Orthopaedics Flashcards
(99 cards)
1
Q
What is the definition of osteoporosis?
A
Bone density over 2.5 SDs less than average for a young, healthy person of the same age and gender
2
Q
What is the definition of osteopenia?
A
Bone density over 1.5 SDs less than average for a young, healthy person of the same age and gender
3
Q
How would you manage an open fracture?
A
A-E assessment
Assess neurovascular supply of the limb
Remove any gross contamination + photograph the wound
Cover in saline-soaked gauze + splint on backslab
IV antibiotics within the hour and 8 hourly
Take to theatre <24 hours
In highly contaminated wounds, take straight to theatre
4
Q
What nerve is likely to be damaged in a mid-shaft of the humerus fracture?
A
Radial nerve
Runs along the radial groove of the humerus
5
Q
What is the most common nerve affected by supracondylar fractures?
A
Median nerve
6
Q
What is the most common nerve to be affected in shoulder dislocation?
A
Axillary nerve
7
Q
What is the most common nerve affected in hip dislocation?
A
Sciatic nerve
8
Q
What is the most common nerve affected when the neck of the fibula is fractured?
A
Common peroneal nerve
9
Q
What are the features of a Colle’s fracture?
A
Usually a fall onto outstretched hand
Dorsal displacement of the distal radius
Dinner fork type of deformity
Classic triad:
Transverse fracture of the radius
1 inch proximal to the radio-carpal joint
Dorsal displacement and angulation
10
Q
How is a Colle’s fracture managed?
A
Closed reduction and fixation in a Colle’s cast (6 weeks)
Colle’s cast holds the wrist in a flexed, ulnar deviated position
More displaced fractures may require plates and pins
11
Q
What are the features of a Smith’s fracture?
A
Palmar displacement of the distal radius
Often caused by fall onto the back of the hand/while holding something
12
Q
What are the features of a scaphoid fracture?
A
Anatomical snuffbox tenderness
FOOSH
Wrist swelling
Pain worse on circumduction and resisted pronation, ulnar deviation
13
Q
How do you diagnose a scaphoid fracture?
A
X-ray of the wrist- incl scaphoid views
If no signs of fracture but clinical suspicion, repeat x-ray in 10 days
Ct superior and MRI = definitive but rarely used unless radiographs completely inconclusive
14
Q
Why do we worry about scaphoid fractures?
A
Risk of avascular necrosis of bone due to retrograde blood supply from the hand
15
Q
How are scaphoid fractures managed?
A
If stable and non-displaced: Cast immobilisation “Futuro splint”
If unstable or displaced: Herbert screw or ORIF
16
Q
What is the blood supply to the neck of the femur?
A
Medial circumflex branch of the femoral artery
-> risk of avascular necrosis in intracapsular fractures
17
Q
What is often the most appropriate pain relief to prescribe in NOF fractures?
A
Femoral block
18
Q
What is the classification used for intracapsular NOF fractures?
A
Garden classification:
1: Non-displaced and incomplete
2: Non-displaced and complete
3: Displaced but incompletely so
4: Complete + completely displaced
1,2 = dynamic hip screw 3,4= Hemiarthroplasty
19
Q
What are the types of extracapsular NOF fractures?
How are they managed?
A
Intertrochanteric
Subtrochanteric
- if reduced and non-displaced: hip screw
- if displaced: IM nail in sub-trochanteric, Screw in intertrochanteric
20
Q
Which classification is used in fibular fractures?
A
Weber classification
21
Q
What is the classification system for growth plate fracture?
A
Salter-Harris Fracture:
1: transverse fracture between metaphysic and epiphysis
2: most common, as above but with separation of a fraction of metaphysis
3: Transverse fracture of the physis and epiphysis, may affect the point surface
4: fracture through all three parts and into the joint
5: Crush fracture causing imposition of the plate
22
Q
How are Salter-Harris fractures managed?
A
1 & 2: closed reduction, cast immobilisation + reassess 7-10 days
3 & 4: ORIF with wires or traction screws
5: often diagnosis made in retrospect
23
Q
What is the most common place for a buckle fracture?
A
Distal radial metaphysis due to a fall onto an outstretched hand
24
Q
What are the features of supracondylar fractures?
