Ortho + Rheumatology Flashcards
What is a Lisfranc joint injury?
in the MIDFOOT there is an injury to the ligaments, cartilage or even a break in the bones
caused by a twisting fall or commonly seen when the foot is flexed downward in the push-off position
if not treated –> chronic pain and arthritis
treated with open reduction and plates/screws
Why is a scaphoid break so bad and what is the treatment?
the blood supply comes from the distal part first rather than the proximal.
usually can’t see the break on the initial x-ray, so put a futura splint on and bring them back in a week-10 days to re x-ray or MRI.
most breaks are at the waist
If broken UNDISPLACED then put on cast
If broken DISPLACED/POLE fracture then surgical fixation
most commonly from FOOSH
painful when resisted pronation
What is a Jefferson Fracture?
bone fracture of the vertebra C1
common cause: diving headfirst into shallow water
diagnosed using a CT
not usual to have neuro deficits –> treat conservatively with hard collar
How is an Achilles Heel rupture treated?
ultrasound to diagnose rupturen –> if no rupture then could be tendonitis
-plaster or moon boot
-only surgery if late presentation and athletes
CIPROFLOXACIN can cause a rupture
What would a moth eaten appearance” on an x-ray suggest?”
malignant cancer spreading fast usually through bone
What would a shortened and externally rotated leg suggest in trauma?
Fractured femur
What drug must you put a patient on who has just broken their foot/leg and will be immobile?
blood thinners to stop clots
What would be affected in a fracture of the surgical neck of the humerus?
Axillary nerve –> abduction of arm, sensation to the area over deltoid (regimental area) C5
What is Thoracic outlet syndrome (TOS) and what is the difference between this and frozen shoulder (adhesive capsulitis)?
TOS is caused by compression of the neurovascular bundle between the supraclavicular fossa and the axilla (brachial plexus).
Frozen shoulder is strongly with diabetes. Characterised by chronic dull shoulder ache and limited range of active and passive movement. NO neurological symptoms, unlike TOS.
EXTERNAL rotation affected
ACTIVE and PASSIVE movement affected
What is a clinical sign of osteoarthritis?
squaring of thumb
What is the difference between Rheumatoid arthritis and osteoarthritis?
Rheumatoid arthritis = symmetrical and multiple joints
-warm, red, swollen, stiff in morning, helps with exercise
-swan neck, boutonnaire, ulnar deviation, baker (popliteal) cyst, felty syndrome
-anti-CCP antibody and rheumatoid factor
-methotrexate, hydroxychloroquine (only one safe to use in pregnancy as well as sulfasalazine and causes VISION changes), anti-TNFs
osteoarthritis = singular joints-age is a big risk factor (F sex for osteoporosis)
-Heberden (distal finger) and Bouchard (proximal) nodes
-stiff in morning for less than an hour, worse with activity and no swelling
-losing weight, hyaluronic acid injections, replacement of joint
What de Quervain tendinopathy?
swelling of the tendons that run along the thumb side of the wrist and attach to the base of the thumb
pain during the Finkelstein test (thumb into fist and tilt hand down)
pain when:
Moving the thumb
Forming a fist
Grasping or gripping something
Turning the wrist
at radial styloid
What is gout and what is the treatment for gout?
build up of urate crystals
most common in big toe
- NSAIDS e.g. colchicine - short term to treat a flare up take for 3 days then restart long term drugs- main side effect of colchicine is diarrhoea
- consider a PPI if on NSAIDs
- allopurinol- long term
- cold therapy- ice packs
On walking the patient drops to the right side and this is a positive Trendelenburg sign. What sets of muscles are weak?
LEFT gluteus medius and gluteus minimus
What is Battle’s sign?
bruising over the mastoid process (behind ear) due to a fracture at the base of the skull
Sometimes people with Battle’s sign also have “raccoon eyes.” This term refers to bruising around the eyes that’s also related to a skull fracture.
Cannot give a nasopharangyeal tube for intubation
What is the worst type of femur neck fracture?
