Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

Year 5 > Orthopaedics > Flashcards

Orthopaedics Flashcards

(386 cards)

Start Studying
1
Q

What 5 things should be covered in the ‘look’ section of REMS hand and wrist?

A 
Skin/nail changes
Muscle wasting
Swelling 
Joint deformity 
Scars
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is a swan neck deformity?

A

PIP hyperextension

DIP flexion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is a boutonniere deformity?

A

PIP flexion

DIP hyperextension

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

How is sensation tested in REMS hand and wrist?

A

Radial - web space
Median - thenar eminence
Ulnar - little finger

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What nerves are responsible for thumb abduction, wrist extension and finger abduction?

A

Thumb abduction - median
Wrist extension - radial
Finger abduction - ulnar

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is the most important thing to consider when assessing a fracture?

A

Soft tissue injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What investigation is best for assessing intra-articular fractures?

A

CT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What 7 things are involved in fracture assessment?

A 
Soft tissue injury 
Location 
Configuration
Displacement 
Stability 
Open fractures
Intra-articular fractures
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are the 9 types of fracture configuration?

A 
Transverse
Oblique
Spiral 
Comminuted 
Segmental
Avulsion
Compression
Torus/buckle
Greenstick
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is meant by the angulation of a fracture?

A

Position of distal relative to proximal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is meant by the translation of a fracture?

A

Medio-lateral/antero-posterior position

Expressed in percentage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Describe the Gustilo-Anderson grading for open fractures

A

Grade I - <1cm, mild contamination
Grade II - 1-10cm, moderate contamination
Grade IIIA - minimal periosteal stripping
Grade IIIB - significant periosteal stripping
Grade IIIC - associated vascular injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are the risks of an intra-articular fracture?

A

Pain
Stiffness
Post-traumatic OA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Give 4 types of conservative immobilisation

A

Cast
Splint
Sling
Traction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Give 4 types of surgical immobilisation

A

Smooth wires
Intramedullary nail
Plates and screws
External fixator

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

How can malunion be managed?

A

Osteotomy and refixation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What are the types and causes of non-union?

A

Atrophic - smoking, malnutrition, immunocompromised

Hypertrophic - immobilisation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What are the 3 main principles of fracture management?

A

Reduce
Retain
Rehabilitate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is the difference in management between an intracapsular and extracapsular hip fracture?

A

Intracapsular - blood supply likely disrupted; needs replacement
Extracapsular - blood supply likely preserved; can be fixed with dynamic hip screw

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are the complications of a hip fracture/replacement?

A

Mortality (10% at 1 month, 30% at 1 year)
DVT
Chest infection
Dislocation of femoral head

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What are the main concerns with a high energy pelvic fracture?

A

Damage to pelvic structures/organs

Damage to major blood vessels causing internal bleeding

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

How is a high energy pelvic fracture managed?

A

ATLS
Immobilisation - pelvic binder
Fixation - plates and screws

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

How is a low energy pelvic fracture managed?

A

Conservatively - usually heal spontaneously

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What fracture is associated with hip dislocation?

