Orthopaedics Flashcards
(156 cards)
1
Q
What is subluxation?
A
Incomplete or partial dislocation
2
Q
What three injuries comprise the unhappy triad?
A
- ACL tear
- MCL tear
- Medial meniscal tear
3
Q
Why is the medial meniscus more commonly injured than the lateral meniscus?
A
It is relatively immobile, being attached to the MCL and joint capsule
4
Q
Why is the ACL more commonly torn than the PCL?
A
The PCL is shorter and stronger
5
Q
On physical examination, what manoeuvre will reproduce the pain of Osgood-Schlatter disease?
A
Knee extension against resistance
6
Q
Explain the pathophysiology of Osgood-Schlatter disease
A
- The tibial tuberosity develops separately from the proximal tibia
- Normally it ossifies with the tibia
- With repeated tension on the patellar ligament, the tuberosity avulses
- This avulsed fragment continues to grow and the intervening space fills with new bone or connective tissue
7
Q
What is osteochondritis dissecans?
A
Necrosis of subchondral bone in which a bone-cartilage fragment detaches and becomes displaced in the joint space
8
Q
A popping and locking sensation in the knee is characteristic of an injury to which structure?
A
Menisci
9
Q
What is the most sensitive and specific test for meniscal tears?
A
Thessaly test
Clicking/locking/catching with rotation
10
Q
What is the characteristic MRI finding of a meniscal tear?
A
Hyperdense line
11
Q
What are the 6 P’s of acute limb ischaemia?
A
- Pain
- Pallor
- Paraesthesias
- Poikilothermia (inability to regulate temperature)
- Pulselessness
- Paralysis
12
Q
What is the major complication of acute forearm compartment syndrome?
A
Volkmann contracture
13
Q
What upper limb injury is particularly prone to the development of a Volkmann contracture?
A
Fractures around the elbow, particularly supracondylar humeral fractures due to compression of the brachial artery
14
Q
Which nerve is most commonly affected by compartment syndrome in the lower limb?
A
Deep peroneal nerve
15
Q
What are the 5 types of Salter-Harris fractures?
A
- S - straight across
- A - above
- L - lower
- T - through/two
- ER - Erasure
16
Q
When in a child’s life are Salter-Harris fractures most common?
A
Growth spurts at the beginning of puberty
11-12 for females
12-14 for males
17
Q
Where on a bone is the metaphysis, epiphysis and physis?
A
18
Q
What is the difference between adult and child periosteum and what is the clinical significance of this in terms of fractures?
A
Children have thicker and stronger periosteum
- Limits fracture displacement
- Reduces the likelihood of open fractures
- Maintains fracture stability
19
Q
What type of collagen predominates in bone?
A
I
20
Q
What is an avulsion fracture?
A
Injury to the bone in a location where a tendon or ligament attaches to bone
The tendon or ligament pulls of a piece of the bone
21
Q
What is a comminuted fracture?
A
More than 2 fracture fragments
22
Q
What is a segmental fracture?
A
A type of comminuted fracture in which a completely separate segment of bone is bordered by fracture lines
23
Q
What is a greenstick fracture?
A
Bone that is bent with a fracture line that does not extend completely through the width of the bone
(common in children)
24
Q
What is a torus/buckle fracture?
A
Incomplete fractures of the shaft of a long bone that is characterised by bulging of the cortex. They result from trabecular compression from an axial loading force along the long axis of the bone.
25
List 3 potential complications of a fracture at the surgical neck of the humerus
1. Axillary nerve damage
2. Posterior circumflex humeral artery damage → necrosis of the humeral head
3. Suprascapular nerve damage
4. Adhesive capsulitis
26
What is the major complication of humeral shaft fractures?
Radial nerve damage
| (triceps muscle is spared)
27
What is a Galeazzi fracture?
Radius fracture + dislocation of the distal radioulnar joint
28
What is a Smith fracture?
Palmar displacement of the distal radius fragment
29
What is a Monteggia fracture?
Ulna fracture + dislocation of the radial head
30
What test is used the assess the function of the supraspinatus?
Empty can test/Jobe's test
31
What test is used to assess the function of the infraspinatus?
External rotation against resistance
32
What test is used to assess the subscapularis?
Internal rotation against resistance
33
What test can be used to assess the function of the teres minor?
Position the arm in 90° of abduction and bend the elbow to 90°
Passively externally rotate the shoulder to its maximum degree
34
During shoulder abduction, pain through during which arc is suggestive of glenohumeral impingement?