A
Fracture of olecranon
Anterior fat pad showing joint effusion- may also have posterior fat pad
Anterior line of the humerus normally intersects the middle third of the capitellum, so if this isn’t the case then there is often displacement.
May have neuromuscular compromise
25
What are the differentials for a limping child?
```
0-5:
Developmental dysplasia of the hip
Toddler's fracture
Transient synovitis
Neurological conditions e.g. cerebral palsy
```
```
5-10:
Perthe's disease
Transient synovitis
Reactive arthritis / Septic arthritis
Idiopathic juvenile arthritis
Osgood schlatter's
```
```
10-15:
Slipped upper femoral epiphysis
Trauma
Infection / inflammation
Transient synovitis
```
26
What are the features of slipped upper femoral epiphysis?
Usually an overweight, male early teen
Painful limp on affected side, c/o sore hip and knee often
Limitation to internal rotation is usually seen.
Knee pain is usually present 2 months prior to hip slipping.
Limited ROM with pain elicited at extremes
Involuntary muscle guarding/spasm
Bilateral in 20%.
27
How is slipped upper femoral epiphysis managed?
Bed rest and non-weight bearing. Aim to avoid avascular necrosis.
Usually open reduction and internal fixation with screw left in-situ
Often bilateral procedure with prophylactic screw being placed into opposite side
28
What is Perthe's disease?
Idiopathic avascular necrosis of the capital epiphysis of the femur
Presents with a painful limp
4-6w week history of worsening limp
Pain may be referred to the knee
Loss of internal rotation, abduction and flexion
On x-ray, loss of shape of spherical head of femur
Remove pressure from joint to allow normal development.
Physiotherapy. Usually self-limiting if diagnosed and treated promptly.
29
How is developmental dysplasia of the hip diagnosed and managed?
Ortolani's and Barlow's tests at birth
| USS scan of the hips of all breech babies / those at suspicion of DDH when >4m old
30
How is developmental dysplasia of the hip diagnosed and managed?
Ortolani's and Barlow's tests at birth
USS scan of the hips of all breech babies / those at suspicion of DDH when >4m old
Managed using Pavlik harness or in more severe cases, reduction surgery
31
What are the symptoms of compartment syndrome?
Initially:
Pain out of proportion to injury, worse with stretching
Tight/woody feeling tissue which is very tender to touch
Paraesthesia, swelling
Pulses maintained in early stages
```
Later:
Worsened pain and swelling
Muscle weakness/paralysis
Cold peripheries, absent pulses
6 Ps of ischaemia
```
32
How is compartment syndrome managed?
Fasciotomy within 5 hours (tissue death can occur within 4-6hrs)
Escharotomy in case of external burn scars causing compression
Debridement of any clearly necrotic tissue
Myoglobinuria may occur following fasciotomy and result in renal failure and for this reason these patients require aggressive IV fluids
33
How is compartment syndrome diagnosed?
Intracompartmental pressure measurements- Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic
Compartment syndrome will typically not show any pathology on an x-ray
Regular U&Es should also be taken due to the risk of rhabdomyolysis and myoglobulinuria
34
Where is compartment syndrome most common?
Anterior compartment of the lower leg following fibular fractures
Affects deep peroneal nerve- footdrop, sensory loss between big toe and 2nd toe
35
What is the most common cause of sciatica?
Lumbar disk herniation
36
What is the management for non-critical sciatica?
```
Try to stay as active as possible
Physiotherapy
NSAIDs + PPI, weak opioids
Weight loss
TENS
Referral to pain clinic: pregabalin/gabapentin, topical capsaicin, epidural injections
```
37
What are the rotator cuff muscles and their functions?
Supraspinatus- abduction
Infraspinatus- external rotation
Teres Minor- external rotation
Subscapularis- internal rotation
38
Which rotator cuff muscle is most likely to suffer a tear?
Supraspinatus
39
What is the nerve supply to the rotator cuff muscles?
Supraspinatus, infraspinatus, subscapularis: subscapular nerve
Teres minor: axillary nerve
40
What are the signs of rotator cuff injury?
Painful arc of abduction.
With subacromial impingement, this is typically between 60 and 120 degrees. With rotator cuff tears the pain may be in the first 60 degrees.
Tenderness over anterior acromion
May have asymmetry of muscles
41
What are the tests for the individual rotator cuff muscles?
