Orthopaedics Flashcards
(282 cards)
1
Q
What are the main principles of fracture management
A
Reduce
Hold
Rehabilitate
2
Q
What is involved in reduction in fracture management
A
Restore anatomical alignment of fracture/deformity
Tamponades bleeding
Reduces swelling in surrounding tissue
Reduces risk of nerve damage
Reduces pressure in blood vessels
Clinical requirements: analgesia, consider conscious sedation
3
Q
What is osteoarthritis
A
Progressive loss of articular cartilage and remodelling of underlying bone
4
Q
What is the pathophysiology of osteoarthritis
A
Degeneration of cartilage and remodelling of bone
Get release of enzymes that break down collagen and proteoglycans
Underlying subchondral bone becomes exposed
Get: sclerosis, remodelling (formation of osteophytes and subchondral cysts), joint space narrowing
5
Q
What are the risk factors for osteoarthritis
A
Obesity
Increasing age
Female
Tissue disease
Trauma
Infiltrative disease
Connective tissue disease
6
Q
How might osteoarthritis present
A
Joint pain and stiffness
Worse on activity
Relieved by rest
Pain worsens throughout day
Stiffness improves throughout day
7
Q
What are Bouchard’s nodes
A
Swelling of PIPJs
8
Q
What are Heberden’s nodes
A
Swelling of DIPJs
9
Q
What are the X-ray features of osteoarthritis
A
Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis
10
Q
What is the management for osteoarthritis
A
Education
Weight loss
Physio
Analgesia (topical/oral/intra-articular)
Osteotomy
Joint fusion
Arthroplasty
11
Q
What are the different classes of open fractures
A
Gustilo-Anderson classification
Type 1: < 1cm, clean
Type 2: 1-10cm, clean
Type 3A: > 10cm, high energy, adequate soft tissue coverage
Type 3B: > 10cm, high energy, inadequate soft tissue coverage
Type 3C: all injuries with vascular injury
12
Q
What investigations are needed for open fractures
A
Clotting screen
Group and save
X-ray
13
Q
What is the management for open fractures
A
Realignment and splinting
Broad spectrum antibiotics
Tetanus vaccination status check/administration
Photograph wound
Remove gross debris (re-dress with saline-soaked gauze)
If have vascular compromise, immediate surgical exploration by vascular
14
Q
What is compartment syndrome
A
Critical pressure increase within a confined compartmental space
Any fascial compartment can be affected
15
Q
What are the causes of compartment syndrome
A
High-energy trauma
Crush injuries
Fractures causing vascular compromise
Iatrogenic vascular injury
Tight cast/splint
DVT
Post-reperfusion swelling
16
Q
What are the sequence of events that lead to compartment syndrome
A
Intra-compartmental pressure increase
Veins compressed
Increased hydrostatic pressure (fluid moves out of veins)
Further intra-compartmental pressure increase
Traversing nerves compressed
Get paraesthesia
Intra-compartmental pressure reaches diastolic pressure
Arterial flow compromised
Ischaemia
17
Q
How might compartment syndrome present
A
Within 48 hours of injury
Severe pain: disproportionate to injury, not improved with analgesia/removing splint, made worse by passive stretching
Paraesthesia
Tenseness in affected compartment
Not swollen (fascial layer not able to distend)
18
Q
What are the 5 signs of arterial insufficiency
A
Pain
Pallor
Persistently cold
Paralysis
Pulselessness
19
Q
What investigations are needed for compartment syndrome
A
Usually clinical diagnosis
Intra-compartmental pressure monitoring
Creatine kinase levels
20
Q
What is the management for compartment syndrome
A
Early recognition
Immediate management: limb in neutral position, high flow oxygen, improve blood pressure, remove all dressings/casts, analgesia
Surgical fasciotomy
Post-fasciotomy: incision left open, re-look in 24-48 hrs (assess for dead tissue), can close wound but leave fascia open
Monitor renal function (can get rhabdomyolysis or reperfusion injury)
21
Q
What are the main causative organisms of septic arthritis
A
S aureus
Streptococcus
Gonorrhoea
Salmonella
22
Q
What are the risk factors for septic arthritis
A
> 80
Pre-existing joint disease
Diabetes
Immunosuppression
Chronic renal failure
Hip/knee prosthesis
IV drug use
23
Q
How might septic arthritis present
A
Single swollen joint
Severe pain
Pyrexia
Unable to weight bear
Joint red, swollen, warm
Pain on active and passive movement
May have an effusion
24
Q
What investigations are needed for septic arthritis
A
Routine bloods
Blood cultures
Joint aspiration
Joint fluid analysis
X-ray
25
What are the X-ray signs of septic arthritis
Usually normal appearance
In severe disease: in capsule and soft tissue swelling, fat pad shift, joint space widening
26
What is the management for septic arthritis
Early resuscitation and investigation
Empirical antibiotics (2 weeks IV, further 2-4 weeks oral)
Native joint: irrigation and debridement
Prostatic joint: washout, may need revision
27
What is osteomyelitis
Infection of bone
Acute - bacterial
Chronic - fungal
Adults - vertebrae
Children - long bones
Due to: haematological spread, direct inoculation, direct spread from nearby infection
28
What are the common causative organisms for osteomyelitis
S aureus
Streptococci
Enterobacter spp
H influenzae
P aeruginosa
Salmonella
29
What is the pathophysiology of osteomyelitis
Bacteria enter bone, express adhesins to bind host cells, produce polysaccharide extracellular matrix, pathogens: propagate, spread, seed
Get devascularisation of affected bone, necrosis
Resorption of surrounding bone ('floating' pieces of dead bone - reservoir for infection)
30
What are the risk factors for osteomyelitis
Diabetes (suspect in all diabetics with deep/chronic joint infection)
Immunosuppression
Alcohol
IV drug use
31
How might osteomyelitis present
Severe, constant pain
Worse at night
Low grade pyrexia
Tender at site
Swelling
Erythema
May not be able to weight bear
Look for source of infection: pock marks in IVDU, cellulitic areas, penetrating wounds
32
Give an overview of Pott's disease
Infection of vertebral body and vertebral disc
By mycobacterium tuberculosis
Presentation: back pain, neurological features, low grade fever, non-specific infective symptoms
