Orthopaedics

Question 1

Bone Composition

Answer 1

Cells - osteoblasts, osteoclasts, osteocytes, OPCs

Matrix
Organic (osteoid 40%)
 Collagen Type I
 Resists tension, twisting and bending

Inorganic (60%)
 Calcium hydroxyapatite
 Resists compressive forces

Question 2

Classification

Answer 2

Woven Bone - disorganised structure forms embryonic skeleton and fracture callus

Lamellar bone - mature bone (2 types)

• cortical/compact - dense outer layer
• Cancellous/trabecular - porous central layer

Question 3

Intramembranous Ossification

Answer 3

Direct ossification of mesenchymal bone models - formed during embryonic development

skull bones, mandible + clavicle

Question 4

Endochondral Ossification

Answer 4

Mesenchyme → cartilage → bone

Most bones ossify this way

Question 5

Fracture Healing

Answer 5

Reactive Phase (injury - 48h)

1. bleeding into # site - haematoma
2. inflammation - granulation tissue by leukos + fibroblasts

Reparative phase (2 days- 2weeks)

3. proliferation - osteoblasts + fibroblasts > cartilage + woven bone production > callus formation
4. Consolidation (endochondral ossification) of woven bone > lamellar bone

Remodelling Phase (1wk - 7yrs)
5. Remodelling of lamellar bone to cope w mechanical forces applied to it

Question 6

healing time

Answer 6

Closed, paediatric, metaphyseal, upper limb: 3wks

“Complicating factor” doubles healing time
 Adult
 Lower limb
 Diaphyseal
 Open

Question 7

Fracture Classification

Answer 7

Traumatic #

• direct (eg assault w metal bar)
• indirect (FOOSH > clavicle #)
• avulsion

Stress #

• bone fatigue due to repetitive strain
• eg foot # in marathon runners

Pathological #
- normal force, diseased bone
 Local: tumours
 General: osteoporosis, Cushing’s, Paget’s

Question 8

Describing Fractures

Answer 8

Radiographs must be orthogonal
Need Images below and above joint #

D PAID S S

Demographics
 Pt. details
 Date radiograph taken
 Orientation and content of image

Pattern
 Transverse
 Oblique
 Spiral
 Multifragmentary
 Crush
 Greenstick
 Avulsion 

Anatomical Location

Intra/extra-articular (dislocation or subluxation)

Deformity (distal relative to proximal)
 Translation
 Angulation or tilt
 Rotation
 Impaction (→shortening) 

Soft tissues
 Open or closed
 Neurovascular status
 Compartment syndrome

Specific # classification type
 Salter-Harris
 Garden
 Colles’, Smith’s, Galeazzi, Monteggia

Question 9

Management

Answer 9

4 Rs 
Resuscitation 
Reduction
Restriction
Rehabilitation

Question 10

Mx 1. Resuscitation

Answer 10

ATSL guidelines
Trauma series in 1mary survey: C-spine, chest and pelvis
# usually assessed in 2ndary survey
Assess neurovascular status + look for dislocations

Consider reduction + splinting before imaging
 ↓ pain
 ↓ bleeding
 ↓ risk of neurovascular injury

X-ray once stable

Open frature requires urgent attention

Question 11

Open fracture urgent attention

Answer 11

6As
 Analgesia: M+M
 Assess: NV status, soft tissues, photograph
 Antisepsis: wound swab, copious irrigation, cover with
betadine-soaked dressing.
 Alignment: align # and splint
 Anti-tetanus: check status (booster lasts 10yrs)
 Abx
 Fluclox 500mg IV/IM + benpen 600mg IV/IM
 Or, augmentin 1.2g IV

Mx: debridement and fixation in theatre

Question 12

Gustillo Classification of Open #s

Answer 12

1. Wound <1cm in length
2. Wound ≥1cm c¯ minimal soft tissue damage
3. Extensive soft tissue damage

Question 13

Fracture Mx 2. Reduction

Answer 13

Displaced #s should be reduced (unless no effect on outcome - ribs)
Aim for anatomical reduciton (esp if articular surfaces)
Alignment more important than opposition

Methods
- Manipulation/closed reduction
 Under local, regional or general anaesthetic
 Traction to disimpact
 Manipulation to align

-Traction
 Not typically used now.
 Employed to overcome contraction of large
muscles: e.g. femoral #s
 Skeletal traction vs. skin traction

- Open reduction (+ internal fixation)
 Accurate reduction vs. risks of surgery
 Intra-articular #s
 Open #s
 2 #s in 1 limb
 Failed conservative Rx
 Bilat identical #s

Question 14

Fracture Management 3. Restriction

Answer 14

Interfragmentary strain hypothesis > tissue formed at # site depends on strain it experiences
Fixation → ↓ strain → bone formation
Fixation also → ↓ pain, ↑ stability, ↑ ability to function

Methods
Non-Rigid - slings, elastic supports

Plaster - POP
- in first 24-48h use back slab or split cast (risk of compartment syndrome)

Functional bracing - joints free to move but bone shafts support in cast segments

Continuous traction (collar + cuff)

Ex-fix

• Fragments held in position by pins/wires > connected to external frams
• intervention is away from field of injury
• useful in open #s, burns, tissue loss to allow wound access + ↓ infection risk.
• risks pin site infections