Supraspinatus: empty can test + pain arc 6-120 degrees
Infraspinatus + teres minor: painful resisted external rotation
Teres minor: painful external rotation in ABduction
Subscapularis: Gerber's lift off test
42
How are rotator cuff tears managed?
Simple analgesia
Physiotherapy
Subacromial steroid + anaesthetic injections
Surgical repair of tear with bone anchoring
Arthroplasty
43
What is adhesive capsulitis?
Frozen shoulder
Glenohumoral joint capsule contraction and adhesion to humeral head - pain and reduced ROM
Increased risk in diabetes, thyroid disease + those having had breast/shoulder surgery
44
What are the features of adhesive capsulitis?
Deep, constant pain in the shoulder
May radiate to biceps
Disturbs sleep
Joint stiffness and reduced ROM, especially in external rotation
Both active and passive movement are affected
May have loss of arm swing, deltoid atrophy and tenderness on palpation
45
How is adhesive capsulitis managed?
```
Self-limiting over months-years but may recur
Physiotherapy
NSAIDs
Glenohumoral joint steroid injection
surgical release
```
46
What are the symptoms of subacromial bursitis?
```
Lateral or anterior shoulder pain
Pain worse at night time
Overhead reaching and lifting is very difficult
Reduced ROM
May have redness or swelling
```
Positive: empty can test, pain arc 60-120, speed's test (painful forward flexion)
47
What are the features of supraspinatus impingement?
Usually caused by overhead lifting/trauma or secondary to other shoulder pathology
Progressive ache
Tenderness and burning which may radiate to the lateral/anterior arm
Increasing pain on reaching and overhead work
Weakened abduction or forward flexion - hard to brush hair, get dressed etc
Reduced ROM
Pain arc 60-120
If arm is fully externally rotated, no pain on abduction as this isolates supraspinatus
48
What is the most common type of shoulder dislocation?
Anterior (95%), usually due to trauma e.g. FOOSH
49
What are the features of shoulder dislocation?
Severe pain and inability to move shoulder
Arm held in external rotation and abduction
Empty glenoid fossa on palpation with clear displacement of scapula
Humeral head may be able to be palpated below coracoid process
Numbness/paraesthesia/pain in region supplied by axillary nerve / brachial plexus injury
50
How is shoulder dislocation investigated?
Full examination + assessment of integrity of NV supply
Shoulder x-ray: AP, lateral and Y-view needed
Hill-Sachs deformity is a sign of anterior: indentation on posterolateral humeral head
Light-bulb sign = posterior dislocation
MRI scan to assess soft tissues
51
What is the cause of medial scapular winging?
Damage to long thoracic nerve or serratus anterior
Most commonly traction nerve injury e.g. weight-lifting, compressive injury or iatrogenic nerve injury
Causes discomfort trying to sit back against a chair
52
What causes lateral winging of the scapula?
Damage to trapezius muscle or spinal accessory nerve
| Most common caused by iatrogenic interventions
53
What are the symptoms of fibromyalgia?
Chronic, widespread pain- especially where muscle/tendons attach to bone
Morning stiffness
Tactile allodynia
Headache, fatigue, poor sleep ability/quality, cognitive dysfunction
Autonomic dysfunction: IBS, weight problems, palps, sexual dysfunction, night sweats
54
What are the criteria for diagnosis of fibromyalgia?
>3 months of symptoms
Affects both sides of the body, above and below the waist and along the axial spine
Widespread pain index + symptom severity index scores
18 tender points exist, pain on palpation of >11= suggestive of diagnosis
Laboratory tests and imaging all normal
55
How is fibromyalgia managed?
Low dose amitryptiline
SSRIs
Anticonvulsants
Avoid NSAID and opioid analgesia
Psychological therapy and input from pain management team.
56
What are the features of medial epicondylitis?
Golfer's elbow
Pain at medial elbow which radiates down arm
Worsens over weeks-months
Usually affects dominant side
Tenderness on palpation of medial epicondyle with concurrent stiffness and weakness
Numbness or tingling in ulnar nerve distribution
Resisted wrist flexion elicits pain
57
What are the features of lateral epicondylitis?