MRI
Management: prolonged course of anti-TB meds, abscess drainage
33
What investigations are needed for osteomyelitis
Routine bloods
Blood cultures
X-ray
MRI (definitive diagnosis)
Bone biopsy at debridement (gold standard)
34
What are the X-ray signs of osteomyelitis
Osteopenia
Periosteal thickening
Endosteal scalloping
Focal cortical bone loss
35
What is the management for osteomyelitis
Clinically well: > 4 weeks IV antibiotics
Deteriorating: surgery (curettage of affected area, prevent chronic osteomyelitis developing)
36
What can osteomyelitis lead to in children
Growth disturbances (premature physeal closure)
37
What are some benign bone tumours
Osteoma
Osteoid osteoma
Osteoblastoma
Chondroma
Osteochondroma
Chondroblastoma
Fibroma
Fibromatosis
Benign osteoclastoma
38
What are some malignant bone tumours
Osteosarcoma
Chondrosarcoma
Fibrosarcoma
Malignant osteoclastoma
Ewing's tumour
Myeloma
39
What are the risk factors for bone tumours
Genetics (RB1, p53, TSC1, TSC2)
Previous exposure to radiation
Previous alkylating agent chemotherapy
Benign bone conditions
40
How might bone tumours present
Pain
At rest
Worse at night
Fracture without trauma
41
What staging system is used for orthopaedic tumours
Enneking
42
How are clavicle fractures classified
Allman classification
Type 1: middle 3rd (weakest segment), most common, generally stable, significant deformity seen
Type 2: lateral 3rd, unstable when displaced
Type 3: proximal 3rd, seen in multi-system polytrauma, associated with neurovascular compromise/pneumothorax/haemothorax
43
Which ways are fragments displaced in clavicle fractures
Medial fragment displaced superiorly (pull of SCM)
Lateral fragment displaced inferiorly (weight of arm)
44
What are the differentials for clavicle fractures
Sternoclavicular dislocation
Acromioclavicular joint separation
45
What investigations are needed for clavicle fractures
X-ray (anteroposterior, modified-axial)
CT (only for medial injuries)
46
What is the management for clavicle fractures
Slings
Early movement (prevent frozen shoulder)
Surgery for: open fractures, very comminuted (2+ fragments), very shortened arm, bilateral
May need ORIF if don't unite in 2-3 months
47
What is the prognosis for clavicle fractures
Non-union associated with distal 3rd fractures
Usually heal in 4-6 weeks
48
How are rotator cuff tears classified
Acute - < 3 months
Chronic - > 3 months
Partial thickness
Full thickness (small - < 1 cm, medium - 1-3 cm, massive - > 5 cm)
49
What are the muscles in the rotator cuff
Supraspinatus (abduction)
Infraspinatus (external rotation)
Teres minor (external rotation)
Subscapularis (internal rotation)
All muscles stabilise humeral head in glenoid fossa
50
What is the pathophysiology of rotator cuff tears
Minimal force - pre-existing degeneration
Large force - in young
51
What are the risk factors for rotator cuff tears
Increasing age
Trauma
Overuse
Repetitive overhead shoulder motion
BMI > 25
Smoking
Diabetes
52
How might rotator cuff tears present
Pain over lateral shoulder
Inability to abduct arm > 90 degrees
Mostly in dominant arm
Tenderness of greater tuberosity
Tenderness of subacromial bursa
53
What are the special tests for rotator cuff tears
Jobe's test (empty can test): tests supraspinatus
Gerber's lift-off test: dorsum of hand on lower back, lift off against resistance, tests subscapularis
Posterior cuff test: elbow flexed at 90 degrees, externally rotate against resistance, tests infraspinatus and teres minor
54
What are the differentials for rotator cuff tear
Fracture
Persistent glenohumeral subluxation
Brachial plexus injury
Radiculopathy
55
What investigations are needed for rotator cuff tears
X-ray (exclude fracture)
Ultrasound (size of tear)
MRI (size, characteristics, location)
56
What are the X-ray signs of chronic rotator cuff tears
Reduced acromiohumeral distance
Sclerosis
Cyst formation
57
What is the management for rotator cuff tears
Analgesia
Physio
Activity modification
Trial corticosteroid injections
Surgery: arthroscopy or open (for > 2 weeks since injury, symptomatic despite conservative strategies, large and massive)
58
Which factors lead to poor outcomes for rotator cuff tears
Large/massive tears
> 65
Poor compliance with rehabilitation
Smoking
59
How might shoulder dislocation present
Recent trauma
Painful shoulder
Acutely reduced mobility
Feels unstable
Reluctant to move limb
Asymmetry
Loss of shoulder contours
Anterior bulge from head of humerus
60
What associated injuries can shoulder dislocation lead to
Neurovascular (axillary nerve and suprascapular nerve very prone to injury)
Bony Bankart lesion (fracture of anterior inferior glenoid bone, common in recurrent dislocations)
Hill-Sachs defect: fracture of greater tuberosity/surgical neck of humerus
Rotator cuff injuries
61
What investigations are needed for shoulder dislocations
X-ray (trauma shoulder series): light bulb sign in posterior dislocations
MRI (if labral/rotator cuff injury suspected)
62
What is the management for shoulder dislocation
A to E
Analgesia
Reduce, immobilise, rehabilitate
Closed reduction
Broad-arm sling (2 weeks)
Physio
Surgery for: ongoing pain, joint instability, large Hill-Sach's lesion, large Bankart lesion
63
Which part of the humerus is normally fractures
Middle 3rd
64
What is Holstein-Lewis fracture
Fracture of distal 3rd of humerus
Entrapment of radial nerve
Loss of sensation in radial distribution
Wrist drop
Needs surgical management
65
What investigations are needed for humeral shaft fractures
X-ray (andteroposterior and lateral views)
CT (in severe cases, for pre-op planning)
66
What is the management for humeral shaft fractures
Re-align limb
Functional humeral brace or U slab
Usually have full union in 8-12 weeks
Surgery: ORIF (with plate), intramedullary nailing (pathological fractures, polytrauma, osteoporosis)
67
What is biceps tendinopathy
Range of pathologies
Usually due to overuse
Swollen, painful, weak tendon
Risk of rupturing
Young: tennis/cricket players
Old: degenerative tendinopathy
68
How might biceps tendinopathy present
