Orthopaedics Flashcards
(107 cards)
1
Q
What % of back pain is due to mechanical back pain?
A
85 - 90%
2
Q
Causes of mechanical back pain
A
- trauma
- muscular / ligamentous pain
- fibrositic nodulosis
- postural back pain (sway back)
- lumbar spondylosis
- facet joint syndrome
- lumbar disc prolapse
- spinal and root canal stenosis
- spondylolisthesis
- disseminated idiopathic skeletal hyperostosis
- fibromyalgia
3
Q
Red flags in back pain history
A
- Serious trauma / fall from height
- minor trauma in osteoporosis
- age < 20 or > 50 at onset
- history of cancer / drug abuse / HIV / immunosuppression / prolonged corticosteroids
- constitutional symptoms - fever, chills, weight loss
- pain worse when supine
- severe pain at night
- thoracic pain
- constant and progressive pain
- severe morning stiffness
- patient unable to walk / self care
- saddle anaesthesia
- recent onset problems with bladder and bowels
4
Q
What are waddel’s signs used for
A
Used to indicate non-organic psychological component to chronic back pain
5
Q
What are Waddel’s signs
A
- Superficial non-anatomical tenderness
- overreaction
- pain on axial loading
- pain on passive rotation
- straight leg raise test discrepancy between supine and standing
- non-dermatomal sensory loss
- give-way weakness
6
Q
Red flags on back pain examination
A
- structural deformity
- severe / progressive neurological deficit
- anal sphincter laxity
- peri-anal / perineal laxity
- major motor weakness
7
Q
Symptoms suggesting cauda equina syndrome
A
Bladder dysfunction (retention +/- overflow) Sphincter disturbance Saddle anaesthesia Lower limb weakness Gait disturbance
8
Q
Investigation of back pain
A
Spinal x-ray - if neuro syx, 50yo, worse at night/morning, systemic syx MRI - better for neuro CT -better for bone Bone scan - for infection / malignancy FBC, ESR, CRP - for infection LFTS - Paget's disease, bony mets PSA - prostate ca CXR - lung ca USS - renal stones, pancreatitis, leaking AAA endoscopy - posterior ulcer
9
Q
Risk factors for recurrent mechanical back pain
A
Female ^ age Job dissatisfaction Pre-existing widespread chronic pain Psychological distress - depression / anxiety
10
Q
Types of trauma that may cause mechanical back pain
A
Lifting Sports Fall RTA occupation Housework Sudden jolts Gardening
11
Q
What are fibrositic nodules
A
Tender nodule in a muscle. Usually buttock / along iliac crests
Causes unilateral or bilateral low back pain.
Radiates to buttock and posterior thigh.
12
Q
In whom is postural back pain most common
A
Pregnancy
Obesity
Muscle weakness
13
Q
What is sway back
A
Postural back pain
14
Q
What disc changes occur in spondylosis
A
Changes in disc gel - breaks up, shrinks, loss of compliance
Surrounding fibrous zones develop circumferential fissures
Discs become thinner and less compliant
15
Q
What is facet joint syndrome
A
Arthritic changes and inflammation of facet joints
May be secondary to spondylosis
16
Q
Symptoms of facet joint syndrome
A
Lower back pain - worse on bending forward + on straightening from flexion.
Radiation to buttocks
Unilateral or bilateral
17
Q
Management of facet joint syndrome
A
Diagnostic injection of LA into facet joint.
Then corticosteroid injection into joint
Physiotherapy
Weight loss
18
Q
What happens in disc herniation (prolapse)
A
Herniation of the nucleus pulposus (gelatinous centre part) through the annulus fibrosus (fibrocartilaginous outer layer)
19
Q
What is spondylolisthesis
A
Slipping of one vertebral disc forward over the lower one
20
Q
In what age group is spondylolisthesis most common
A
Adolescents / young adults
21
Q
What happens in disseminated (diffuse) idiopathic skeletal hyperostosis?
A
Bony overgrowths + ligamentous ossification
Characterised by flowing calcification over the anterolateral vertebrae
22
Q
What is Forrestier’s disease
A
disseminated (diffuse) idiopathic skeletal hyperostosis
23
Q
What is fibromyalgia
A
A syndrome of long-term widespread body pain - affects joints, muscles, tendons and soft tissues.