Displaced intrascapular—> AVN
What is a Tuft fracture?
broken the tip (tuft) of your fingerassociated with crush injuries
treated with a plastic splint for 10-14 days
Why would you not use adrenaline with lidocaine in the hand?
as it can cut off the blood supply, cause necrosis and the fingers can eventually lose power, sensation etc.you can use adrenaline in scalp injuries
What is the first line treatment for osteoporosis?
Bisphosphonates e.g. Alendronic acid or risedronate
What is a volar plate injury?
volar plate is a thick ligament that connects two bones in the fingerhappens when the finger is hyperextended
usually most pain around the middle of finger
the damaged volar plate can pull pieces of bone off –> avulsion fracture
treatment –> buddy strapping
What is the difference between ankylosing spondylitis, Pars defect/spondylolysis and spondylolisthesis?
ankylosing spondylitis =
-sacro-ilitis on pelvic x-ray, bamboo spine, ‘chalk stick’ fractures can also occur as all the bone is fused together so it snaps like chalk
-pain gets better with movement
-young mid teens/twenties—> exercise and NSAIDs
Pars = The pars is the area of bone between the facet joint processes and can be seen on oblique scotty dog X-rays – the neck of the dog appears broken.
-often symptomatic in very active children and are thought to arise from repetitive hyperextension
–> steroids, NSAIDs, surgery
spondylolisthesis = Slippage of one bone on the other. If there is a lot of slippage (more than 50% of vertebral body) it is called high grade
–> steroids, NSAIDs, surgery
When looking for fractures on children’s arm/hand/HIP x-rays what must you remember?
their growth plates might have not fused at the end of the radius/ulna/HIP yet
girls - 13/14-17/18boys- 14/15-18/19
What is the Simmonds-Thompson test?
to test for an achilles tendon rupture/tare
squeeze the calf and the foot should move
no movement = achilles tare = positive test
What is a Nursemaid’s elbow aka pulled elbow”?”
Can happen when pulling a child’s elbow such as swinging their child
Annular ligament in children is weaker therefore a pulled elbow can lead to subluxation of the radial head
treatment = can be reduced
What is the pneumonic for the hand bones?
Please Take Lovely Suzy To The Coffee House
pisiform
triquetral
lunate
scaphoid
trapezium
trapezoid
capitate
hamate
What is injured in an unhappy triad”/blown knee/O’Donoghues triad?”
medial collateral ligament, medial meniscus and anterior cruciate ligament–> hard blow to your lower leg while your foot is planted on the ground: pushes your knee inward
What are the 6Ps of compartment syndrome and PAD?
Can you see it on an x-ray?
pain, paresthesia, paresis, pallor, perishingly cold, and pulselessness
NOT SHOWN ON AN X-RAY
What can a neck of the femur fracture result in?
Injury to common peroneal nerve —> Foot drop
What is Marfan’s syndrome?
connective tissue disorder
-autosomal dominant
- FBN1 gene is affected
-tall, slim with long slender limbs, fingers and toes (arachnodactyly) –> stretch marks
-pigeon chest
-scoliosis
-cannot extend elbows to 180 degrees
-downward slant to eyes
-predisposed to aortic dissection, rupture and aneurysm
-predisposed to retinal detachment, pneumothorax
treatment: beta-blockers and losartan to stop aortic widening
What is Ehlers-Danlos syndrome?
defective collagen synthesis-joint hypermobility-stretchy skin-fragile skin that breaks or bruises easily-spontaneous artery dissection, organ rupture
What is reactive arthritis?
can’t SEE, PEE or climb a TREE
triad of uveitis (the red eye in the patient), joint pain (arthritis) and dysuria (producing pain on urination)
It can be due to an STI (commonly chlamydia trichinosis) or a gut infection (campylobacter, shigella flexneri, salmonella enteritis)
Treatment options include NSAIDs, intra-articular steroids, analgesia
DIFFERENTIAL FOR GOUT/SEPTIC ARTHRITIS
What is osteomyelitis?
infection of the bone
Staph. aureus is the most common cause except in patients with sickle-cell anaemia where Salmonella species predominate
MRI then flucloxacillin for 6 weeks
What is Sjogren’s syndrome?
dryness of the eyes, mouth, and other mucous membranes –> The amount of tears produced can be estimated by placing a filter paper strip under each lower eyelid and observing how much of the strip is moistened (Schirmer test).–> only symptom relief
1/3 of patients with primary Sjögren’s syndrome also have diffuse parotid gland enlargement (could be surgically removed)
Raynaud syndrome occurs in about one third of people with Sjögren syndrome.