Pain, weakness, stiffness
Worse on stressing tendon
Alleviated by rest and ice
Tenderness over tendon
Reduced muscle bulk
69
What are the special tests for biceps tendinopathy
Speed test (proximal biceps tendon)
Yargason's test (distal biceps tendon)
70
What are the differentials for biceps tendinopathy
Inflammatory arthropathy
Radiculopathy
Osteoarthritis
Rotator cuff disease
71
What investigations are needed for biceps tendinopathy
Clinical diagnosis
Routine bloods
X-ray (exclude differentials)
Ultrasound/MRI (thickened tendon)
72
What is the management for biceps tendinopathy
Analgesia
Ice therapy
Physio
Steroid injections
Arthroscopic tenodesis (tendon severed and reattached)
Tenotomy (division of tendon)
73
What are the risk factors for biceps tendon rupture
Previous episode of biceps tendinopathy
Steroid use
Smoking
CKD
Fluoroquinolone antibiotics
74
How might biceps tendon rupture present
Sudden onset pain and weakness
'Pop' during incident
Swelling and bruising of antecubital fossa
Can get bulge in arm (reverse popeye sign, as proximal muscle belly retracts)
75
What is the special test for biceps tendon rupture
Hook test
76
What investigations are needed for biceps tendon rupture
Clinical diagnosis
Confirm via ultrasound
77
What is the management for biceps tendon rupture
Analgesia
Physio
Surgery
78
Which nerves can be damaged during surgery for biceps tendon rupture
Lateral antebrachial cutaneous nerve
Posterior interosseous nerve
Radial nerve
79
What is adhesive capsulitis
Frozen shoulder
Glenohumeral joint capsule contracts and adheres to humeral head
80
What are the causes of adhesive capsulitis
Idiopathic
Rotator cuff tendinopathy
Subacromial impingement syndrome
Biceps tendinopathy
Previous surgery/trauma
Joint arthropathy
81
What are the stages of adhesive capsulitis
Initial painful stage
Freezing stage
Thawing stage
(Pain and limited movement throughout)
82
How might adhesive capsulitis present
Deep, constant pain
Radiates to bicep
Disturbs sleep
Joint stiffness
Reduced function
Reduced range of motion (external rotation and flexion)
Loss of arm swing
Atrophy of deltoid
Tender on palpation
83
What investigations are needed for adhesive capsulitis
Clinical diagnosis
X-ray (rule out differentials)
MRI (thickening of glenohumeral joint capsule)
HbA1c (more common in diabetes)
84
What is the management for adhesive capsulitis
Usually self-limiting (over months to years)
Education and reassurance
Physio
Analgesia
Glenohumeral joint corticosteroid injections
Surgery (no improvement): manipulation under GA (remove capsular adhesion), arthrographic distension, surgical release of glenohumeral joint capsule
85
What is subacromial impingement syndrome
Inflammation and irritation of rotator cuff tendons as they pass through subacromial space
Get pain, weakness, reduced range of motion
Mostly in < 25, active people
86
What are the intrinsic mechanisms of subacromial impingement syndrome
Pathologies of rotator cuff tendon due to tension: muscular weakness, overuse of shoulder, degenerative tendinopathy
87
What are the extrinsic mechanisms of subacromial impingement syndrome
Pathologies of rotator cuff due to external compression: anatomical abnormalities, scapular musculature, glenohumeral instability
88
How might subacromial impingement syndrome present
Progressive pain in anterior superior shoulder
Exacerbated by abduction, relieved by rest
Some weakness and stiffness due to pain
89
What are the special tests for subacromial impingement syndrome
Neers test
Hawkins test
90
What investigations are needed for subacromial impingement syndrome
Clinical diagnosis
MRI
91
What are the MRI signs of subacromial impingement syndrome
Subacromial osteophytes
Subacromial sclerosis
Subacromial bursitis
Humeral cystic changes
Narrowing of subacromial space
92
What is the management for subacromial impingement syndrome
Analgesia
Physio
Corticosteroid injections into subacromial space
Education
Surgery (if > 6 months with no response): surgical repair of muscle tear, surgical removal of subacromial bursa, surgical removal of sections of acromion
93
What are the complications of subacromial impingement syndrome
Rotator cuff degeneration
Rotator cuff tear
Adhesive capsulitis
Complex regional pain syndrome
94
What is a supracondylar fracture
Common paediatric elbow injury
Usually 5 - 7s
After FOOSH with elbow extended
95
How might supracondylar fracture present
Recent trauma
Sudden onset severe pain
Reluctance to move arm
Gross deformity
Swelling
Limited range of elbow movement
Ecchymosis of antecubital fossa
96
Which nerves need to be examined in supracondylar fracture
Median
Radial
Ulnar
Anterior interosseous (deep motor branch of median)
97
What are the differentials for supracondylar fracture
Distal humeral fracture
Olecranon fracture
Soft tissue injury
Subluxation of radial head
98
What investigations are needed for supracondylar fracture
X-ray: posterior fat pad sign - lucency on lateral view, displacement of anterior humeral line
CT: for comminuted fracture and when intra-articular extension suspected
99
What are the classes of supracondylar fracture
Gartland classification
Type 1: undisplaced
Type 2: displaced, with intact posterior cortex
Type 3: displaced in 2-3 planes
Type 4: displaced, with complete periosteal disruption
100
What is the management for supracondylar fracture
Immediate closed reduction: need K-wire fixation in children, remove in 3-4 weeks
Above elbow cast
Open reduction with percutaneous pinning (open fractures)
May need vascular exploration if have ongoing vascular compromise
101
What are the complications of supracondylar fracture
Nerve palsies (common)
Malunion (gunstock deformity, extended forearm deviates towards midline)
Volkmann's contracture (ischaemia and necrosis of flexor muscles in forearm, wrist and hand in permanent flexion, claw-like deformity)
102
Where is the olecranon
Part of proximal ulna
Articulates with trochlea and distal humerus
Site of insertion of triceps
103
How might olecranon fracture present
History of FOOSH
Elbow pain
Swelling
Lack of mobility
