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Finals > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

Risk factors for mechanical lower back pain

A
  • Smoking
  • Increasing age
  • Pre-existing chronic widespread pain
  • High levels of psychological distress
  • poor self-related health
  • dissatisfaction with work
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2
Q

Causes of mechanical lower back pain

A
  • Lumbar disc prolapse
  • Osteoarthritis
  • Fractures
  • Spondylolisthesis
  • Heavy manual handling
  • Stooping and twisting whilst lifting
  • Exposure to whole body vibration
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3
Q

Presentation of mechanical lower back pain

A
  • Sudden onset back pain and stiffness
    o Pain worse in evening and during exercise
    o Morning stiffness absent
    o Relieved by rest
  • Scoliosis may be present when standing = spine twists and curves to side
  • Muscular spasm visible and palpable
  • Causes local unilateral pain and tenderness
  • Episodes generally short-lived and self-limiting
  • Once had one, increased risk of further back pain episodes
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4
Q

Red flags for mechanical lower back pain

A
  • Starts before age of 20 or over 50
  • Persistent and serious cause is suspected
  • Worse at night/in morning, when inflammatory arthritis = e.g. ankylosing spondylitis, infection or spinal tumour
  • Associated with systemic illness, fever or weight loss
  • Associated with neurological symptoms/signs
  • Hx of previous malignancy
  • Hx of trauma
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5
Q

Investigations of mechanical lower back pain

A
  • Spinal x-rays if red flags
  • MRI more preferable than CT = Better for bone pathology
  • Bone scans
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6
Q

Management of mechanical lower back pain

A
  • Urgent neurosurgical referral if any neurological deficit
  • Analgesia (paracetamol), NSAIDs (ibuprofen), codeine
  • Combined with physiotherapy, back muscle training regimens and manipulation
  • Acupuncture helps some
  • Excessive rest avoided
  • Re-education in lifting and exercises to prevent further attacks of pain
  • Comfortable sleeping position using mattress of medium firmness
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7
Q

Presentation of S1 root lesion

A

o Pain = buttock down back of thigh to ankle/foot
o Sensory loss posterolateral aspect of leg and lateral aspect of foot
o Weakness in plantar flexion of foot
o Reduced ankle reflex
o Positive sciatic nerve stretch test
o Diminished straight leg raising

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8
Q

Presentation of L5 root lesion

A

o Pain = buttock to lateral aspect of leg and top of foot
o Sensory loss dorsum of foot
o Weakness in foot and big toe dorsiflexion
o Reflexes intact
o Positive sciatic nerve stretch test
o Diminished straight leg raising

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9
Q

Presentation of L4 root lesion

A

o Pain = lateral aspect of thigh to medial side of calf
o Sensory loss anterior aspect of knee and medial malleolus
o Weak knee extension and hip adduction
o Reduced knee reflex
o Positive femoral stretch test

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10
Q

Presentation of L3 root lesion

A

o Sensory loss over anterior thigh
o Weak hip flexion, knee extension and hip adduction
o Reduced knee reflex
o Positive femoral stretch test

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11
Q

Management of acute disc degeneration

A
  • Acute stage
    o Bed rest on firm mattress
    o Analgesia  NSAIDs
    o Epidural corticosteroid injection
  • If Sx persisist after 4-6 weeks then referral for MRI if surgery considered
  • Surgery
    o Only for severe or increasing neurological impairment = foot drop or bladder symptoms
    o Physio in recovery phase = help correct posture and restore movement
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12
Q

Types of hip dislocation

A
  • Posterior dislocation (90%) = Affected leg is shortened, adducted and internally rotated
  • Anterior dislocation = Affected leg abducted and externally rotated, no leg shortening
  • Central dislocation
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13
Q

Management of hip dislocation

A
  • ABCDE
  • Analgesia
  • Reduction under GA within 4 hrs
  • Long-term Mx: physio to strengthen surrounding muscles
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14
Q

Complications of hip dislocation

A
  • Sciatic or femoral nerve injury
  • Avascular necrosis
  • Osteoarthritis
  • Recurrent dislocation
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15
Q