60-120 degrees
35
During shoulder abduction, pain through during which arc is suggestive of acromioclavicular impingement?
170-180
May also be due to osteoarthritis
36
Which two test can be used to assess a biceps tendon rupture?
Speed's test - elbow flexion against resistance
Yergason's test - forearm supination against resistance
37
What is the sail sign?
Wide anterior fat pad
Suggests an occult fracture (hidden, does not appear clearly on x-ray)
38
What is the significance of a posterior fat pad on an x-ray of the elbow?
Suggests an effusion caused by significant trauma
39
What is neuropraxia?
Temporary loss of nerve function due to compression/stretch of the nerve. There is no structural damage to the nerve, but to the myelin sheath
40
Which branch of the median nerve is most commonly injured in supracondylar humeral fractures?
Anterior interosseous (AION)
41
What are the features of an injured anterior interosseous nerve?
No sensory changes (AION lacks a superficial sensory component)
Hand weakness, weak "OK" sign
Proximal forearm pain
42
How are supracondylar humeral fractures graded?
I. Undisplaced
II. Angulated with intact posterior cortex
III. Displaced distal fragment posteriorly with no cortical contact
43
What does radial head malalignment on x-ray suggest?
*Radial head should point towards the capitellum*
Lateral condylar fracture
Monteggia fracture
44
What is the significance of the anterior humeral line in x-rays of supracondylar humeral fractures?
In a normal elbow, a line drawn through the anterior cortex of the humerus intersects the capitellum in its middle third
The anterior humeral line passes through the anterior third of the capitellum or fails to intersect it if the humerus is posteriorly displaced
45
How are ligamentous injuries of the knee graded?
1. No tear, no instability
2. Partial tear, reduced stability
3. Complete tear, poor stability
46
Which tendons are most commonly used as native grafts for ACL tears?
Patellar tendon
Hamstring tendon
Quadriceps tendon
47
How do you differentiate rotator cuff impingement from a tear?
Tears are associated with weakness
48
What are the 5 Ottowa knee rules?
A knee x-ray series is only required for knee injury patients with any of these findings:
1. Age 55 or older
2. Isolated tenderness of the patella
(No bone tenderness of knee other than patella)
3. Tenderness of the head of the fibula
4. Cannot flex to 90 degrees
5. Unable to bear weight both immediately and in the emergency room department for 4 steps
(Unable to transfer weight twice onto each lower limb regardless of limping)
49
What is the management for a rotator cuff tear \< 50% of the tendon's thickness?
Arthroscopic debridement
50
What is the management for a rotator cuff tear \>50% of the tendon's thickness?
Arthroscopic repair (sutures)
51
How do you perform the Hawkin's Kennedy test?
The clinical stabilises the shoulder with one hand and, with the patient's elbow flexed at 90 degrees, internally rotates the shoulder using the other hand
Pain = positive test
*Assesses shoulder impingement*
52
What are 3 potential complications of a proximal humeral fracture?
1. Avascular necrosis of the humeral head (circumflex artery)
2. Axillary nerve palsy
3. Suprascapular nerve palsy
4. Adhesive capsulitis
53
What is a floating shoulder injury?
Fracture of the clavicle and glenoid neck
54
Which two conditions are most strongly associated with adhesive capsulitis?
1. Diabetes mellitus
2. Thyroid disease
55
What is a bankart lesion?
Detachment of the anterior inferior labrum from the glenoid due to an anteriorly dislocated humeral head
56
What's the difference between a strain and a sprain?
Strain: overstretching/tearing of LIGAMENTS
Sprain: overstretching/tearing of MUSCLES or TENDONS
57
Which shoulder conditions may cause pain at night?
Impingement
Adhesive capsulitis
58
What is the conservative treatment of proximal humeral fractures?
Immobilisation with a sling (no splinting needed)
Ice, analgesia, mobilisation
59
What is the Neer classification of proximal humeral fractures?
Fractures are classified according to how many of the four major segments of the proximal humerus are displaced
1. Anatomical neck
2. Surgical neck
3. Greater tuberosity
4. Lesser tuberosity
Displacement exists when a segment is angulated more than 45 degrees or displaced more than one centimetre from a normal anatomic position.
60
What is the management of non-complicated clavicular fractures of the middle third?
Sling for 2 weeks (children)
Figure 8 can be used but they may be less comfortable and there is little evidence to show increased efficacy
61
What is the most common complication of a scaphoid fracture?