Tenderness over posterior elbow
Inability to extend elbow against gravity (disruption of triceps mechanism)
104
What investigations are needed for olecranon fracture
Routine bloods (+ clotting + group and save)
X-ray: often displaces (pull of triceps)
CT: for complex fractures, can work out degree of comminution
105
What is the management for olecranon fracture
Analgesia
< 2 mm displacement: cast
> 2 mm displacement: tension band wiring, olecranon plating
106
What is the most common fracture of the elbow
Radial head fracture
107
What is the classification for radial head fracture
Mason classification
Type 1: non-displaced, minimally displaced (< 2 mm)
Type 2: partial articular fracture with > 2 mm displacement or angulation
Type 3: Comminuted fracture and displacement
108
How might radial head fracture present
History of FOOSH
Elbow pain
Swelling, bruising
Tender on palpation of lateral elbow and radial head
Pain and crepitations on pronation and supination
Elbow effusion
109
What investigations are needed for radial head fracture
Routine bloods (+ clotting + group and save)
X-ray: sail sign (elbow effusion causing elevation of anterior fat pad on lateral view)
CT: complex injuries
MRI: suspected ligament injuries
110
What is the management for radial head fracture
Analgesia
Mason 1: sling, early mobilisation
Mason 2: sling, or ORIF
Mason 3: ORIF, radial head excision, radial head replacement
111
What are the types of elbow dislocations
Simple
Complex (associated with a fracture)
Anterior
Posterior (90%)
112
How might elbow dislocation present
High energy fall
Painful
Deformed joint
Swelling
Decreased function
Usually have neurovascular abnormalities in ulnar nerve region
113
What investigations are needed for elbow dislocation
X-ray: loss of radiocapitellar and ulnotrochlear congruences
CT: if other fractures
114
What is the management for elbow dislocation
Closed reduction
Analgesia
Above-elbow backslab (1-2 weeks)
Early rehabilitation
ORIF
115
In which positions is the arm more stable based on the ligaments damaged in elbow dislocation
Damaged lateral collateral ligament: more stable in pronation
Damaged medial collateral ligament: more stable in supination
116
What are the complications of elbow dislocation
Early stiffness
Loss of terminal extension
Ulnar nerve most commonly stretched
Injury to brachial artery/median nerve (rare)
Recurrent instability
117
What is the terrible triad for elbow dislocation
Elbow dislocation with: lateral collateral ligament injury, radial head fracture, coronoid fracture
Causes a very unstable elbow
Often seeds surgical fixation
118
Why is the olecranon bursa prone to inflammation
Superficial position
Vulnerable to pressure and trauma
119
What are the causes of olecranon bursitis
Repetitive flexion-extension movements
Gout
Rheumatoid arthritis
Infection through abrasion
120
How might olecranon bursitis present
Pain and swelling over olecranon
Small swelling over time, but recent increase in size/discomfort
Full range of movement (joint capsule not affected)
Minimal discomfort
Systemic symptoms if infected
121
What are the differentials for olecranon bursitis
Inflammatory arthropathies
Gout
Cellulitis
Septic arthritis
122
What investigations are needed for olecranon bursitis
Routine bloods
X-ray: rule out bony injury
Aspiration of fluid: microscopy and culture for definitive diagnosis
123
What is the management for olecranon bursitis
Analgesia
Rest
Consider splinting
IV antibiotics
Washout
Surgical drainage
Bursectomy (long term, don't respond)
124
What is lateral epicondylitis
Chronic symptomatic inflammation of forearm tendons at elbow
Due to overuse
Lateral epicondylitis: tennis elbow
Medial epicondylitis: golfer's elbow
125
How might lateral epicondylitis present
Pain radiates down forearm
Worsens over weeks-months
Local tenderness on palpation
Reduced grip strength
126
What are the special tests for lateral epicondylitis
Cozen's test: elbow flexed at 90 degrees, pain on extending wrist against resistance
Mill's test: pain on palpation of lateral epicondyle whilst pronating arm/flexing wrist/extending elbow
127
What are the differentials for lateral epicondylitis
Cervical radiculopathy
Elbow osteoarthritis
Radial carpal tunnel syndrome
128
What investigations are needed for lateral epicondylitis
Clinical diagnosis
Ultrasound/MRI to confirm
129
What is the management for lateral epicondylitis
Modification of activities
Analgesia
Corticosteroid injections
Physio
Brace
Tendon release/repair
Open/arthroscopic debridement
130
What is carpal tunnel syndrome
Compression of median nerve within carpal tunnel
131
What are the risk factors for carpal tunnel syndrome
F>M
45 - 60
Pregnancy
Obesity
Previous injury
Comorbidity: diabetes, rheumatoid arthritis, hypothyroidism
Repetitive hand movements
132
How might carpal tunnel syndrome present
Pain, numbness, paresthesia in lateral 3.5 fingers
Palm spared (palmar cutaneous branch of median nerve passes over carpal tunnel)
Worse at night
Weakness of thumb abduction
Wasting of thenar eminence
133
What are the special tests for carpal tunnel syndrome
Tinel's: percussion over median nerve
Phalen's: hold wrist in full flexion for one minute
134
What are the differentials for carpal tunnel syndrome
Cervical radiculopathy
Pronator teres syndrome
Flexor carpi radialis tenosynovitis
135
What investigations are needed for carpal tunnel syndrome
Clinical diagnosis
Can use nerve conduction studies to confirm
136
What is the management for carpal tunnel syndrome
Wrist splint
Physio
Corticosteroid injections
Carpal tunnel release
137
What is De Quervain's tenosynovitis
Inflammation of tendons within first extensor compartment of wrist
Wrist pain and swelling
F>M
30 - 50
138
Which tendons are involved in De Quervain's tenosynovitis
Tendons of extensor pollicis brevis and abductor pollicis longus
139
How might De Quervain's tenosynovitis present
Pain near base of thumb
Swelling (thickening of tendon sheath)
Pain on grasping/pinching
140
What is the special test for De Quervain's tenosynovitis
Finkelstein's test
141