Internal fixation

• pins, plates, screws, IM nales
• usually perfect anatomical alignment
• increase stability
• aid early mobilisation

Question 15

Mx 4. Rehabilitation

Answer 15

 Immobility → ↓ muscle and bone mass, joint stiffness
 Need to maximise mobility of uninjured limbs
 Quick return to function ↓s later morbidity

Methods
 Physiotherapy: exercises to improve mobility
 OT: splints, mobility aids, home modification
 Social services: meals on wheels, home help

Question 16

Complications (General)

Answer 16

Tissue Damage

• haemorrhage + shick
• infection
• muscle damage - rhabdomyolysis

Anaesthesia

• anaphylaxis
• damage to teeth
• aspiration

Prolonged Bed rest

• chest infection, UTI
• Pressure sores + muscle wasting
• DVT, PE
• ↓ BMD

Question 17

Complications (Specific)

Answer 17

Immediate

• neurovascular damage
• visceral damage

Early

• Compartment syndrome
• infection
• fat embolism - ARDS

Late

• problems w union
• AVN
• growth disturbance
• Post-traumatic osteoarthritis
• Complex regional pain syndromes
• Myositis ossificans

Question 18

Neuro complications

Answer 18

severance is rare, stretching over bone edge more common

Seddon classification - 3 types
neuropraxia
axonotmesis
neurotmesis

Question 19

Neuropraxia

Answer 19

temporary interruption of conduction w/o loss of axonal continuity

Question 20

Axonotmesis

Answer 20

disruption of nerve axon > distal wallerian

Question 21

neurotmesis

Answer 21

disruption of entire nerve fibre

surgery required and recovery usually incomplete

Question 22

complications - Common Palsies

Ant shoulder dislocation, humeral surgical neck

Answer 22

> Axillary nerve Palsy

Test/result
Numb chevron - weak abduction

Question 23

humeral shaft

complications - Common Palsies

Answer 23

Radial Nerve

Waiter’s tip

Question 24

complications - Common Palsies

Elbow dislocation

Answer 24

Ulnar nerve

Claw hand

Question 25

complications - Common Palsies Hip dislocation

Answer 25

Sciatic nerve foot drop

Question 26

complications - Common Palsies ``` # neck of fibula knee dislocation ```

Answer 26

fibular nerve foot drop

Question 27

Compartment Syndrome

Answer 27

Osteofacial membranes divide limbs into separate compartments of muscles. Oedema following # → ↑ compartment pressure → ↓ venous drainage → ↑ compartment pressure If compartment pressure > capillary pressure → ischaemia Muscle infarction →  Rhabdomyolysis and ATN  Fibrosis → Volkman’s ischaemic contracture

Question 28

Compartment syndrome Presentation + Rx

Answer 28

 Pain > clinical findings  Pain on passive muscle stretching  Warm, erythematous, swollen limb  ↑ CRT and weak/absent peripheral pulses Rx - elevate limb - remove all bandages + split/remove cast - fasciotomy

Question 29

``` # complications Problems with union ``` Causative factors 5 Is

Answer 29

Delayed union/Non-union of fracture Causative factors - 5 Is - Ischaemia (poor blood supply or AVN) - Infection - ↑ interfragmentary strain - Interposition of tissue between fragments - intercurrent disease - eg malignancy or malnutrition

Question 30

complications Non-union classifcation Mx Malunion

Answer 30

Non-union classification - hypertrophic - bone end rounded, dense and slerotic - atophic - bone looks osteopenic Management  Optimise biology: infection, blood supply, bone graft, BMPs  Optimise mechanics: ORIF Malunion - #healed in imperfect position  Poor appearance and/or function  E.g. Gunstock deformity

Question 31

Avascular necrosis

Answer 31

Death of bone due to deficient blood supply. Sites: femoral head, scaphoid, talus Consequence: bone becomes soft and deformed → pain, stiffness and OA. X-ray: sclerosis and deformity.

Question 32

Myositis Ossificans

Answer 32

Heterotopic ossification of muscle at sites of haematoma formation > restricted painful movements > commonly elbows + quadriceps > can be excised surgically Pellegrini-Stieda disease - form of MO - calcification of superior attachment of Medial Collateral Ligament at knee following trauma

Question 33

Hip fracture RF

Answer 33

Osteoporosis w minor trauma Major trauma RF - Age + SHATTERED ``` Steroids Hyper-para/thyroidism Alcohol + Cigarrettes Thin (BMI <22) Testosterone low Early Menopause Renal/Liver Failure Erosive/inflamed bone disease (RA, myeloma) Dietary Ca Low/ Malabsorption, DM ```

Question 34

Hip Fracture Presentation

Answer 34

O/E shortened and externally rotated ``` Qs  Mechanism  RFs for osteoporosis / pathological #  Premorbid mobility  Premorbid independence  Comorbidities  MMSE ```

Question 35

Hip Fracture Initial Mx

Answer 35

Resuscitate: dehydration, hypothermia Analgesia: M+M Assess neurovascular status of limb Imaging: AP and lateral films ``` Prep for theatre  Inform Anaesthetist and book theatre  Bloods: FBC, U+E, clotting, X-match (2u)  CXR  DVT prophylaxis: TEDS, LMWH  ECG  Films: orthogonal X-rays  Get consent ```

Question 36

Hip fracture Imaging

Answer 36