Linked to fatigue, sleep problems, depression, anxiety, headaches
24
Q
What spinal fracture is more common in osteoporosis?
A
Vertebral crush fracture
25
What causes a widows stoop
Increased thoracic kyphosis due to multiple osteoporotic vertebral fractures
26
How do you diagnose osteoporotic crush fractures
X-ray - loss of anterior vertebral body height and wedging.
27
Tx of osteoporotic crush fractures
Bed rest and analgesia - until pain subsides
Gradual mobilisation
May need hospitalisation - IV bisphosphonates or SC calcitonin.
28
What do yellow flags signify
Psychological barriers to active rehabilitation and risks of chronicity.
29
Yellow flags in back pain include:
```
Belief pain and activity are harmful
Sickness behaviours
Social withdrawal
Low / negative mood / anxiety
Problems at work / job dissatisfaction
Compensation / claims
Lack of family support
Inappropriate expectation of tx
```
30
What % of the general population have a bulging disc on MRI
Upto 79%
31
What % of people with back pain return to their GP within 3m
>29%
32
Risk factors for osteoarthritis
```
>65yo
Female (usually more severe - but prevalence = in both sexes)
Genetic
Obesity
Joint injury
Muscle weakness
Meniscal damage
```
33
Radiological features of osteoarthritis
Joint space narrowing
Osteophyte formation
Bone cysts
Sclerosis
34
Features suggestive of osteoarthritis
Pain - exacerbated by activity, relieved by res
Stiffness - transient, after rest / in morning
Reduced movement
Swelling
Crepitus
Increased age
35
Common sites of osteoarthritis
Hands
Knees
Hips
36
Management of osteoarthritis
```
Weightloss
Appropriate footwear
Physiotherapy
NSAIDS / opiates
Effusion aspiration
surgery - osteotomy / joint replacement
```
37
Location of Hebredens nodes
distal interphalangeal joints
In osteoarthritis
38
Location of Bouchards nodes
Proximal interphalangeal joints
In osteoarthritis
39
Risk factors for rheumatoid arthritis
Female:male 3:1
Age 40-60
Family history
Smoking
40
Common deformities in RA
Swan neck
Boutonnière
Z thumb
Ulnar deviation
41
Where is the olecranon bursa
Over the ulna at the posterior tip of the elbow
| Near the surface. Therefore, often exposed to trauma.
42
Syx of olecranon bursitis
Focal swelling over tip of elbow +/- pain
Pain may be exacerbated by pressure
Onset may date from trauma - onset without trauma suggests infection.
43
Signs of olecranon bursitis
```
Well demarcated swelling
Red
Warm
Skin may show contusion or abrasion.
Movement decreased at end of flexion - due to pain.
```
44
What does elbow pain on passive or active movement suggest
Possible olecranon process fracture
45
DDX of olecranon bursitis
```
Fractured olecranon process
Haemarthrosis
Inflammatory arthropathy e.g RA
Crystal arthropathy e.g. Gout
Autoimmune disease
Ehlers Danlos Syndrome
Synovial cyst
```
46
Investigations for olecranon bursitis
```
FBC - WCC
Uric acid levels
CRP / ESR
RF
Plain x-ray if hx of trauma
Aspiration of bursa
```
47
What are gout crystals made of
Monosodium urate crystals
48
What are pseudogout crystals made of
Calcium pyrophosphate
OR
Hydroxyapatite
49
Management of olecranon bursitis
RICE - rest, ice, compression, elevation
Antibiotics if septic
Aspiration
Steroid instillation
50
Possible complications of olecranon bursitis
Septicaemia
Osteomyelitis
Persistent pain
51
Causes of non-specific neck pain
```
Poor posture
Neck strain
Sports
Occupation
Anxiety and depression
```
52
Causes of neck pain
```
Posture, injuries etc
RA, OA, Fibromyalgia, osteoarthritis
Cervical spondylosis
Cervical intervertebral disc prolapse
Spinal stenosis
Osteomyelitis
Whiplash / trauma
CV, Resp, upper GI problems
```
53
Rick factors for neck pain
```
Neck posture
Arm posture
Prolonged sitting
Twisting / bending of the body
Hand / arm vibration
Excessive pillows
Excessive concerns
Issues of injury compensation
Psychosocial problems