What are the differentials for De Quervain's tenosynovitis
Arthritis of carpometacarpal joint
Intersection syndrome (tendons of first and second compartment cross)
Wartenberg's syndrome (neuritis of superficial radial nerve)
142
What is the management for De Quervain's tenosynovitis
Avoid repetitive movements
Splint
Steroid injections
Decompression of extensor compartment
Transverse/longitudinal incision in tendon sheath at centre
143
What is distal radial fracture
Fracture through distal metaphysis of radius
Mostly due to FOOSH
Risk increases with age
144
What are the types of distal radial fracture
Colle's
Smith's
Barton's
145
What is a Colle's fracture
A type of distal radial fracture
A fragility fracture
Wrist forced into supination
Extra-articular fracture of distal radius with dorsal angulation and dorsal displacement within 2cm of articular line
146
What is a Smith's fracture
A type of distal radial fracture
Volar angulation of distal fragment of extra-articular fracture
Due to forced pronation of wrist
147
What is Barton's fracture
A type of distal radial fracture
Intra-articular fracture, with associated dislocation of radio-carpal joint
Can be volar or dorsal
148
How might distal radial fracture present
Following trauma
Pain
Deformity
Swelling
149
What are the risk factors for distal radial fracture
Osteoporosis
Increasing age
F>M
Early menopause
Smoking
Alcohol
Prolonged steroids
150
What investigations are needed for distal radial fracture
X-ray
CT/MRI
151
What is the management for distal radial fracture
Closed reduction
Backslab
Physio
ORIF with plating
K-wire fixation
152
What is Dupuytren's contracture
Starts as painless nodule, fibrous cords and flexion contractures at MCP and interphalangeal joints
Can progress to severely limit finger movement
M>F
40 - 60
Mostly in ring and little finger
Due to contraction of longitudinal palmar fascia
153
What is the pathophysiology of Dupuytren's contracture
Fibroplastic hyperplasia and altered collagen matrix of palmar fascia
Pitting and thickening of palmar skin and underlying tissue
Formation of firm, painless nodule
Tendon-like cord develops
Contraction of cord pulls on MCP and PIP joints
154
What are the risk factors for Dupuytren's contracture
Smoking
Alcoholic liver cirrhosis
Occupational exposure (vibrating tools, heavy manual work)
Genetics
155
How might Dupuytren's contracture present
Reduced range of movement of affected finger
Nodular deformity
Usually affects right hand
Skin blanching on active extension
156
What is the special test for Dupuytren's contracture
Hueston's test
Positive if patient can't lay their hand flat on a table
157
What are the differentials for Dupuytren's contracture
Stenosing tenosynovitis
Ulnar nerve palsy
Trigger finger
158
What investigations are needed for Dupuytren's contracture
Clinical diagnosis
Routine bloods
159
What is the management for Dupuytren's contracture
Hand therapy
Injectable collagenase clostridium histolyticum (CCM)
Excision of diseased fascia (regional fasciotomy, segment fasciotomy, dermofasciectomy)
Finger amputation (severe cases)
160
What is ganglionic cyst
Non-cancerous soft tissue lump
Can occur in any joint or tendon
Due to degeneration within joint capsule/tendon sheath
161
What are the risk factors for ganglionic cyst
F>M
20 - 40
Osteoarthritis
Previous joint/tendon injury
162
How might ganglionic cyst present
Smooth, spherical, painless lump adjacent to affected joint
Transilluminates
May affect range of movement
163
What are the differentials for ganglionic cyst
Tenosynovitis
Giant cell tumour of tendon sheath
Lipoma
Osteoarthritis
Sarcoma
164
What investigations are needed for ganglionic cyst
Clinical diagnosis
X-ray
Ultrasound/MRI
Aspiration
165
What is the management for ganglionic cyst
Monitor
Aspiration
Steroid injections
Remove cyst capsule (and portion of associated tendon sheath)
166
What are the contents of the anatomical snuffbox
Radial artery
Superficial radial nerve
Cephalic vein
167
What is the pathophysiology of scaphoid fracture
Fracture can compromise blood supply, can get avascular necrosis
Can get degenerative wrist disease
Blood supply via radial artery (80% dorsal branch, 20% volar branch)
The more proximal the fracture, the higher the chances of avascular necrosis
168
How might scaphoid fracture present
Following high-energy trauma
Sudden onset wrist pain
Bruising
Tender in floor of anatomical snuffbox
Pain on palpating scaphoid tubercle
Pain on telescoping thumb
169
What are the differentials for scaphoid fracture
Distal radial fracture
Alternative carpal bone fracture
Fracture at base of 1st metacarpal
Ulnar collateral ligament injury
Wrist sprain
De Quervain's tenosynovitis
170
What investigations are needed for scaphoid fracture
X-ray (scaphoid series)
MRI (repeat negative X-rays, but suspect)
171
What is the management for scaphoid fracture
Undisplaced: strict immobilisation, surgery if high risk of avascular necrosis
Displaced: operative fixation (percutaneous variable-pitched screw)
172
What are the complications of scaphoid fracture
Avascular necrosis
Non-union
173
What is trigger finger
Stenosing flexor tenosynovitis
Finger/thumb clicks/locks when flexing
Nodal formation in tendon at metacarpal joint, distal to A1 pulley
174
What are the risk factors for trigger finger
Occupations/hobbies involving prolonged gripping/use of hand
F>M
Increasing age
Rheumatoid arthritis
Diabetes
175
How might trigger finger present
Painless clicking/snapping/catching when extending finger
Becomes painful over time
176
What are the differentials for trigger finger
Dupuytren's contracture
Infection within tendon sheath
Ganglion
Acromegaly (swelling o flexor synovium within tendon sheath)
177
What is the management for trigger finger
Advice about specific movements
Splint (hold in extension overnight)
Steroid injections
Percutaneous trigger finger release
Surgical decompression of tendon tunnel
178
What is radiculopathy
Conduction block in axon of spinal nerve or spinal nerve root
Can impact motor and sensory axons
179
What is radiculopathy caused by