```  Ask for AP and lateral film  Look @ Shenton’s lines  Intra- or extra-capsular?  Displaced or non-displaced  Osteopaenic? ```

Question 37

Hip fracture Key Anatomy

Answer 37

Capsule attaches proximally to acetabular margin and distally to intertrochanteric line. Blood supply to fem head: 1. Retinacular vessels, in capsule, distal → prox 2. Intramedullary vessels 3. Artery of ligamentum teres. If retinacular vessels damaged there is risk of AVN of the femoral head → pain, stiffness and OA

Question 38

Hip Fracture Classification | (Garden classification

Answer 38

Intracapsular: subcapital, transcervical, basicervical Extracapsular: Intertrochanteric, subtrochanteric Garden Classification of Intracapsular Fractures 1. Incomplete #, undisplaced 2. Complete #, undisplaced 3. Complete #, partially displaced 4. Complete #, completely displaced

Question 39

Hip Fracture Surgical Mx

Answer 39

Intracapsular  1,2: Open Reduction Internal Fixation w cancellous screws  3,4: <55: ORIF c¯ screws.  f/up in OPD and do arthroplasty if AVN develops (in 30%) 55-75: total hip replacement >75: hemiarthroplasty  Mobilises: cemented Thompson’s  Non-mobiliser: uncemented Austin Moore Extracapsular  ORIF c¯ DHS

Question 40

Hip # Surgical Discharge complications Prognosis

Answer 40

Involve OT + physio Discharge when mobile + social circumstances permit Spec complications - AVN of femoral head if displaced # - Non/malunion - Infection - Osteoarthritis Prgn - 30% mortality at 1 year - 50% never regain premorbid function 10+% unable to return to premorbid residence - majority will have residual pain/disability

Question 41

Colle's Fracture

Answer 41

Falling onto outstretched hands elderly females w osteoporosis dinner fork deformity ``` Radiology xtra-articular # of dist. radius (w/i 1.5” of joint) Dorsal displacement of distal fragment Dorsal angulation of distal fragment Normally 11 degrees volar tilt ↓ radial height (norm =11mm) ↓ radial inclination (norm=22degrees) ± avulsion of ulna styloid ± impaction ```

Question 42

Colle's# Mx

Answer 42

Examine neurovascular injuries - median nerve and radial artery lie close. If displaced a lot > reduce  Under haematoma block, IV regional anaesthesia (Bier’s block) or GA.  Disimpact and correct angulation.  Position: ulnar deviation + some wrist flexion  Apply dorsal backslab: provide 3-point pressure Re- XR - ortho review if not satisfactory position (MUA w K wires) - if ok - home + #clinic w/i 48 hours for completion of POP (plaster) If comminuted, intra-articular or re-displaces - surgical fixation w ex-fix, kirschner wires or ORIF + plates