```
54
What is cervical radiculopathy
Compression or injury to a nerve root in the c- spine
55
Syx of cervical radiculopathy
Pain - unilateral neck, shoulder or arm
Motor dysfunction - weakness
Sensory deficit - altered sensation, paraesthesia
Altered tendon reflex
56
Red flags in neck pain
New syx 55yo
Weakness in >1 myotome
Intractable / increasing pain
Neurological syx - gait disturbance, clumsy/weak hands, loss of bladder/bowel syx
Malaise, fever, weight loss
Hx of inflammatory arthritis, cancer, TB, immunosuppression, HIV,
Lymphadenopathy
Hx of violent trauma / fall from a height
Dizziness / blackouts
57
DDX of neck pain
Disc prolapse
Tonsillitis
C-spine injury --> muscle strain, dislocation, fracture
Vertebral osteomyelitis
Cervical lymphadenopathy due to cancer
Eye disorders
Dystonia secondary to stroke, encephalitis etc
Dystonic reaction - antipsychotics, metoclopramide, cocaine
Pseudodystonia
Somatisation
58
What is tunnels test + what's it for
Tap over median nerve at wrist
| To reproduce syx in carpal tunnel.
59
What is phalens test + what's it for
Hold the wrists palmar flexed together for 1 min
| To reproduce syx in carpal tunnel
60
What are the LOAF muscles
Lateral 2 lumbricals
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis
61
What is supplied by the ulnar nerve
```
Hand muscles (except LOAF muscles)
Sensation to ring and little finger
```
62
Syx of chronic ulnar lesions
Clawing of the hand
63
Do proximal or distal ulnar nerve lesions cause more marked clawing of the hand
Distal = more clawed
64
Which cancers metastasise to bone?
```
Lung
Breast
Thyroid
Renal
Prostate
```
65
What part of the rotator cuff is most commonly injured?
Spraspinatus
66
What is hypertrophic pulmonary osteoarthropathy?
Subperiosteal new bone formation in the long bones
| Pain and painting of the anterior shin
67
Presentation of posterior dislocation of the shoulder
Painful shoulder
Most commonly occurs after a seizure
On examination the coracoid process may be prominent
68
What does a dinner fork deformity suggest?
Colles fracture
69
Presentational De Quervain's tenosynovitis
Pain on wrist adduction and flexion
| Radial side of wrist
70
What is an important side effect of bisphosphonates
Osteonecrosis of the jaw
71
Features of carpal tunnel syndrome
Lateral 3 1/2 fingers
Pain
Paraethesia
72
What does a prominent tender tibial tubercle suggest
Osgood-schlatter disease
73
Radiological features of rheumatoid arthritis
Loss of joint space
Subluxation of joints
Erosions
Soft tissue swelling
74
Radiological features of Paget's disease
Local bone enlargement
lytic lesions with nearby sclerosis
Long bone bowing
75
Radiological features of ankylosing spondylitis
Syndesmophytes
| Bamboo spine
76
X-ray appearance of Sunday speculation suggests....
Osteosarcoma
77
X-ray appearance of onion peel sign suggests....
Ewings sarcoma
78
What is perthes disease
self-limiting hip disorder
caused by ischaemia and necrosis of the femoral head.
avascular necrosis of the proximal femoral epiphysis.
Abnormal growth of the epiphysis results.
Eventual remodelling of regenerated bone.
79
Classical patient with perthes disease
```
4 - 8 year-old boy
delayed skeletal maturity.
Male to female ratio: 5:1
Rare in non-Caucasians.
Increased incidence with family history, low birthweight, abnormal pregnancy/ delivery.
```
80
Presentation of perthes disease
```
all movements at the hip are limited.
early phase - limited hip abduction, limited internal rotation
antalgic gait
Trendelenburg gait - seen late.
No history of trauma.
```
81
Management of Perthes disease
Children 8yp - surgery + physio
82
What does SUFE stand for?
Slipped upper femoral epiphyses
83
Classical patient with SUFE
Adolescent - 10-17yo
Peak age = 13 years for boys. 11.5 years for girls.
left hip is more commonly affected than right
bilateral in 20-40%
3x more common in boys.