Nerve compression due to:
Intervertebral disc prolapse
Degenerative disease of spine
Fracture
Malignancy
Infection
180
How might radiculopathy present
Sensory and motor features
Burning, deep pain
181
What are the differentials for radiculopathy
Referred pain
Myofascial pain
Thoracic outlet syndrome
Greater trochanter bursitis
Meralgia paraesthetica
Piriformis syndrome
182
What is the management for radiculopathy
Analgesia (amitriptyline first line)
Physio
Benzodiazepines for muscle spasms
Emergency surgery for cauda equina syndrome
183
What is degenerative disc disease
Natural deterioration of intervertebral disc structure
Related to ageing
Factors leading to damage of intervertebral discs: progressive dehydration of nucleus pulposus, daily activities causing tear in annulus fibrosus, injury/pathology causing instability
184
What are the 3 stages of degenerative disc disease
Dysfunction: outer annular tears, separation of endplate, cartilage dysfunction, facet synovial reaction
Instability: disc resorption, loss of disc space height, facet capsular laxity, can get subluxation and spondylolisthesis
Restabilisation: degenerative changes lead to osteophyte formation and canal stenosis
185
How might degenerative disc disease present
Localised spine tenderness
Contracted paraspinal muscles
Hypermobility
Painful extension of back/neck
Instability
Paraesthesia
Stiffness
Reduced mobility
Scoliosis
186
What is the special test for degenerative disc disease
Lasegue test
Pain on straight leg raise is positive
187
What investigations are needed for degenerative disc disease
MRI (gold standard)
Only image if: red flags, > 6 weeks, evidence of spinal cord compression
188
What is the management for degenerative disc disease
Analgesia
Encourage mobility
Physio
Emergency surgery for cauda equina
189
Where can neck of femur fractures be located
Anywhere between subcapital region of femoral head and 5cm distal to greater trochanter
Intracapsular: from subcapital region of head to basocervical region of neck
Extracapsular: outside capsule. Intertrochanteric (between greater to lesser trochanter) or subtrochanteric (lesser trochanter to 5cm below)
190
Explain the bloodflow to the head of the femur
Retrograde blood flow
Goes distal to proximal (neck to head)
Through medial circumflex femoral artery
Displaced intracapsular fractures disrupt blood to femoral head (get avascular necrosis) - need joint replacement (rather than fixation)
191
What is the classification system for neck of femur fracture
Garden classification
Type 1: incomplete fracture, non-displaced
Type 2: complete fracture, non-displaced
Type 3: complete fracture, partially displaced
Type 4: complete fracture, fully displaced
192
How might neck of femur fracture present
History of trauma
Pain in groin/thigh/knee
Shortened and externally rotated leg (pull of short extensors)
Pain on pin-rolling leg and axial loading
193
What investigations are needed for neck of femur fracture
X-ray (AP and lateral of hip, other hip, full length femur)
Routine bloods (+ clotting + group and save)
Urine dip and CXR in elderly
194
What is the management for neck of femur fracture
A to E
Analgesia
Early rehabilitation
Displaced subcapital - hip hemiarthroplasty
Intertrochenteric and basocervical - dynamic hip screw
Non-displaced intracapsular - cannulating hip screw
Subtrochanteric - intramedullary femoral nail
195
What are the long term complications of neck of femur fracture
Joint dislocation
Aseptic loosening
Peri-prosthetic fracture
Deep infection/prosthetic joint infection
196
What are the causes of femoral shaft fracture
High energy trauma
Fragility fracture
Pathological fracture
Bisphosphonate-related fracture
197
Describe the blood supply of the femoral shaft
Highly vascularised
Supplied by penetrating branches of profunda femoris artery
198
How might femoral shaft fracture present
Pain (thigh/hip/knee)
Inability to weight bear
Obvious deformity
Proximal section pulled into flexion and external rotation
199
What are the classifications for femoral shaft fracture
Winquist and Hansen classification. Assesses degree of comminution
Type 0 - no comminution
Type 1 - insignificant amount of comminution
Type 2 - > 50% cortical contact
Type 3 - < 50% cortical contact
Type 4 - segmental fracture, no contact between proximal and distal fragments
200
What investigations are needed for femoral shaft fracture
Routine bloods (+ clotting + group and save)
X-ray (AP and lateral views of whole femur)
CT (if suspect polytrauma)
201
What is the management for femoral shaft fracture
A to E
Analgesia
If open: antibiotics, prophylaxis, tetanus shot
Immediate reduction and immobilisation
Traction splinting: for mid-shaft fractures (hold against action of thigh muscle mass)
Long-leg cast: undisplaced fractures with significant comorbidities
Surgical fixation: within 24-48 hrs
Antegrade intramedullary nail
External fixation
202
What is distal femoral fracture
Can extend from distal metaphyseal-diaphyseal junction of femur to articular surface of femoral condyles
Can be related to knee replacements
203
What are the classifications of distal femoral fracture
Type A - extraarticular
Type B - partially articular
Type C - completely articular
204
How might distal femoral fracture present
History of trauma
Severe pain in distal thigh
Inability to weight bear
Obvious deformity
Swelling
Ecchymosis of distal thigh
205
What investigations are needed for distal femoral fracture
Normal bloods (+ clotting + group and save)
X-ray (AP and lateral)
CT (if have intraarticular extension)
206
What is the management for distal femoral fracture
Realign
Analgesia
Immobilise (skin traction)
Retrograde nailing (proximal extraarticular, simple intraarticular)
ORIF with distal plate (distal, complex intraarticular)
207
What are the different classification systems for pelvic fracture
Young and Burgess classification (based on disrupting force and degree of displacement)
Tile classification (based on stability of pelvic ring)
Denis classification (describes line of fracture in relation to sacral foramina)
208