Question 43

Colle's # Spec Complications

Answer 43

```  Median N. injury  Frozen shoulder / adhesive capsulitis  Tendon rupture: esp. EPL  Carpal tunnel syn.  Mal- /non-union  Sudek’s atrophy / CRPS ```

Question 44

Smith’s / Reverse Colles’

Answer 44

 Fall onto back of flexed wrist  Fracture of distal radius c¯ volar displacement and angulation of distal fragment.  Reduce to restore anatomy and POP for 6wks

Question 45

Barton's Fracture

Answer 45

Oblique intra-articular # involving the dorsal aspect of distal radius and dislocation of radio-carpal joint Reverse Barton’s involves the volar aspect of the radius

Question 46

Scaphoid #s

Answer 46

Clinical features FOOSH (fall onto outstretched hand) Pain in anatomical snuffbox pain on telescoping thumb Mx - Request scaphoid XR view - If hx and exam > scaphoid #, initially treat even if XR normal  # may become apparent after 10d > localised decalcification. - Place wrist in scaphoid blaster (beer glass position) - if initial XR negative, pt returns to clinic after 10 days for re-XR  # visible → plaster for 6 wks  No visible # but clinically tender → plaster for 2 wks  # not visible and not clinically tender → no plaster

Question 47

Scaphoid # complications

Answer 47

AVN of scaphoid - supply runs distal to proximal | > stiffness + pain at wrist

Question 48

Radial + Ulna Shaft # Classification

Answer 48

Monteggia  # of proximal 3rd of ulna shaft  Anterior dislocation of radial head at capitellum  May → palsy of deep branch of radial nerve → weak finger extension but no sensory loss Galleazzi  # of radial shaft between mid and distal 3rds  Dislocation of distal radio-ulna joint

Question 49

Radial + Ulna Shaft #

Answer 49

Spec Mx Unstable fractures  Adults: ORIF  Children: MUA + above elbow plaster ``` Fractures of forearm should be plastered in most stable position:  Proximal #: supination  Distal #: pronation  Mid-shaft #: neutral ```

Question 50

Shoulder Dislocation Classification

Answer 50

Anterior  95% of shoulder dislocations.  Direct trauma or falling on hand  Humeral head dislocates antero-inferiorly Posterior  Caused by direct trauma or muscle contraction (seen in epileptics).

Question 51

Shoulder dislocation associated lesions

Answer 51

Bankhart Lesion - damage to anteroinferior glenoid labrum Hill-Sachs Lesion - cortical depression in posterolateral part of humeral head following impaction against glenoid rim during anterior dislocation - 35-40% anterior dislocation

Question 52

Shoulder dislocation presentation

Answer 52

 Shoulder contour lost: appears square  Bulge in infraclavicular fossa: humeral head  Arm supported in opposite hand  Severe pain

Question 53

Shoulder dislocation specific Mx

Answer 53

assess neurovasc deficit (esp axillary nerve)  Sensation over “chevron” area before and after reduction.  Occurs in 5% XR - AP and transcapular view Reduction under sedation (propafol)  Hippocratic: Longitudinal traction c¯ arm in 30O abduction and counter traction @ the axilla  Kocher’s: external rotation of adducted arm, anterior movement, internal rotation Rest Arm in sling 3-4 weeks Physio

Question 54

Shoulder Dislocation Complications

Answer 54

Recurrent dislocation - 90% pt <20yr with traumatic dislocation Axillary Nerve Injury

Question 55

Recurrent Shoulder instability

Answer 55

TUBS - Traumatic Unilateral dislocations w Bankhart lesion oft require Surgery AMBRI - Atraumatic Multidirectional Bilateral shoulder dislocation treated w Rehabilitation - may require inferior capsular shift

Question 56

Impingement Syndrome/Painful arc

Answer 56

Entrapment of supraspinatus tendon + subacromial bursa betw acromnion + greater tuberosity of humerus > subacromial bursitis +/or supraspinatous tendonitis

Question 57

Impingement Syndrome/Painful arc Presentation + Ix

Answer 57

Presents  Painful arc: 60-120 degrees  Weakness and ↓ ROM  +ve Hawkin’s test Ix  Plain radiographs: may see bony spurs  US  MRI arthrogram

Question 58

Impingement Syndrome/Painful arc Rx

Answer 58

Conservative  Rest  Physiotherapy Medical  NSAIDs  Subacromial bursa steroid ± LA injection Surgical  Arthroscopic acromioplasty

Question 59

Impingement Syndrome/Painful arc | DDx

Answer 59

 Impingement  Supraspinatous tear or partial tear  AC joint OA

Question 60

Frozen shoulder - Adhesive capsulitis

Answer 60

Progressive ↓ active and passive ROM  ↓ ext. rotation <30O  ↓ abduction <90O  Shoulder pain, esp night (can’t lie on affected side) Cause - unknwon, may follow trauma in elderly (assw DM) Rx - conservative - rest, physio - Medical - NSAIDs, subacromial bursa steroid +/- LA injection

Question 61

Rotator Cuff Tear

Answer 61

2ndary to degen or sudden jolt/fall Partial Tears > painful arc Complete tear > shoulder tip pain - full range of passive movement - inability to abduct arm - active abduction possible following passive abduction to 90 degrees - lowering arm beneath this > sudden drop (DROP ARM SIGN)

Question 62

Supracondylar fractures of the humerus Presentation

Answer 62

 Common in children after FOOSH  Elbow very swollen and held semi-flexed.  Sharp edge of proximal humerus may injure brachial artery which lies anterior to it.

Question 63

Supracondylar fractures of humerus Classification

Answer 63

Extension - Commonest type - Distal fragment displaces posteriorly - Gartland further classified extension type Gartland further classified extension type:  Type 1: non-displaced  Type 2: angulated c¯ intact posterior cortex  Type 3: displaced c¯ no cortical contact Flexion - less common - distal fragment displaces anteriorly

Question 64

Supracondylar fractures of humerus Spec Mx

Answer 64

Ensure no neurovascular damage  If radial pulse absent or damage to brachial artery suspected, URGENT theatre for reduction ± on-table angiogram.  Median nerve is also vulnerable Restore anatomy No displacement → flex the arm as fully as possible and apply a collar and cuff for 3wks – triceps acts as sling to stabilise fragments. Displacement → MUA + fixation with K-wires + collar and cuff with arm flexed for 3wks.

Question 65

Supracondylar fractures of humerus Specific Complications

Answer 65

Neurovascular Injury - Brachial artery - Radial nerve - Median nerve - esp anterior interosseus branch >supplies deep forearm felxors (FPL, lateral half of FDP and pronator quadratur) Compartment Syndrome  Monitor closely first 24h  Pain on passive extension of the fingers (stretches flexor compartment) is early sign.  Mx: try extension of the elbow, surgical Rx may be needed.  Volkmann’s ischaemic contracture can result → fibrosis of flexors → claw hand. Gunstock Deformity  Valgus, varus and rotational deformities in the coronal plane do not remodel and → cubitus varus.  Cubitus varus deformity is referred to as a “gunstock” deformity.

Question 66

Femoral + Tibial Fractures

Answer 66

``` Spec Mx - Resus + Mx life-thretening - X-match  Tibial #: 2 units  Femoral #: 4 units ``` - Assess neurovascular status (esp distal pulses) If Open - abx + ATT (tetanus?) - theatre for urgent debridement + washout + stabilisation Fixation methods - IM nail - Ex- fix - plates + screws - MUA (manipulation under anaethesia) w fixed traction for 3-4m