Presentation of hip fracture

A
  • Pain
  • Shortened and externally rotated leg
  • May be able to weight bear (non-displaced or incomplete NOF fractures)
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16
Q

Location of hip fracture

A
  • Intracapsular – from edge of femoral head to insertion of capsule of hip joint
  • Extracapsular – trochanteric or subtrochanteric
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17
Q

Classification of hip fracture

A

Garden system
- Type I = stable fracture with impaction in valgus
- Type II = complete fracture but undisplaced
- Type III = displaced fracture, usually rotated and angulated but still has bony contact
- Type IV = complete bony disruption

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18
Q

Management of intracapsular hip fracture

A

o Undisplaced = internal fixation or hemiarthroplasty
o Displaced = arthroplasty or hemiarthroplasty
 Total hip replacement if able to walk independently, not cognitively impaired and medically fit for anaesthesia and procedure

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19
Q

Management of extracapsular hip fracture

A

o Stable intertrochanteric = dynamic hip screw
o Reverse oblique, transverse or subtrochanteric = intramedullary device

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20
Q

Complication of hip fracture

A

Avascular necrosis

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21
Q

Causes of lateral epicondylitis

A
  • House painting
  • Tennis
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22
Q

Presentation of lateral epicondylitis

A
  • Pain and tenderness localised to lateral epicondyle
  • Pain worse on wrist extension against resistance with elbow extended or suprination of forearm with elbow extended
  • Episodes last 6m-2y
  • Acute pain for 6-12 wks
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23
Q

Management of lateral epicondylitis

A
  • Advice on avoiding muscle overload
  • Simple analgesia
  • Steroid injection
  • Physiotherapy
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24
Q

Features of ACL injury

A

o Sporting injury
o High twisting force applied to bent knee
o Sudden popping sound
o Knee swelling (haemoarthrosis)
o Poor healing
o Instability, feeling knee will give way
o Anterior draw test
o Lachman’s test
o Mx: intense physio or surgery

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25
Q

Features of PCL injury

A

o Hyperextension injuries
o Tibia lies back on femur
o Paradoxical anterior draw test

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26
Q

Features of MCL injury

A

o Leg forced into valgus via force outside leg
o Knee unstable when put into valgus position

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27
Q

Features of meniscal lesion

A

o Rotational sporting injuries
o Delayed knee swelling
o Joint locking
o Recurrent episodes of pain and effusions, often following minor trauma

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28
Q

Features of chondromalacia patellae

A

o Teenage girls, following injury to knee
o Pain on going down stairs or at rest
o Tenderness
o Quadriceps wasting

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29
Q

Features of patella dislocation

A

o Traumatic primary event
o RF: Genu valgum, tibial torsion, high riding patella
o Skyline XR of patella

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30
Q

Features of a tibial plateau fracture

A

o Elderly
o Knee forced into valgus or varus but knee fractures before ligaments rupture
o Schatzker system classification

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31
Q

Epidemiology of adhesive capsulitis (frozen shoulder)

A

Middle-aged females

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32
Q

Association of adhesive capsulitis

A

Diabetes

33
Q

Presentation of adhesive capsulitis

A
  • Shoulder pain and stiffness develops over days
  • External rotation is affected more than internal rotation or abduction
  • Both active and passive movement is affected
  • Painful freezing phase, adhesive phase and recovery phase
  • Bilateral in up to 20%
  • Episode last 6m-2y
34
Q

Management of adhesive capsulitis

A
  • NSAIDs
  • Physio
  • Oral corticosteroids
  • Intra-articular corticosteroids
35
Q

Definition of ankle sprain

A
  • Stretching, partial or complete tear of ligament
  • High ankle sprains  syndoesmosis
  • Low ankle sprains  lateral collateral ligaments
36
Q

Presentation of ankle sprain

A
  • Low ankle
    o Most common with injury to ATFL
    o Inversion injury most common mechanism
    o Pain, swelling, tenderness over affected ligaments and sometimes bruising
    o Patients usually able to weight bear unless severe
  • High ankle sprains
    o Injuries t syndesmosis are rare and severe
    o Mechanism usually external rotation of foot causing talus to push tibula laterally
    o Weight-bearing painful
    o Hopkin’s squeeze test  Pain when tibia and fibula squeezed together at level of mid calf
37
Q