More common than medial- Tennis elbow
Pain at elbow, radiating down arm + usually dominant side
Local tenderness on palpation of lateral epicondyle and extensor tendons
Reduced grip strength
Resisted wrist extension elicits pain
58
How would you examine for achilles tendon rupture?
| What is the gold standard investigation?
Simmond's triad: Patient should lay proned
Look for abnormal angle of declination: greater dorsiflexion of the injured foot compared to the uninjured limb
Feel for a gap in the tendon
Squeeze the calf (simony's test)
Rupture can be confirmed by USS
59
What are the indications for ankle x-ray?
Malleolar pain +
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
60
What is the most common mechanism for ankle sprain?
| Which ligament is most commonly affected?
Inversion injuries
| Anterior talofibular ligament
61
What are the causes of avascular necrosis of the hip?
Trauma and NOF fractures
Long term steroid use
Alcohol excess
Chemotherapy
62
What are the risk factors for biceps tendon rupture?
| Where is rupture most common?
```
Age >60
Heavy overhead lifting
Shoulder overuse / injury where more stress on biceps
Steroids
Smoking
```
63
What are the symptoms of biceps rupture?
Sudden pop or tear at the shoulder which is followed by pain, bruising and swelling.
'Popeye' deformity; this is when the muscle bulk results in a bulge in the middle of the upper arm.
Weakness in the shoulder and elbow typically follows including difficulty with supination
64
How would you diagnose biceps tendon rupture?
Examination of the biceps
Biceps squeeze: if in-tact, squeeze will cause supination
USS
MRI if still ambiguous
65
What is Paget's disease of bone?
Imbalance of bone remodelling process, causing focal bone resorption followed by excessive and chaotic bone deposition.
Affects: spine -> skull -> pelvis -> femur
Small risk of sarcomatous change + risk of cardiac failure
66
What are the signs of Paget's disease?
Symptoms: bone pain, joint pain and swelling, fractures, fatigue, hearing loss, neuropathy, nerve pain, spinal stenosis
Serum ALP raised
Abnormal thickened and sclerotic areas of bone on x-ray
Can cause Hypercalcaemia and hyperuricaemia
67
How is Paget's disease of the bone managed?
Bisphosphonates
68
What are symptoms of carpal tunnel syndrome?
Pain/paraesthesia in thumb, index and middle finger
Need to shake hand to provide relief
Struggle with grip
Often worst at night
69
What are signs of carpal tunnel syndrome on examination?
Wasting of the thenar eminence
Weakness of thumb abduction especially
Tinel's sign: tapping causes numbness
Phalen's test: flexion of wrist >1min causes symptoms
70
What is the management of carpal tunnel syndrome?
Steroid injection
Wrist splint, especially at night time
Surgical decompression of the carpal tunnel
71
What is a late sign of cauda equine which may indicate irreversible damage?
Urinary incontinence
71
What is a late sign of cauda equina which may indicate irreversible damage?
Urinary incontinence
72
What is cubital tunnel syndrome?
| What are the main features?
Compression of the ulnar nerve as it passes through the cubital tunnel
Often a history of OA or prior trauma
Features:
Numbness and tingling in 4th and 5th fingers, becomes constant
Weakness and Hypothenar eminence wasting
Pain worse when leaning on affected elbow
73
What is De Quervain's tenosynovitis?
Inflammation of the sheath containing extensor pollicis brevis and abductor pollicis longus tendons
Typically affects women between the ages of 30 and 50
74
What are signs of De Quervain's tenosynovitis on examination?
Pain on radial side of the wrist
Tenderness over radial styloid process
Painful abduction against resistance
Finkelstein's test
75
What is the most common cause of discitis and how is it best diagnosed?
Staphylococcus aureus
MRI +/- CT-guided biopsy
76
How should discitis be managed?
6 weeks IV antibiotics - guided by blood/biopsy cultures
All patients should be investigated for endocarditis e.g. via TTE or TOE as it is usually due to haematogenous seeding
77
Which fingers are most commonly affected by Dupuytren's contracture?
Little and ring fingers
78
What are differentials for elbow pain?
```
Medial epicondylitis: golfer's elbow
Lateral epicondylitis: tennis elbow
Radial tunnel syndorme
Cubital tunnel syndrome
Olecranon bursitis
Fracture- supracondylar common esp in children.
```
79
What is a Bennett's fracture?