Question 67

Femoral + Tibial Fractures Spec Complications

Answer 67

Hypovolaemic shock Neurovascular  SFA: swelling and check pulses  Sciatic nerve Compartment syndrome Respiratory complications  Fat embolism  ARDS  Pneumonia

Question 68

Ankle Injury Ligament Strains

Answer 68

Typically twisting inversion injury  Strains anterior talofibular part of lateral collateral ligament Medial deltoid ligament strains are rare. May be assw malleolar avulsion #s

Question 69

Ankle Fracture Ottowa ankle rules

Answer 69

X-ray ankle if pain in malleolar zone + in any of:  Tenderness along distal 6cm of posterior tib / fib including posterior tip of the malleoli.  Inability to bear weight both immediately and in ED

Question 70

Ankle Fracture Weber Classification

Answer 70

Relation of fibula # to joint line  A: below joint line  B: at joint line  C: above joint line Weber’s B and C represent possible injury to the syndesmotic ligaments between tib and fib → instability

Question 71

Ankle Fracture Mx

Answer 71

Weber A  Boot or below-knee POP Non-displaced Weber B/C  Below-knee POP Displaced Weber B/C  Closed reduction and POP if anatomical reduction achieved  ORIF if closed reduction fails

Question 72

Knee Injury Hx

Answer 72

Mechanism Swelling  Immediate = haemarthrosis = # or torn cruciates  Overnight = effusion = meniscus or other lgt Pain / tenderness  Joint line = meniscal  Med/lateral margins = collateral lgts. Locking: meniscal tear → mechanical obstruction Giving way: instability following lgt. injury

Question 73

Knee haemarthrosis

Answer 73

Primary Spont Bleeding - coagulopathy, warfarin, haemophilia Secondary trauma - ACL injury 80% - Patella Dislocation 10% - Meniscal injury 10% - outer third where its vascularised - osteophyte

Question 74

Unhappy triad of O'Donoghue

Answer 74

ACL MCL Medial Meniscus

Question 75

Mx of acutely injured knee

Answer 75

Full examination of acutely swollen knee after injury is difficult.  Take x-ray to ensure no #s Fluid level indicates a lipohaemarthrosis and indicates either a # or torn cruciate. If no # → RICE + later re-examination for pathology If meniscal or cruciate injury suspected → MRI

Question 76

Arthoroscopy

Answer 76

 Direct vision of inside of knee joint by arthroscope  Can examine knee under anaesthesia (↓ muscle tone)  Meniscal tears can be trimmed or repaired.

Question 77

Mx of Ruptured ACL

Answer 77

Conservative  Rest  Physio to strengthen quads and hamstrings  Not enough stability for many sports Surgical  Gold-standard is autograft repair  Usually semitendinosus ± gracilis (can use patella tendon)  Tendon threaded through heads of tibia and femur and held using screws

Question 78

Osteoarthritis

Answer 78

Degenerative Joint disorder - progressive loss of hyaline cartilage + new bone formation at joint surface and its margin RF Age, obesity, joint abnormality Classification - Primary - no underlying cause - Secondary - obesity, joint abnormality

Question 79

Osteoarthritis Sx + Signs

Answer 79

Sx  Affects: knees, hips, DIPs, PIPs, thumb CMC  Pain: worse c¯ movement, background rest/night pain, worse @ end of day.  Stiffness: especially after rest, lasts ~30min (e.g. AM)  Deformity  ↓ ROM Signs  Pouchards (prox), Heberdips (dist.)  Thumb CMC squaring  Fixed flexion deformity

Question 80

Osteoarthritis Hx

Answer 80

```  Pain severity, night pain  Walking distance  Analgesic requirements  ADLs and social circumstances  Co-morbidities  Underlying causes: trauma, infection, congenital ```

Question 81

Osteoarthritis Path

Answer 81

Softening of articular cartilage → fraying and fissuring of smooth surface → underlying bone exposure. Subchondral bone becomes sclerotic c¯ cysts. Proliferation and ossification of cartilage in unstressed areas → osteophytes. Capsular fibrosis → stiff joints.

Question 82

Osteoarthritis XR changes

Answer 82

```  Loss of joint space  Osteophytes  Subchondral cysts  Subchondral sclerosis  Deformity ```

Question 83

Osteoarthritis Bloods

Answer 83

 CRP may be mildly elevated |  Ca, PO4 and ALP all normal

Question 84

Osteoarthritis Rx Conservative + Medical

Answer 84

MDT: GP, physio, OT, dietician, orthopod Conservative Lifestyle: ↓ wt., ↑ exercise Physio: muscle strengthening OT: walking aids, supportive footwear, home mods Medical Analgesia (paracetamol, NSAIDs, Tramol) Joint injection - local anaesthetic + steroids

Question 85

Osteoarthritis Surgical Rx

Answer 85

Arthroscopic Washout >Mainly knees >Trim cartilage >Remove loose bodies. Realignment Osteotomy >Small area of bone cut out >Useful in younger (<50yrs) pts. w medial knee OA >High tibial valgus osteotomy redistributes wt. to lateral part of joint. Arthroplasty: replacement (or excision) Arthrodesis: last resort for pain management Novel Techniques Microfracture: stem cell release → fibro-cartilage formation Autologous chondrocyte implantation