Investigations of ankle sprain

A
  • Low ankle
    o Radiographs
    o MRI if persistent pain and useful for evaluating perineal tendons
  • High ankle
    o Radiographs  widening of tibiofibular joint or ankle mortise
    o MRI if high suspicion of syndesmotic injury but normal plain films
38
Q

Management of ankle sprain

A
  • Low ankle
    o Non-operative with RICE
    o Removal orthosis, cast and/or crutches for ST Sx relief
  • High ankle
    o If no diastasis then non-weight bearing orthosis or cast until pain subsides
    o If diastasis or failed non-operative MX then operative fixation
39
Q

What is a colles fracture

A

Distal radius fracture with dorsal displacement of fragments

40
Q

Presentation of colles fracture

A
  • Fall onto outstretched hand (FOOSH)
  • Dinner fork type deformity
41
Q

XR findings of colles fracture

A

transverse fracture of radius, 1 inch proximal to radio-carpal joint, dorsal displacement and angulation

42
Q

Early complications of colles fracture

A

o Median nerve injury  carpal tunnel syndrome
o Compartment syndrome
o Vascular compromise
o Malunion
o Rupture of extensor pollicis longus tendon

43
Q

Late complications of colles fracture

A

Osteoarthritis, Complex regional pain syndrome

44
Q

Cause of scaphoid fracture

A
  • FOOSH
  • Contact sports
  • Road traffic accident
45
Q

Presentation of scaphoid fracture

A
  • Pain along radial aspect of wrist, at base of thumb
  • Loss of grip/pinch strength
  • Point of maximal tenderness over anatomical snuffbox
  • Wrist joint effusion
  • Pain elicited by telescoping of thumb  pain on longitudinal compression
  • Tenderness of scaphoid tubercle
  • Pain on ulnar deviation of wrist
46
Q

Investigations of scaphoid fracture

A
  • XR of wrist
  • CT scan
  • MRI  definitive
47
Q

Management of scaphoid fracture

A
  • Immobilisation with Futuro splint or standard below-elbow backslab
  • Referral to ortho
    o Displaced fractures  cast for 6-8 wks
    o Displaced scaphoid wrist and proximal scaphoid pole fractures  surgical fixation
48
Q

Complications of scaphoid fracture

A
  • Avascular necrosis of scaphoid
  • Non-union  pain and early osteoarthritis
49
Q

What is compartment syndrome

A

Complication following fractures characterised by raised pressure within a closed anatomical space

50
Q

Causes of compartment syndrome

A
  • Supracondylar fractures
  • Tibial shaft injuries
51
Q

Presentation of compartment syndrome

A
  • Pain, especially on movement, Excessive use of breakthrough analgesia
  • Parasthesiae
  • Pallor
  • Arterial pulsation may still be felt
  • Paralysis of muscle group
52
Q

Investigations of compartment syndrome

A

Intracompartmental pressure measurements  >40mmHg diagnostic

53
Q

Management of compartment syndrome

A
  • Prompt and extensive fasciotomies
  • Aggressive IV fluids
54
Q

Complications of compartment syndrome

A
  • Death of muscle groups within 4-6 hrs
  • Myoglobinuria
55
Q

Causes of carpal tunnel syndrome

A
  • Idiopathic
  • Pregnancy
  • Oedema (heart failure)
  • Lunate fracture
  • Rheumatoid arthritis
56
Q

What is carpal tunnel syndrome

A

Compression by median nerve in carpal tunnel

57
Q

Presentation of carpal tunnel syndrome

A
  • Pain/pins and needles in thumb, index, middle finger
  • Symptoms may ‘ascend’ proximally
  • Shakes hand for relief, classically at night
  • Weakness of thumb abduction (abductor pollicis brevis)
  • Wasting of thena eminence
  • Tinel’s sign  tapping causes paraesthesia
  • Phalen’s sign  flexion of wrist causes symptoms
58
Q