How do you treat Raynaud’s and who is susceptible to it?
-Nifedipine as prophylaxis
-IV prostacyclin (epoprostenol) infusions every few weeks/months
-Lifestyle measures: keep warm, stop smoking
-Refer to rheumatology
primary- Raynaud’s disease (young woman bilaterally)
secondary- Raynaud’s phenomenon causes:
-connective tissues disorders (scleroderma, rheumatoid arthritis, SLE)
-leukaemia
-vibrating tools
-COCP
What is plantar fascitis?
most common cause of heel pain seen in adults
The pain is usually worse around the medial calcaneal tuberosity
WORSE when walking on heels
Management:
-rest the feet where possible
-wear shoes with good arch support and cushioned heels
-insoles and heel pads may be helpful
-NO routine ibuprofen
What is and how do you treat polymyalgia rheumatica?
Pain, stiffness and inflammation in the shoulders, neck and hips
prednisolone (if this doesn’t work then it is not PMR)
What is temporal arteritis (Giant Cell Arteritis)?
vasculitis of large arteries
occurs in OVER 60 years old and rapid onset
linked with polymyalgia rheumatica
headache
jaw pain with movement
visual loss - swollen pale disc and blurred margins
skip lesions may be seen on artery biopsy
ESR blood test
-steroids: prednisolone if no visual loss and IV methylprednisolone if there is visual loss
-ophthalmology review
-bisphosphonates
-aspirin
If there was a ‘pop-eye’ deformity in a muscle what would this suggest?
biceps rupture
In growing pains, do you get pain as soon as you wake up and does it affect sport?
No
What is carpal tunnel syndrome?
compression of median nerve
weakness of thumb abduction (abductor pollicis brevis)
wasting of thenar eminence (NOT hypothenar)
Tinel’s sign: tapping causes paraesthesia
Phalen’s sign: flexion of wrist causes symptoms
6-week trial of conservative treatments if the symptoms are mild
-moderate:
corticosteroid injection
wrist splints at night
if there are severe symptoms or symptoms persist with conservative management: surgical decompression (flexor retinaculum division)
What are the differences between these causes of knee problems in children/young adults:
chondromalacia patellae
osgood-schlatter
osteochondritis dissecans
patellar subluxation
patellar tendonitis?
chondromalacia patellae = softening of patella cartilage, teen girls, anterior pain on walking up and down stairs from prolonged sitting
Osgood-Schlatter (tibial apophysitis) = sporty teens, pain, tenderness and swelling over tibial tubercle, seen in footballers
osteochondritis dissecans = pain after exercise, swelling and locking
patellar subluxation = medial knee pain due to lateral subluxation of patella, knee gives way
patellar tendonitis = athletic teen boys, anterior knee pain after running, tender below patella on exam
What is a Baker’s cyst?
known as a popliteal cyst
They may be primary or secondary
Primary: no underlying pathology, typically seen in children
Secondary: underlying condition such as osteoarthritis, typically seen in adults
They present as swellings in the popliteal fossa behind the knee.
Rupture may occur resulting in similar symptoms to a deep vein thrombosis, i.e. pain, redness and swelling in the calf. However, the majority of ruptures are asymptomatic.
Baker’s cysts in children typically resolve and do not require treatment.
What is cubital tunnel syndrome?
compression of the ulnar nerve at the elbow
-tingling and numbness of 4th and 5th finger
-pain when leaning on affected elbow
nerve conduction studies can be used to diagnosis
physio
steroid injection
surgery
What are high and low grade ankle sprains?
Low grade:
-inversion of foot (MOST COMMON OUT OF THEM ALL)–> can lead to 5th metatarsal fracture
-injury to ATFL (anterior talofibular ligament)
-can weight bear
-RICE treatment
High grade:
-external rotation of foot
-cannot weight bear
-Hopkin’s test: tibia and fibula squeezed together causing pain
-splint, cast, surgery
How is osteoporosis diagnosed?