Question 86

Back pain (Mechanical Pain)

Answer 86

Soft tissue injury > dysfunction of whole spine > muscle spasm > pain May have incited event (lifting) Younger pt w no sinister features Mx - Conservative  Max 2d bed rest  Education: keep active, how to lift / stoop  Physiotherapy  Psychosocial issues re. chronic pain and disability  Warmth: e.g. swimming in a warm pool Medical  Analgesia: paracetamol ± NSAIDs ± codeine  Muscle relaxant: low-dose diazepam (short-term)

Question 87

Disc Prolapse definition + presentation

Answer 87

Herniation of nucleus pulposus through annulus fibrosus Presents  L5 and S1 roots most commonly compressed by prolapse of L4/5 and L5/S1 discs.  May present as severe pain on sneezing, coughing or twisting a few days after low back strain  Lumbago: low back pain  Sciatica: shooting radicular pain down buttock and thigh

Question 88

Disc Prolapse Signs

Answer 88

 Limited spinal flexion and extension  Free lateral flexion  Pain on straight-leg raise: Lesague’s Sign  Lateral herniation → radiculopathy  Central herniation → corda equina syndrome

Question 89

L4/5 disc prolapse > L5 root compression

Answer 89

Weak hallux extension ± foot drop  In foot drop due to L5 radiculopathy, weak inversion (tib. post.) helps distinguish from peroneal N. palsy. ↓ sensation on inner dorsum of foot

Question 90

L5/S1 disc prolapse → S1 Root Compression

Answer 90

 Weak foot plantarflexion and eversion  Loss of ankle-jerk  Calf pain  ↓ sensation over sole of foot and back of calf

Question 91

Disc Prolapse Ix + Rx

Answer 91

Ix: MRI (emergency if cauda equina) Rx  Brief rest, analgesia and mobilisation effective in ≥90%  Conservative: brief rest, mobilisation/physio  Medical: analgesia, transforaminal steroid injection  Surgical: discectomy or laminectomy may be needed in cauda-equina syndrome, continuing pain or muscle weakness.

Question 92

Lumbar Microdisectomy

Answer 92

 Commonest procedure for disc prolapse  Microscopic resection of the protruding nucleus pulposus  Posterior approach c¯ pt. in prone position.  May be performed endoscopically

Question 93

Spondylolisthesis

Answer 93

Displacement of one lumbar vertebra on another - usually forward - usually L5 on S1 May be palpable Causes - congen malf, spondylosis, OA Presentation - onset of pain usually in adolescence or early adulthood > worse on standing +/- sciatica, hamstring tightness, abn gait Dx - Plain Radiography Rx - Corset, nerve release, spinal fusion

Question 94

Spinal Stenosis

Answer 94

Dev predisposition +/- facet joint OA > generalised narrowing of lumbar spinal canal ``` Presents Spinal Claudication - aching or heavy buttock and lower limb pain on walking - Rapid onset - May c/o paraesthesiae/numbness - Pain eased by leaning forward ``` Pain on spine extension Ix - MRI Rx - Corsets NSAIDs Epidural steroid injection Canal decompression surgery

Question 95

Neurosurgical Emergencies Acute Cord Compression

Answer 95

 Bilateral pain: back and radicular  LMN signs at compression level  UMN signs and sensory level below compression  Sphincter disturbance

Question 96

Neurosurgical Emergencies Acute Cauda Equina Compression

Answer 96

Alternate or bilateral radicular pain in legs Saddle anaesthesia Loss of anal tone Bladder +/- bowel incontinence

Question 97

Neurosurgical emergencies Rx Acute cord compression and Acute cauda equina compression

Answer 97

Large prolapse - laminectomy/disectomy Tumours - radiotherapy and steroids Abscesses - decompression

Question 98

Osteochondritis

Answer 98

idiopathic condition > bony centres of children/adolescents become temporarily softened due to osteonecrosis Pressure > deformation Bone hardens in new deformed position Radiography - intially ^density/sclerosis - then patchy appearance

Question 99

Osteochondritis Scheuermann's Disease

Answer 99

Vertebral ring epiphyses AD Vertebral Tenderness + kyphosis XR - wedge-shaped thoracic vertebra

Question 100

Osteochondritis Kohler's Disease

Answer 100

Navicular Bone Children 3-5 years Pain in mid-tarsal region > limp

Question 101

Osteochondritis Kienbochs Disease

Answer 101

Lunate bone Adults Pain over lunate, esp on active movement impaired grip

Question 102

Osteochondritis Friedberg's Disease

Answer 102

2nd/3rd metatarsal heads around puberty forefoot worse w pressure

Question 103

Osteochondritis Panner's Disease Perthe's Disease

Answer 103

Panner's - Capitulum of humerus Perthe's - hip

Question 104

Traction Apophysitis Osgood-Shlatter's

Answer 104

Tibial tuberosity apophysitis + patellar tendonitis Children 10-14 years M>F 3:1 Assw physical activity Sx - pain below knee, esp w quads contraction XR - tuberosity enlargement +/- fratmentation Rx - rest, consider POP