Intra-articular fracture of the first carpometacarpal joint (knuckle)
Impact on flexed metacarpal, caused by fist fights
X-ray: triangular fragment at ulnar base of metacarpal
80
What are the features of post-op fat emboli?
Resp: Early persistent tachycardia, tachypnoea, dyspnoea, hypoxia, pyrexia
Derm: Red/brown flat petechial rash
Neuro: confusion and agitation, retinal haemorrhages
May have peripheral ground-glass changes on CT thorax
81
What are symptoms of trochanteric bursitis / greater trochanteric pain syndrome?
Gradual onset of pain over lateral side of the hip radiating down outer thigh
Burning/aching pain
Worse on activity/standing after sitting
Tenderness on palpation of the greater trochanter
Most common in women 50-70
Can be result of repetitive movements, trauma, inflammatory conditions (RA) or infection.
82
What special tests can be done to identify trochanteric bursitis?
Trendelenburg test
Resisted abduction of the hip
Resisted internal rotation of the hip
Resisted external rotation of the hip
83
How is trochanteric bursitis managed?
RICE
Physio
Steroid injection
84
What are the signs of hip dislocation?
Usually occurs following direct trauma e.g. RTA or fall from height
90% posterior: shortened, adducted, and internally rotated leg
In anterior: abducted and externally rotated. No leg shortening.
May have sciatic or femoral nerve injury and later avascular necrosis
85
What are considerations for treating intracapsular hip fractures?
Undisplaced Fracture:
internal fixation, or hemiarthroplasty if unfit.
Displaced Fracture:
NICE recommend replacement arthroplasty to all patients with a displaced intracapsular hip fracture
total hip replacement is favoured to hemiarthroplasty if patients:
were able to walk independently out of doors with max a stick
are not cognitively impaired and
are medically fit for surgery
86
What are the common features of psoas abscess?
Fever
Back/flank pain
Limp
Weight loss
Pain elicited on hip flexion against resistance or on hyperextension of the hip
87
How are psoas abscesses managed?
Antibiotics
Percutaneous drainage (90% successful)
Surgical management
88
What are common features of meniscal tear?
```
Pain worse on straightening the knee
Locking of the knee joint + may 'give way'
Recurrent episodes of pain and effusion
Delated knee swelling
Tenderness along the joint line
```
Usually occurs due to rotating sport injury
89
How does spinal stenosis usually present?
Usually gradual onset
Unilateral or bilateral leg pain, numbness, and weakness which is worse on walking. Resolves when sits down.
May or may not have back pain.
Relieved by sitting down, leaning forwards and crouching down
Clinical examination is often normal
Requires MRI to confirm diagnosis
90
What are the symptoms of different lumbar disc prolapses?
L3: anterior thigh numbness, weak quads, reduced knee reflex, +ve femoral stretch
L4: anterior knee numbness, weak quads, reduced knee reflex, +ve femoral stretch
L5: dorsal foot numbness, weak dorsiflexion, reflexes intact, +ve sciatic stretch
S1: lateral foot and leg numbness, weak plantar flexion, reduced ankle reflex, +ve sciatic stretch
91
Where is the most common place for a stress fracture?
2nd metatarsal shaft
92
What are the features of hand OA?
```
Bilateral
CMCs and DIPs most commonly affected
Intermittent ache
Stiffness after inactivity
Heberden's and Bouchard's nodes
Square thumbs
```
93
What are the complications of hip replacement?
```
VTE
Intraoperative fracture
Nerve injury
Surgical site infection
Leg length discrepancy
Posterior dislocation
Aseptic loosening of the prosthesis
Prosthesis infection
```
94
How is osteomyelitis managed?
6 weeks IV flucloxacillin
Clindamycin if penicillin allergic
Most commonly staph aureus infection
95
What are features of osteoporotic vertebral fractures?
May be asymptomatic and found on c-ray
Acute back pain
Breathing difficulties
May have history of trauma/fall (pain often out of proportion with mechanism)
Loss of height
Kyphosis
Localised tenderness on palpation of spinous processes
96
Where is the most common site for humerus fracture?
Surgical neck of the humerus
97
What are features of osteomalacia on blood tests?
Low serum calcium, low serum phosphate, raised ALP and raised PTH
98
What is the telltale sign of Paget's disease on blood results?
Isolated rise in ALP
