nerve damage

what are the muscles of the rotator cuff and their function

supraspinatus = 0-15 degrees of shoulder abduction [deltoid does 15-90] teres minor = shoulder extension subscapularis = shoulder internal rotation infraspinatus = shoulder external rotation

what is spondylothesis

slippage of one vertebrae over another

what is spondylolysis

defect in pars interarticularis of a vertebra

what is spondylosis

degenerative disease of the spine

Tx for rotator cuff tear

if complete = arthroscopic repair if not = physio + pain relief

brown sequard injury

ipsilateral loss of proprioception, vibration and motor function contralateral loss of temp and pain

where is most likely fractured at humeral neck, what nerve is at risk and what is the management

Surgical neck = axially nerve Mx - if minimally displaced = sling and conservation - if displaced = manipulation/ORIF

mx of anterior shoulder dislocation

closed reduction + pain relief sling for 2-4 weeks physio

mx of # = humeral shaft

splint + immobilise = 8-12 weeks if polytrauma = I.F. w/ IM nail/plate

mx of # = olecranon

tension wire banding = ORIF to repair tricep function

mx of # = supracondylar

ORIF

mx of # = radial head/neck

Collar and cuff sling + physio ORIF

mx of = pulled elbow

forced supination

mx of # = colles

if minimally displaced = splint if displaced + old = closed reduction + cast if displaced + young = ORIF

mx of # = scaphoid

XR lateral, AP and 2x oblique if unsure = splint and further XR in 2 weeks if sure = plaster for 6-12 weeks if displaced = compression screw

mx of # = intracapsular hip

undisplaced + young = internal fixation undisplaced + old = hemiarthroplasty displaced + < 70y/o = internal fixation + hemiarthroplasty displaced + > 70y/o and mobile = THR displaced + > 70y/o and immobile = hemiarthroplasty

mx of # = extracapsular hip

dynamic hip screw

mx of # = proximal femoral

IM nail

mx of # = femoral shaft

thomas splint IM nail

Ortho Flashcards

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