DEXA scan and measurement of BMD g/cm2 (bone mineral density).
The T score must be more than 2.5 SD below the mean
- this only applies to post
-menopausal women and men over 50
In younger adults the diagnosis is made using Z-scores.
What is meralgia paraesthica?
nerve compression causing a burning/stinging sensation on upper lateral aspect of the thigh
-symptoms may be reproduced by deep palpation just below the ASIS (pelvic compression) and also by extension of the hip
-no motor weakness
-normal on X-ray
pregnancy and obesity can increase risk
What is trigger finger?
abnormal flexion of the digits from overuse usually
more common in women than men
rheumatoid arthritis
diabetes mellitus
Features:
more common in the thumb, middle, or ring finger (unlike Dupyutren’s)
initially stiffness and snapping (‘trigger’) when extending a flexed digit
a nodule may be felt at the base of the affected finger
Management:
steroid injection is successful in the majority of patients
A finger splint may be applied afterwards
surgery should be reserved for patients who have not responded to steroid injections
When is the Salter-Harris scoring system used?
In paediatric ANY growth plate fracture (wrist, fingers etc)
Types:
I - normal xray
II - most common
III - surgery
IV - surgery
V - surgery
What are the typical signs of a meniscal tear?
Typically result from twisting injuries.
Features
pain worse on straightening the knee
knee may ‘give way’
displaced meniscal tears may cause knee locking
tenderness along the joint line
Thessaly’s test - weight bearing at 20 degrees of knee flexion, patient supported by doctor, positive if pain on twisting knee
What is Still’s disease?
This is a systemic onset of juvenile idiopathic arthritis
Inflammatory arthritis with fevers, rash and joint pain
rash is a salmon pink colour
How can you tell the difference between osteomalacia, osteoporosis, Paget’s, primary hyperparathyroidism and bone mets?
osteomalacia = low calcium and low phosphate
osteoporosis = normal
Paget’s = high Alk Phos
primary hyperparathyroidism = High calcium and high PTH
bone mets = high calcium and low PTH
What is Dupuytren’s?
contracture of fingers
Specific causes include:
manual labour
phenytoin
alcoholic
liver disease
diabetes mellitus
trauma to the hand
Features:
the ring finger and little finger are the fingers most commonly affected
Management:
consider surgical treatment of Dupuytren’s contracture when the metacarpophalangeal joints cannot be straightened and thus the hand cannot be placed flat on the table
What is psoriatic arthropathy?
arthritis with psoriases
similar to rheumatoid arthritis (so if it sounds like rheumatoid but has nail changes then it’s this)
asymmetrical oligoarthritis (joint stiffness and swelling)
DIP joint nail changes!!
‘pencil in cup’ x-ray appearance
NSAIDs
ustekinumab and secukinumab
What is a Buckle (torus) fracture?
Seen in a child above ^ incomplete fracture of the shaft of a long bone with bulgingusually in children aged 5-10
splinting first line
What antibodies are seen in drug induced lupus and what causes it?
anti-histone
caused by: procainamide, hydralazine, isoniazid, phenytoin
What classification is used for femur fractures?
Garden classification:
1) undisplaced incomplete
2) undisplaced complete
3) displaced incomplete
4) displaced complete
What is the difference between intracapsular and extracapsular fractures?
intra:
-femoral head fracture
-femoral neck fracture
extra:
-intertrochanteric
-subtrochanteric
Learn foot anatomy.
What are the side effects of hydroxychloroquine (taken for R.arthritis)?
bull’s eye retinopathy - may result in severe and permanent visual loss
–> baseline ophthalmological examination and annual screening
What conditions can cause a painful arc on examination and how can you tell the difference between them?
Subacromial impingement:
-painful arc between 60 and 120 degrees
Rotator cuff tears:
-painful arc in the first 60 degrees
What is shown on the x-ray?
patella dislocation
Explain the Weber classification.
swiss orthopaedic surgeon
Used for ankle fractures
Weber A: below the syndesmosis
Weber B: at the level
Weber C: above the syndesmosis
Below the photo shows the tibia and fibula
What is shown in the x-ray?
Pepperpot skull
Indicative of primary hyperparathyroidism