What investigations are needed for pelvic fracture
X-ray (AP, inlet and outlet views)
CT
209
What is the management for pelvic fracture
A to E
Pelvic bindle (gives skeletal stabilisation)
Surgery for: life threatening haemorrhage, unstable fractures, open fractures, associated urological injury
210
What is the classification system for acetabular fracture
Judet and Letournel classification
Elementary: posterior wall, posterior column, anterior wall, anterior column, transverse
Associated: combination of regions
211
What investigations are needed for acetabular fracture
X-ray (AP, Judet, obturator and iliac oblique views)
CT (gold standard)
212
What is the management for acetabular fracture
A to E
Reduce any associated hip dislocation (minimise further damage to acetabulum)
Conservative
Fixation
213
What is the classification system for knee osteoarthritis
Kellgren and Lawrence system
Grade 0: no radiological features of OA
Grade 1: unclear joint space narrowing and possible osteophytic lipping
Grade 2: definitive osteophytes and possible joint space narrowing on AP weight-bearing view
Grade 3: multiple osteophytes, definite joint space narrowing, evidence of sclerosis, possible bony deformity
Grade 4: large osteophytes, marked joint space narrowing, severe sclerosis, definite bony deformity
214
Give an overview of patellofemoral osteoarthritis
OA affecting articular cartilage along trochlear groove and underside of patella
Risk factors: patella dysplasia, previous patella fracture
Anterior knee pain (worse on climbing stairs), stiffness, swelling
Skyline view X-ray
Conservative management, then patellofemoral replacement
215
What does the ACL do
Stabilises knee joint
Stops tibia slipping forward (relative to femur)
Provides rotational stability
216
How might ACL tear present
Twist knee whilst weight bearing (sudden change of direction on flexed knee)
Unable to weight bear
Rapid joint swelling
Significant pain
Leg gives way
217
What are the special tests for ACL tear
Lachman test (stabilise femur with one hand, pull tibia forward with other hand)
Anterior draw test (flex to 90 degrees, pull lower leg forward)
218
What investigations are needed for ACL tear
X-ray: AP and lateral views (exclude bony injury)
MRI: gold standard
219
What is the management for ACL tear
RICE
Physio
ACL reconstruction (use tendon/artificial graft)
Acute surgical repair of ACL (re-suture ends of ligament together)
220
What is the PCL
Less commonly tears than ACL
Prevents posterior movement of tibia
Prevents hyperflexion of knee
221
How might PCL tear present
Following high-energy trauma (or low energy where there is hyperflexion of knee on plantar-flexed foot)
Immediate posterior knee pain
Instability
Positive draw test
222
What imaging is needed for PCL tear
MRI
223
What is the management for PCL tear
Knee brace
Physio
Graft insertion (for recurrent instability)
224
How might MCL tear present
Trauma to lateral knee
Hear 'pop'
Immediate medial joint line pain
Swelling within hours
Increased laxity on valgus stress test
May be able to weight bear
225
What are the different grades for MCL tear
Grade 1: mild injury, minimally torn fibres, no loss of MCL integrity
Grade 2: moderate injury, incomplete tear, increased laxity of MCL
Grade 3: severe injury, complete tear, gross laxity of MCL
226
What investigations are needed for MCL tear
X-ray (exclude fracture)
MRI (gold standard)
227
What is the management for MCL tears
RICE
Analgesia
Physio
Knee brace
Surgery only for grade 3 where there is associated distal avulsion
228
Which nerve can be damaged as a complication of MCL tear
Saphenous nerve
229
How can you differentiate between the medial and lateral menisci of the knee
Medial: more circular, attached to MCL
Lateral: less circular, not attached to MCL
230
How might meniscal tears present
Twist knee whilst flexed and weight bearing
Longitudinal tears most common
Tearing sensation
Sudden intense pain
Slow swelling (over 6-12 hrs)
May be locked in flexion
Joint tenderness
Significant joint effusion
231
What are the special tests for meniscal tears
McMurray's test
Apley's grind test
232
What investigations are needed for meniscal tears
X-ray (exclude fractures)
MRI
233
What is the management for meniscal tears
RICE
Small heal spontaneously over a few days
Arthroscopic surgery
234
Which structures may be damaged as a complication of knee arthroscopy
Saphenous nerve
Saphenous vein
Peroneal nerve
Popliteal vessels
235
What are tibial shaft fractures at great risk of
Open fracture
Compartment syndrome
236
How might tibial shaft fractures present
Severe pain
Inability to weight bear
Swelling
Bruising
237
What investigations are needed for tibial shaft fractures
Urgent bloods (+ clotting + group and save)
X-ray: AP and lateral views, including knee and ankle
CT
238
What is the management for tibial shaft fractures
Realignment under analgesia
Above knee backslab
Elevate limb immediately
Post-manipulation X-ray needed
Intramedullary nailing
ORIF with locking plates
239
What classification is used for tibial plateau fracture
Schatzker classification
Type 1: lateral split fracture
Type 2: lateral split-depressed fracture
Type 3: lateral pure depression fracture (rare)
Type 4: medial plateau fracture
Type 5: bicondylar fracture
Type 6: metaphyseal-diaphyseal dislocation
240
What is the management for tibial plateau fracture
Hinge knee brace
Physio
Analgesia
ORIF
External fixation
241
What is the iliotibial band
Branch of longitudinal fibres that form the shared aponeurosis of tensor fascia latae and gluteus maximus
242
What is iliotibial band syndrome
Inflammation of iliotibial band
Most common cause of lateral knee pain in athletes
Due to repetitive flexion and extension of knee
243
How might iliotibial band syndrome present
Lateral knee pain
Exacerbated by exercise
Worse on running downhill
244
What are the special tests for iliotibial band syndrome
Nobles test
Renne test
245
What are the investigations for iliotibial band syndrome
Clinical diagnosis
Imaging (to rule out differentials)
246
What is the management for iliotibial band syndrome