Question 105

Traction Apophysitis Sinding Larsen's Disease

Answer 105

 Tranction tendinopathy with calcification of proximal attachment of patellar tendon  Children 8-10yrs

Question 106

Traction Apophysitis Sever's Disease

Answer 106

Calcaneal apophysitis 8-13 years Sx - pain behind heal + limping Rx - physio

Question 107

Osteochondritis Dissecans

Answer 107

Piece of bone + overlying cartilage dissects off into joint space Commonly knee (Med fem condyle), also elbow, hip , ankle Young adult/adolescent Sx - pain, swelling, locking, decreased ROM XR - loose bodies, lucent crater Mx arthroscopic removal

Question 108

Avascular necrosis

Answer 108

``` # or dislocation SCD, thallassaemia SLE Gaucher's Drugs - steroids, NSAIDs ```

Question 109

Acute Osteomyelitis Pathophysiology

Answer 109

Source - local or haematogenous ``` RF Vascular disease Trauma SCD (sickle cell) Immunosuppression (e.g. DM) Children  Rich blood supply to growth plate  :. usually affects metaphysis ``` ``` Organisms  Staph  Strep  E. coli  Pseudomonas  Salmonella (in SCD) ```

Question 110

Acute Osteomyelitis Sx + Signs Ix Mx

Answer 110

Symptoms and Signs  Pain, tenderness, erythema, warmth, ↓ROM  Effusion in neighbouring joints  Signs of systemic infection Investigations  ↑ESR/CRP, ↑WCC  +ve blood cultures in 60% ``` X-ray:  Changes take 10-14d  Haziness + ↓ bone density  Sub-periosteal reaction  Sequestrum and involucrum ``` MRI is sensitive and specific Management  IV Abx: Vanc + cefotaxime until MCS known  Drain abscess and remove sequestra  Analgesia

Question 111

Septic Arthritis Pathyphysiology

Answer 111

Source: local or haematogenous. ``` RFs  Joint disease (e.g. RA)  CRF  Immunosuppression (e.g. DM)  Prosthetic joints ``` ``` Organisms  Staph: 60%  Streps  Gonococcus  Gm-ve bacilli ```

Question 112

Septic Arthritis Sx + Ix

Answer 112

Symptoms  Acutely inflamed tender, swollen joint.  ↓ROM  Systemically unwell ``` Investigations  Joint aspiration for MCS  ↑↑ WCC (e.g. >50,000/mm3) : mostly PMN  ↑ESR/CRP, ↑WCC, Blood cultures  X-ray ```

Question 113

Septic Arthritis Mx + Complications

Answer 113

``` Management  IV Abx: vanc + cefotaxime  Consider joint washout under GA  Splint joint  Physiotherapy after infection resolved ``` Complications  Osteomyelitis  Arthritis  Ankylosis: fusion

Question 114

High (C5/6): Erb’s Palsy

Answer 114

abductors + external rotators paralysed waiter's tip position Loss of sensation in C5/6

Question 115

Low C8/T1: Klumpke's Paralysis

Answer 115

Paralysis of small hand muscles Claw hand Loss of senstaion in C8/T1 Dermatomes

Question 116

Radial Nerve C5-T1 injury

Answer 116

Low lesions - posterior interosseous nerve  Site: # around elbow or forearm (eg #head of radius)  Loss of extension of CMC joints (finger drop)  No sensory loss High Lesions  Site: # shaft of humerus where N. is in radial groove.  Wrist drop  Loss of sensation to dorsum of thumb root (snuff box)  Triceps functions normally Very High Lesions  Site: axilla – e.g. crutches or Sat night palsy  Paralysis of triceps and wrist drop

Question 117

Ulnar nerve C8-T1 injury

Answer 117

Site  Elbow: cubital tunnel  Wrist: in Guyon’s Canal Effects  Intrinsic hand muscle paralysis → claw hand  Ulnar paradox: lesion at elbow has less clawing as FDP is paralysed, decreasing flexion of 4th/5th digits.  Weakness of finger ad/abduction (interossei)  Sensory loss over little finger Tests  Can’t cross fingers for luck  Froment’s Sign: flexion of thumb IPJ when trying to hold onto paper held between thumb and finger.  Indicates weak adductor policis.

Question 118

Median Nerve C5-T1 Damage

Answer 118

Injury Above the Antecubital Fossa  Can’t flex index finger IPJs (e.g. on clasping hands)  Can’t flex terminal thumb phalanx (FPL)  Loss of sensation in median distribution Injury at the Wrist  Typically affects abductor pollicis brevis Carpal Tunnel Syndrome

Question 119

Carpal Tunnel Syndrome Anatomy

Answer 119

Carpal tunnel formed by flexor retinaculum and carpal bones. ``` Contains  4 tendons of FDS  4 tendons of FDP  1 tendon of FPL  Median N. ```  Median N. supplies LLOAF (aBductor pollicis brevis)  Palmer cutaneous branch travels superficial to flexor retinaculum → spares sensation over thenar area