Avascular necrosis
62
Pain with pressure on the anatomic snuffbox suggests what injury?
Scaphoid fracture
63
How are femoral neck fractures classified?
Garden classification
64
Which muscle tendons are affected by De Quervain's tenosynovitis?
Extensor pollicis brevis
Abductor pollicis longus
65
What are two causes of de Quervain's tenosynovitis?
1. Repeated hand and thumb movements
2. Rheumatoid arthritis
66
Which test is used to confirm de Quervain's tenosynovitis?
Finkelstein test
67
Which injury is classically seen in cyclists due to constant pressure on the wrist/hand from the handlebars?
Guyon canal syndrome
| (ulnar tunnel syndrome)
68
Damage to which two important structures is most important to consider in a mid-shaft humeral fracture?
1. Radial nerve
2. Profunda brachii artery
69
Damage to which four important structures is most important to consider in a supracondylar humeral fracture?
1. Brachial artery
2. Median nerve (particularly the anterior interosseous branch)
3. Ulnar nerve
4. Ulnar collateral artery
70
Damage to which two important structures is most important to consider in a fracture of the medial epicondyle of the humerus?
1. Ulnar nerve
2. Ulnar collateral artery
71
Where is pain from greater trochanteric pain syndrome felt?
Lateral hip
72
What exacerbates pain from greater trochanteric pain syndrome?
Lying on the affected side
Weight-bearing
Palpation of the greater trochanter
73
What causes greater trochanteric pain syndrome?
Gluteus medius or minimus tendinopathy (may also include trochanteric bursa)
Associated with knee OA, high BMI, low back pain, females
74
What is Legg-Calve-Perthes disease?
Idiopathic osteonecrosis of the femoral head in children 2-12 years of age
75
What are 3 radiologic signs of avascular necrosis of the femoral head?
1. Femoral head lucency
2. Subchondral sclerosis
3. Subchondral collapse (crescent sign - photo)
4. Flattening of the femoral head
76
How do you manage undisplaced intracapsular fractures?
Internal fixation with a dynamic hip screw or multiple cannulated screws
77
How do you manage a displaced intracapsular hip fracture?
\< 60 - ORIF
\>60 - arthoplasty
78
What is the management of intertrochanteric hip fractures?
Internal fixation with a dynamic hip screw or intramedullary nail
79
What antibiotic prophylaxis is used for orthopaedic surgery?
Cephazolin
+/- vancomycin if at risk of MRSA
80
What displaces intertrochanteric femoral fractures?
Iliopsoas pulls on the lesser trochanter and the major external rotators and abductors pull on the greater trochanter
81
A positive Trendelenburg gait suggests what?
Weakness of the gluteus medius and minimus
Superior gluteal nerve
82
What is the FABER test? What does a positive result mean?
FABER: flexion, abduction, external rotation
Groin pain: iliopsoas strain, intra-articular hip disorder
SI pain: SI joint disorder
Posterior pain: posterior hip impingement
83
What is the FADIR test?
FADIR: flexion, adduction, internal rotation
Causes:
1. Hip impingement (FAI)
2. Hip labral tear
3. Hip loose bodies
4. Hip chondral lesion
84
What two deformities are associated with femoroacetabular impingement?
Cam
Pincer
85
What is piriformis syndrome?
Compression of the sciatic nerve
Piriformis strain
86
Referred pain from which region is felt in the hip?
Lumbar
87
Transient synovitis in the hip affects people of which age?
2-5
88
Perthes disease affects people of what age?
5-10 years
89
Slipped capital femoral epiphysis (SCFE) affects people of what age?
10-15 years
90
What is the Thomas test?
91
What is the special test for lateral epicondylitis (tennis elbow)?
Wrist extension against resistance
92
What is the special test for medial epicondylitis (Golfer's elbow)?
Wrist flexion against resistance
93
What is a hairline fracture?
Fracture from minimal trauma, not involving fracture displacement
Commonly stress fractures
Often in foot or lower leg
94
If you suspect a fracture but cannot visualise it, what should you do regarding imaging?
1. Ask for more oblique views
2. Re-image in 7-10 days as there will be decalcification at the site
95
How does osteoporosis affect trabecular and cortical bone differently?
Trabecular bone is lost before cortical bone
Fractures occur bones with a high proportion of trabecular bone e.g. vertebrae as opposed to long bones
96
What are the stages of fracture healing?
1. Inflammation
2. Repair
3. Remodelling
97
Which bursa is most commonly affected in "housemaid's knee"?