Modify activities
Analgesia
Local steroid injections
Physio
Surgical release of iliotibial band from attachment to patella (only if symptomatic for > 6 months and treatment resistant)
247
What is ankle fracture
Fracture of lateral/medial/posterior malleolus
With/without disruption of syndesmosis
248
What is the syndesmosis
Where tibia and fibula are connected
Very strong fibrous structure
Anterior inferior tibiofibular ligament
Posterior inferior tibiofibular ligament
Intra-osseous membrane
249
What classification is used for lateral malleolus ankle fracture
Weber classification
Type A: below syndesmosis
Type B: at level of syndesmosis
Type C: above level of syndesmosis
The more proximal the injury, the higher the chances of ongoing instability
250
What investigations are needed for ankle fracture
X-ray (AP and lateral views)
CT (complex cases)
251
What is the management for ankle fracture
Immediate fracture reduction
Below knee backslab
ORIF
252
Give an overview of ankle sprain
Ligamentous injury
High (above syndesmosis) or low
Presentation: inversion injury on plantarflexed foot, significant swelling and pain, may not be able to weight bear, tender over affected ligament
X-ray (rule out fracture)
Management: analgesia, ice, elevation, early mobilisation
253
What is the most commonly fractured tarsal bone
Calcaneus
254
How might calcaneal fracture present
Recent trauma
Pain and tenderness over calcaneus
Inability to weight bear
Swelling and bruising
Shortened and widened heel
May have varus deformity
255
How are calcaneal fractures classified
Intra-articular: 75%, Sanders classification (type 1 - nondisplaced posterior facet, regardless of number of fracture lines, type 2 - one fracture line in posterior facet, 2 fragments, type 3 - two fracture lines in posterior facet, 3 fragments, type 4 - comminuted, >3 fracture lines in posterior facet, 4+ fragments)
Extra-articular: 25%, avulsion fracture
256
What are the X-ray signs of calcaneal fracture
Calcaneal shortening
Varus tuberosity deformity
Decreased Bohler's angle
257
What is the management for calcaneal fracture
Cast immobilisation
Analgesia
Physio
Closed reduction with percutaneous pinning
ORIF
258
What is Achilles tendonitis
Inflammation of Achilles tendon
Common in high intensity activities that chronically overload tendon
Can lead to Achilles tendon rupture
259
What are the risk factors for Achilles tendonitis
Unfit people who have a sudden increase in exercise levels
Poor footwear
M>F
Obesity
Fluoroquinolone use
260
How might Achilles tendonitis present
Gradual onset pain
Worse on movement
Improves with exercise and heat
Stiffness in posterior ankle
Putting pressure over tendon reproduces pain
261
How might Achilles tendon rupture present
Sudden onset severe pain
Audible popping sound
Loss of power of ankle plantarflexion
262
What are the special tests for Achilles tendon rupture
Simmond's test (squeeze calf)
Palpable step in tendon
263
What investigations are needed for Achilles tendon tears
Clinical diagnosis
Ultrasound (differentiate between complete and partial tears)
264
What is the management for Achilles tendonitis
Encourage stopping certain exercises
Ice
NSAIDs
Rehab
Physio
265
What is the management for Achilles tendon rupture
Analgesia
Immobilisation (cast)
Surgical end-to-end repair
266
What is talar fracture
Due to high energy trauma where ankle is forced into dorsiflexion
Most fractures through talar neck
Talus reliant on extraosseous blood supply (very susceptible to disruption, high risk of avascular necrosis)
267
What classification is used for talar fracture
Hawkin's classification
Type 1: undisplaced, low chance of avascular necrosis
Type 2: subtalar dislocation, medium chance of avascular necrosis
Type 3: subtalar and tibiotalar dislocation, 90-100% chance of avascular necrosis
Type 4: subtalar, tibiotalar and talonavicular dislocation, 100% chance of avascular necrosis
268
What is the management for talar fracture
Plaster
Crutches
Closed reduction
Surgery for displaced fractures
269
What is tibial pilon fracture
Severe injury of distal tibia
Due to high energy axial load
Characteristics: articular impaction, severe comminution, considerable soft tissue injury
270
Which nerves may be damaged in tibial pilon fracture
Superficial peroneal
Seep peroneal
Tibial
271
What is the classification for tibial pilon fracture
Ruedi and Allgower
Type 1 - undisplaced intraarticular
Type 2 - diaplaced intraarticular
Type 3 - comminuted or impacted
272
What is the management for tibial pilon fracture
Below-knee backslab
Elevate limb
Analgesia
Surgery
273
What is hallux valgus
Bunion
Deformity of first metatarsophalangeal joint
Characteristics: medial deviation of first metatarsal, lateral deviation of hallux, joint subluxation
274
What are the risk factors for hallux valgus
F>M
Connective tissue disorders
Hypermobility syndrome
Anatomical variant
High heels
275
How might hallux valgus present
Painful medial prominence
Aggravated by walking or standing
Lateral deviation of hallux
276
What investigations are needed for hallux valgus
X-ray (measure angle between first metatarsal and first proximal phalanx)
277
What is the management for hallux valgus
Analgesia
Proper footwear
Physio
Chevron/scarf/lapidus/keller surgical procedure
278
What is plantar fasciitis
Inflammation of plantar fascia of foot
Unilateral or bilateral
40 - 60
279
What are the risk factors for plantar fasciitis
Anatomical factors (excessive pronation, high arches)
Weak plantar flexors
Prolonged standing
Excessive running
Leg length discrepancy
Obesity
Unsupportibe footwear
280
How might plantar fasciitis present
Sharp pain across plantar aspect of foot
Most severe in heel, radiates towards arch
Worse on first few steps of the day
Tenderness on palpating medial calcaneal tubercle
281
What investigations are needed for plantar fasciitis
Clinical diagnosis
X-ray (plantar heel spur)
MRI (for ongoing uncertainty)
282
What is the management for plantar fasciitis
Activity modification
NSAIDs
Adjust footwear
Physio
Steroid injections
Plantar fasciotomy