Question 120

Causes of carpal tunnel syndrome

Answer 120

F>M Primary/idiopathic ``` Secondary  Water: pregnancy, hypothyroidism  Radial #  Inflammation: RA, gout  Soft tissue swelling: lipomas, acromegaly, amyloidosis  Toxic: DM, EtOH ```

Question 121

Carpal Tunnel Sx + Signs

Answer 121

Symptoms  Tingling / pain in thumb, index and middle fingers  Pain worse @ night or after repetitive actions  Relieved by shaking / flicking  Clumsiness ``` Signs  ↓ sensation over lateral 3½ fingers  ↓ 2-point touch discrimination  Early sign of irreversible damage  Wasting of thenar eminence > Late sign of irreversible damage  Phalen’s flexing and Tinel’s tapping ```

Question 122

Carpal Tunnel Syndrome Ix, Non-surgical Mx

Answer 122

Ix  Not usually performed  Nerve conduction studies  US ``` Non-surgical Mx  Mx of underlying cause Wrist splints  Neutral position  Esp. @ night Local steroid injections ```

Question 123

Carpal Tunnel Syndrome Surgical Mx + complications

Answer 123

Carpal tunnel decompression by division of the flexor retinaculum Complications  Scar formation: high risk for hypertrophic or keloid  Scar tenderness: up to 40% Nerve injury  Palmar cutaneous branch of the median nerve  Motor branch to the thenar muscles Failure to relieve symptoms

Question 124

Carpal Tunnel Syndrome Other Locations of Median Nerve Entrapment

Answer 124

Pronator syndrome  Entrapment between two heads of pronator teres Anterior interroseous syndrome > Compression of the anterior interosseous branch by the deep head of pronator teres > Muscle weakness only  Pronator quadratus  FPL (flexor pollicis longus)  Radial half of FDP

Question 125

Dupuytren’s Contracture

Answer 125

Progressive, painless fibrotic thickening of palmar fascia. ``` The Patient  M>F  Middle age / elderly  Skin puckering and tethering  Fixed flexion contracture of ring and little fingers  Often bilateral and symmetrical  MCP and IP joint flexion ```

Question 126

Dupuytren's Contracture Associations

Answer 126

``` BAD FIBERS  Bent penis: Peyronies (3%)  AIDS  DM  FH: AD  Idiopathic: commonest  Booze: ALD  Epilepsy and epilepsy meds (phenytoin) ``` ``` Reidel’s thyroiditis and other fibromatoses  Ledderhose disease >Fibrosis of plantar aponeurosis >5% c¯ dupuytren’s  Retropitoneal fibrosis ```  Smoking

Question 127

Dupuytren's Contracture Mx

Answer 127

Conservative: e.g. physio / exercises Fasciectomy  e.g. when hand can’t be placed flat on the table.  Z-shaped scars: prevent contracture  Can damage ulnar nerve  Usually recurs Differential  Skin contracture: old laceration or burn Differential  Skin contracture: old laceration or burn  Tendon fibrosis, trigger finger  Ulnar N. palsy

Question 128

Trigger Finger

Answer 128

 Tendon nodule which catches on proximal side of tendon sheath → triggering on forced extension.  → Fixed flexion deformity  Usually ring and middle fingers  assw RA  Rx: steroid injection (high recurrence) or surgery

Question 129

Ganglion definition + presentation

Answer 129

 Smooth, multilocular cystic swellings  Mucoid degeneration of joint capsule or tendon sheath  May be in communication w joint capsules / tendons Presentation  90% located on dorsum of wrist. Subdermal, fixed to deeper structures.  Limits planes of movement May cause pain or nerve pressure symptoms

Question 130

Ganglion Mx + differential

Answer 130

Management  50% disappear spontaneously  Aspiration ± steroid and hyaluronidase injection  Surgical excision Differential  Lipoma  Fibroma  Sebaceous cyst

Question 131

Meralgia paraesthetica

Answer 131

Entrapment of lat cutaneous nerve of thigh betw ASIS + inguinal ligament Pain +/- paraesthesia on lateral thigh No motor deficit ↑ risk w obesity: compression by belts, underwear  Relieved by sitting down Can occasionally be damaged in lap hernia repair

Question 132

Chondromalacia Patellae

Answer 132

Predominantly young women Patellar aching after prolonged sitting or climbing stairs Pain on patellofemoral compression: Clarke’s test Ix: no abnormality on X-ray Rx: vastus medialis strengthening

Question 133

Baker's Cyst

Answer 133

Popliteal swelling arising betw the medial head of gastrocnemius and semimembranosus muscle Herniation from joint synovium  Usually 2ndary to OA Rupture: acute calf pain and swelling  DVT differential

Question 134

Hallux Valgus

Answer 134

Great toe deviates laterally @ MTP joint Pressure of MTP against shoe → bunion ↑ wt. bearing @ 2nd metatarsal head  → pain: “Transfer metatarsalgia”  → hammer toe Aetiology  Pointed shoes  Wearing high heals Mx  Conservative: bunion pads, plastic wedge between great and second toes.  Surgical: metatarsal osteotomy

Question 135

Morton's Metatarsalgia/neuroma

Answer 135

Pain from pressure on an interdigital neuroma between the metatarsals. Pain radiates to medial side of one toe and lateral side of another. Rx: neuroma excision