Investigations of carpal tunnel syndrome

A

Electrophysiology  motor + sensory prolongation of action potential

59
Q

Management of carpal tunnel syndrome

A
  • 6 week trial of wrist splints ± corticosteroid injection
  • Surgical decompression.  flexor retinaculum division
60
Q

Smith’s fracture

A

o Reverse of colles’ fracture
o Caused by falling backwards onto palm of outstretched hand or falling with wrists flexed

61
Q

Barton’s fracture

A

o Distal radius fracture with associated radiocarpal dislocation
o Fall onto extended and pronated wrist

62
Q

Bennett’s fracture

A

o Intra-articular fracture at base of thumb metacarpal
o Impact on flexed metacarpal, caused by fist fights
o XR  triangular fragment at base of metacarpal

63
Q

Monteggia’s. fracture

A

o Dislocation of proximal radioulnar joint in association with ulna fracture
o FOOSH with forced pronation
o Needs prompt diagnosis to avoid disability

64
Q

Galeazzi fracture

A

o Radial shaft fracture with associated dislocation of distal radioulnar joint
o Occur after fall on hand with rotational force superimposed on it
o Bruising, swelling and tenderness over lower end of foreaem
o XR  displaced fracture of radius and prominent ulnar head due to dislocation of inferior radio-ulnar joint

65
Q

Radial head fracture

A

o Common in young adults
o Usually caused by FOOSH
o Marked local tenderness over head of radius, impaired movements at elbow and sharp pain at lateral side of elbow at extremes of rotation (pronation and supination)

66
Q

Types of rotator cuff injury

A
  • Subacromial impingement (painful arc syndrome)
  • Calcific tendonitis
  • Rotator cuff tears
  • Rotator cuff arthropathy
67
Q

Presentation of rotator cuff injuries

A
  • Shoulder pain worse on abduction
    o painful arc between 60 and 120 degrees)
    o pain in first 60 degree in rotator cuff tears
  • Tenderness over anterior acromion
68
Q

Primary causes of iliopsoas abscess

A

Staph aureus

69
Q

Secondary causes of iliopsoas abscess

A

o Crohn’s
o Diverticulitis, colorectal cancer
o UTI, GU cancers
o Vertebral osteomyelitis
o Femoral catheter, lithotripsy
o Endocarditis
o IVDU

70
Q

Presentation of iliopsoas abscess

A
  • Fever, weight loss
  • Back/flank pain
  • Limp
  • Hyperextension of hip elicits pain
71
Q

Investigation of iliopsoas abscess

A

CT abdo

72
Q

Management of iliopsoas abscess

A
  • Abx
  • Percutaneous drainage
  • Surgery if failure of percutaneous drainage or prescence of antoher intra-abdominal pathology which requires surgery
73
Q

What is a baker’s cyst

A

Not true cysts but distension of gastrocnemius-semimembranosus bursa

74
Q

Causes of baker’s cyst

A
  • Primary = no underlying pathology, typically seen in children
  • Secondary = osteoarthritis, typically seen in adults
75
Q

Presentation of baker’s cyst

A
  • Swellings in popliteal fossa behind knee
  • Rupture = pain, redness and swelling in calf
76
Q

Management of baker’s cyst

A
  • Children = normally resolve so no treatment
  • Adults = treat underlying cause
77
Q

What is osteochondritis dissecans

A

Pathological process affecting subchondral bone with secondary effects on joint cartilage

78
Q

Presentation of osteochondritis dissecans

A
  • Subacute onset of knee pain and swelling, typically after exercise
  • Knee catching, locking and/or giving way
  • Feeling a painful ‘clunk’ when flexing or extending knee
  • Joint effusion
  • Tenderness on palpation of articular cartilage of medial femoral condyle, when knee is flexed
  • Wilson’s sign for detecting medial condyle lesion
79
Q

Investigations of osteochondritis dissecans

A
  • XR  subchondral crescent sign or loose bodies
  • MRI  evaluate cartilage, visualise loose bodies, stage and assess stability of lesion

Finals (23 decks)

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