84
Risk factors for SUFE
```
Mechanical: local trauma, obesity.
Inflammatory conditions: neglected septic arthritis.
Hypothyroidism,
hypopituitarism,
growth hormone deficiency,
pseudohypoparathyroidism.
Previous radiation of the pelvis,
chemotherapy,
renal osteodystrophy-induced bone dysplasia.
```
85
Presentation of SUFE
Discomfort in hip, groin, medial thigh or knee during walking
pain accentuated by running, jumping, or pivoting.
Pre-slip: slight discomfort.
Acute: Severe pain - unable to walk / stand.
limp on the affected side,
external rotation of the leg.
Hip motion limited - esp internal rotation and abduction
Chronic: Mild symptoms - child able to walk with altered gait.
86
Symptoms of posterolateral intervertebral disc herniation
Acute onset back pain
| Sciatica
87
Symptoms of spondylosis
Aching pain
Worth on activity and in the morning
Some restriction of spinal movement
No muscle spasm
88
Symptoms of spinal stenosis
Back and leg pain on standing and walking
| Relieved by sitting or bending forward
89
What is discitis and who does it affect
Infection of the intervertebral disk
| Occurs in young children
90
Symptoms of discitis
Severe pain
Refusal of movement
Impaired mobility
91
What does a palpable step on examination of the spine indicate
Spondylolisthesis
92
What is Potts disease
TB of the spine
| Often results in abscess formation
93
Management of SUFE
```
Avoid moving or rotating the leg.
Do not walk.
analgesia
Immediate orthopaedic referral.
scheduled for surgery immediately.
Surgical closure of the epiphysis - screws percutaneously.
```
94
Presentation of an anterior dislocation of the shoulder
Usually caused by a fall onto the outstretched hand or shoulder.
Severe shoulder pain
Unwillingness to move arm
Flattened shoulder contour
Humeral head palpable in infra-clavicular fossa
95
Most common type of shoulder dislocation
95% anterior
96
What nerve can an anterior shoulder dislocation damage
Axillary nerve
Weakness of deltoid
Regimental patch numbness
97
Most likely cause of severe pain on shoulder abduction >120 degrees
Suprasipinatus tendonitis
98
Presentation of a frozen shoulder (adhesive capsulitis)
```
Hx of minor trauma
Middle aged
Aching pain
Restricted shoulder flexion, extension, rotation and abduction
Spontaneous recovery over 12m
```
99
What is impingement syndrome (painful arc syndrome)
Pain on adduction between 60-120
Due to mechanical nipping of a tender structure between the acromion and greater tuberosity.
Can be due to incomplete tear of suprasipinatus tendon, chronic suprasipinatus tendonitis, subacromial bursitis
100
What 4 muscles make up the rotator cuff
Suprasipinatus
Infraspinatus
Subscapularis
Teres minor
101
Presentation of rotator cuff tear
Shoulder tip pain
Local tenderness at lateral margin of acromion process.
Inability to abduct the arm
Can hold arm in abduction if passively elevated to 90degrees + due to deltoid.
Once lowered below 90 - arm drops
102
Management of an intracapsular fractured neck of femur
Internal fixation with cannulated screw if undisplaced
| Hemi-arthroplasty if displaced
103
What is the classification system for femoral neck fractures
Garden
Type 1 - stable fracture.
Type 2 - complete but non-displaced.
Type 3 - partially displaced but still has some contact between 2 fragments.
Type 4 - completely displaced + no contact between 2 fragments.
104
What are the 2 main types of hemi-arthroplasty
Cemented - Thompson's
| Non-cemented - Austin-Moore
105
Presentation of patellar fracture
Knee pain
Haemarthrosis
Inability to extend knee
106
Symptoms of transient synovitis
```
Most common cause of hip pain in prepubescent children
Often follows viral infection
Suffer onset hip pain
Slight limp
Reduced range of movement
No pain at rest
No systemic symptoms
```
107
What causes trigger finger
Thickening and constriction of the mouth of the tendon sheath. The tendon beComes swollen under the sheath.
Easy to flex the finger. But difficult to extend