Prepatellar
98
What are the Ottawa foot rules?
Required: pain in the midfoot
Major (1 required)
1. Inability to walk 4 steps
2. Bone tenderness at the navicular or the base of the fifth metatarsal
99
What are the Ottowa ankle rules for the malleolar zone?
Bone tenderness at the posterior edge or tip of the lateral malleolus
OR
Bone tenderness at the posterior edge or tip of the medial malleolus
OR
An inability to bear weight both immediately and in the emergency department for four steps
100
Which nerve is affected in tarsal tunnel syndrome?
Tibial
101
What is the pattern of sensory loss in carpal tunnel syndrome?
Loss on the palmar surface of the thumb, index and middle finger, and radial half of the ring
Sensation on the thenar eminence is preserved (affected in more proximal injuries)
The sensory innervation of this area is supplied by the superficial branch of the median nerve, which arises 5–7 cm proximal to the carpal tunnel and is therefore not compressed.
102
What is the most commonly fractured carpal bone?
Scaphoid
103
What is "Saturday Night Palsy"?
Compression of the radial nerve in the axilla
104
Which nerve can be damaged following a fall onto an outstretched that results in fracture to the hook of the Hamate?
Ulnar
FOOSH puts tension on the transverse carpal ligament and causes avulsion of the hook from the body
105
Why are fractures to the scaphoid prone to avascular necrosis?
Retrograde blood supply from the palmar carpal branch of the radial artery
Proximal end at higher risk of AVN
106
What are the risk factors for a baker's cyst?
Inflammatory knee disease e.g. rheumatoid arthritis
Degenerative knee disease
Knee trauma e.g. meniscal lesions
*Inflammation of the synovium stimulates excess production of synovial fluid*
107
What is the most commonly fractured long bone?
Clavicle
108
Which forces cause displacement of a clavicular fracture?
Lateral fragment: downward displacement (gravity), adduction (shoulder adductors)
Medial fragment: elevation (sternocleidomastoid)
109
What are the implications of the insertion of the pronator teres on the management of radial fractures?
Inserts mid-shaft
Fractures proximal to this point will be supinated by the unopposed action of the biceps brachii
Fractures must be splinted in a supinated position
110
Why are elbow effusions most prominent anteriorly and posteriorly?
The capsule is weakest anteriorly and posteriorly
(Lateral and medial ligaments are thickenings of the capsule)
111
When does damage to the radial nerve not cause wrist drop?
Damage to the posterior interosseous nerve
The extensor carpi radialis longus is spared
112
Why does wrist drop impair grip?
Grip strength is weak in wrist flexion
The flexors must be stretched
113
What is the area of anaesthesia in a radial nerve injury?
Dorsum of the hand between the 1st and 2nd metacarpals
114
Which structure is affected in Dupuytren's contracture?
Palmar aponeurosis
The 4th and 5th digits are disproportionately affected
115
How is apparent leg length measured?
Umbilicus to medial malleolus
116
How is true leg length measured?
ASIS to medial malleolus
117
What is the main purpose of the FABER test?
Differentiating sacroiliac from hip joint pathology
Buttock pain = sacroiliitis
Groin pain = hip joint
118
Why is both true and apparent leg length measured?
True - anatomical shortening
Apparent - functional shortening e.g. joint contracture, ligament laxity, muscle tension
119
In general terms, how good is the sensitivity and specificity of the anterior drawer test?
Sensitivity: poor (27-88%)
Specificity: good (91-99%)
120
In general terms, how good is the sensitivity and specificity of Lachman's test?
Good sensitivity (60-100%)
High specificity (up to 100%)
121
How is the patellar swipe test performed and what constitutes a positive result?
The examiner "milks" fluid into the lateral compartment of the knee
If a wave of fluid can be seen heading back towards the medial side of the knee the test is positive
122
What is the difference in clinical value between the patellar tap and swipe test?
Tap - large effusions
Swipe - small effusions
Both have very variable sensitivity and specificity
123
How do you perform McMurray's test?
Medial meniscus:
One hand of the examiner is placed on the posteromedial edge of the joint, while the other hand holds the foot and externally rotates it with the knee still exed. The knee is then extended
Reverse for lateral meniscus
124
How do you perform the patellar apprehension test?
The patient lies supine with the knee slightly exed (usually to 20–30°). The examiner then applies pressure with both hands, pushing from medial to lateral on the patella, while the patient is instructed to contract the quadriceps muscle. The test is said to be positive if pain occurs or if the anticipation of pain or subluxation.
## Footnote
*Dislocated patellofemoral joint, patellar instability, patellofemoral pain syndrome*
125
What is a positive shoulder apprehension test and what does it suggest?
Positive: patient feels apprehension that the shoulder may dislocate NOT if there is pain
Associations: humeral head subluxation/dislocation, rotator cuff damage, anterior rim damage, detachment of the joint from ligaments
126
What is the sulcus sign?
Pulling down of a relaxed, hanging arm causes dimpling of the skin below the acromion
Suggests glenohumeral laxity
127
What is subacromial decompression?
Removal of the acromial spur and acromioclavicular ligament
Can be used for shoulder impingement
128
What is being tested in the lift-off test?
Subscapularis/internal rotation
129
How is a digital nerve block performed?
Injection into the web space, just distal to the MCP joint
130
What does the Hawkins Kennedy test assess?
Subacromial impingement
131
Which special manoeuvre can be used to assess the acromioclavicular joint?
Crossbody adduction
132
What causes radial head subluxation and who is affected?
Sudden axial traction on a pronated and extended forearm
Affects people aged 1-5 years almost exclusively
*The radial head is still cartilaginous and the annular ligament is not strong*
133
What is a snapping or popping sound in association with a knee injury suggestive of?
Ligamental tear, often ACL
Teenagers and young adults may also hear an audible pop with meniscal tears
134
What is immediate swelling in association with a knee injury suggestive of?
Haemarthrosis
Significant injury e.g. ACL tear
135
What is locking of the knee suggestive of?
Meniscal injury
136
What is a segond fracture?
Avulsion fracture of the knee that involves the lateral tibial plateau
Commonly associated with an ACL tear
137
How are ACL tears diagnosed?
MRI
## Footnote
*Arthroscopy is the gold standard but is not commonly used*
138
How long following injury do ACL reconstructions occur?
2-12 weeks after the injury
Patients should be pain and swelling free, have an almost normal range of motion and normal gait
*Prehabilitation exercises should be done*
139
What is Neer's test?
Passive test of subacromial impingement
https://www.youtube.com/watch?v=bXA8cblZUok
140
What questions do you ask on history following a fracture?
A - allergies
M - medications
P - past MHx
L - last meal
E - events surrounding injury
141
When is open reduction indicated?
NO CAST
N: non-union
O: open fracture
C: neurovascular compromise
A: intra-articular fracture (involve the joint space)
S: Salter-Harris 3, 4, 5
T: polytrauma
Other: failure closed reduction, cannot cast site e.g. hip, infection, non-union
142
List 3 ways fractures can be externally fixated
1. Splints
2. Casts
3. Traction
4. External fixator
143
List 3 ways in which fractures can be internally fixated?
1. Percutaneous pinning
2. Extramedullary fixation (screws, plates, wires)
3. Intramedullary fixation (rods)
144
What occurs in the inflammatory stage of bone healing?
Haematoma formation
Facilitates the migration of acute inflammatory mediators and cells
Bone resorption, swelling, inflammation
Phagocytes and osteoclasts remove dead or damaged tissue
145
What occurs during the reparative stage of bone healing?
Callus formation (fibroblasts and chondroblasts) - begins to stabilise the bone
146
What occurs during the remodelling phase of bone healing?
Endochondral callus is replaced by bone
Osteoclasts resorb the hard callus and osteoblasts deposit lamellar bone
147
How are Gartlant type I fractures managed?
Immobilisation with above-elbow backslab in 90 degrees of flexion
148
How are Gartland type II fractures managed?
Closed reduction (push anteriorly on the distal fragment as the elbow is flexed at 90 degrees)
Immobilisation with above-elbow backslab with 90 degrees flexion
149
How are Gartland type III fractures managed?
ORIF with percutaneous K wires
Splinted with a collar and cuff
150
How are Gartland type II fractures reduced?
Anteriorly push the olecranon while the hand flexes the humerus
151
How are posterior elbow dislocations reduced?
Apply traction of slightly flexed forearm while someone else applies traction on the humerus
152
How are type II gartland fractures reduced?
Push the distal fragment anteriorly as the elbow is flexed at 90 degrees
153
Subcapital femoral neck fracture
154
Transcervical hip fracture
155
Intertrochanteric hip fracture
156
List the order in which ossification of the epiphyses in the elbow occurs
CRITOE
Capitulum
Radial head
Internal (medial) epicondyle
Trochlea
Olecranon process
External (lateral) epicondyle