A

Acetabular

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
What are the risks of hip dislocation?
Nerve damage - sciatic nerve AVN Post-traumatic arthritis Recurrence (if artificial)
26
What artery is at risk of damage in knee dislocation?
Popliteal artery
27
How is a knee dislocation managed?
Reduce and splint Angiogram Ligamental reconstruction
28
What is the main concern with a femur fracture?
Massive haemorrhage causing hypovolaemic shock
29
How is a femur fracture managed?
Thomas-type splint | Intramedullary nail
30
What is the significance of the syndesmosis between the distal tibia and fibula in ankle fracture?
Determines management via Weber classification
31
What should be checked in an ankle fracture and why?
Subluxation/dislocation - needs to be reduced and splinted if present; soft tissue and articular surface can be damaged otherwise
32
What is a Lisfranc fracture?
Dislocation of midfoot between tarsal bones and base of metatarsals Pitfall of foot fractures which is commonly missed but needs reduction and fixation
33
What are the causes of secondary OA in the hip?
``` Trauma Infection AVN DDH SUFE ```
34
Give 3 features of OA of the hip elicited from examination
``` Pain in buttock/groin/thigh/knee Antalgic/Trendelenberg gait Reduced ROM (internal rotation) Contractures +ve Thomas's test ```
35
What are the radiological features of OA?
Joint space narrowing Subchondral sclerosis Subchondral cysts Osteophyte formation
36
What are the management options for OA of the hip?
Conservative - weight loss, walking stick, NSAIDs, PT | Surgical - hip arthroplasty
37
Which side of the knee is more frequently affected in OA?
Medial
38
Give 3 features of OA of the knee elicited from examination
``` Pinpoint pain, particularly when climbing stairs Varus malalignment Effusion in supra-patellar pouch Contractures Reduced ROM Crepitus on movement ```
39
How is OA of the knee managed surgically?
Tibial osteotomy Unicompartmental joint replacement Total knee replacement
40
What is a tibial osteotomy?
Removal of a wedge of bone from the lateral side of the tibia to allow redistribution of load across knee joint and away from damaged medial side
41
What are the traumatic and non-traumatic causes of hip AVN?
Traumatic - femoral head/neck fracture, hip dislocation, SUFE Non-traumatic - alcohol abuse, steroids, irradiation, haematological disease, decompression sickness, hyper-coaguable state, CTD, viral, idiopathic
42
By what mechanism do traumatic and non-traumatic AVN occur?
Traumatic - ischaemia | Non-traumatic - intra-vascular coagulation
43
What classification system is used for hip AVN?
``` Ficat classification 1 - minor osteopenia 2 - sclerosis and cysts 3 - loss of round shape 4 - secondary OA ```
44
Give 3 signs/symptoms of hip AVN
Insidious onset buttock/groin/hip/thigh pain Limping patient Stiff joint
45
What imaging is used for hip AVN in early and advanced disease?
X-ray - advanced disease | MRI - early disease
46
How is hip AVN managed?
Conservative - symptom control, bisphosphonates | Surgical - core decompression +/- bone grafting, rotational osteotomy, total hip resurfacing, total hip replacement
47
Why would a core decompression +/- bone grafting be performed for hip AVN?
Revacularisation of bone
48
What is a SUFE?
Slipped upper femoral epiphysis - fracture through the capital femoral physis, causing the epiphysis to ‘slip’ posteriorly and inferiorly
49
Who is most likely to present with SUFE?
10-16 year olds (rapid growth) Males African Americans Obese
50
How does SUFE present?
Acute or insidious | Limp and groin pain (may be referred to thigh/knee)
51
Give 3 features of SUFE elicited on examination
Limp Externally rotated and shortened leg Tenderness Reduced ROM
52
How is the stability of a SUFE judged?
Stable if able to weight bear
53
What 2 views are essential for SUFE x-ray?
AP | Frog leg lateral
54
What features of SUFE are seen on a frog leg lateral x-ray?
Disrupted Shenton's line Steel sign Apparent widening of physis and decreased epiphysis height Prominent lesser trochanter (external rotation) Klein's line fails to intersect lateral superior femur
55
What is Steel sign?
Additional shadow behind superior femoral neck
56
What is Klein's line?
Line drawn along the superior edge of the femoral neck
57
What is DDH?
Developmental dysplasia of the hip - abnormal development of the hip resulting in shallow underdeveloped acetabulum +/- subluxation and hip dislocation
58
Give 3 risk factors for DDH
``` Female First born Left hip Breech position FH Other MSK abnormalities ```
59
How is DDH identified and managed in neonate to 3 months?
Identified - deep thigh creases, +ve Ortolani test, +ve Barlow test, reduced abduction, hip USS Managed - splint in abduction and flexion using Pavlik harness
60
How is DDH identified and managed from 3-18 months?
Identified - leg length discrepancy, limited abduction, x-ray from 6 months Managed - closed/open reduction under anaesthesia and immobilisation in spica cast for 3 months
61
How is DDH identified and managed from 1 year to walking age?
Identified - difficulty walking, lumbar lordosis, Trendelenberg gait, toe-walking Managed - reduction and spica cast for 3 months +/- femoral/acetabular osteotomy
62
How is DDH identified and managed in later childhood/adolescence?
Identified - leg length discrepancy, large ROM, early OA on x-ray Managed - osteotomy, total hip replacement if OA
63
What makes up the extensor mechanism of the leg and what is its function?
Quadriceps tendon, patella and patellar tendon | Allows extension of the leg at the knee joint
64
What patient type is likely to rupture their quadriceps tendon?
Elderly male with pre-existing tendinopathy
65
Give 3 signs/symptoms of quadriceps tendon rupture
``` Pain Bruising Swelling Tenderness Inability to extend knee against resistance Inability to SLR (total) Effusion ```
66
What is seen on x-ray of a quadriceps tendon rupture?
``` Effusion Patella baja (low lying patella) ```
67
What patient type is likely to rupture their patellar tendon?
Young males
68
Give 3 signs/symptoms of patellar tendon rupture
``` Infra-patellar pain Popping sensation at time of incident Elevated patella with haemarthrosis Tenderness Inability to SLR or extend knee (total) Reduced ROM Difficulty weight bearing ```
69
What is seen on x-ray of a patellar tendon rupture?
Proximal migration of patella (patella alta)
70
How is a quadriceps tendon rupture managed?
Open repair with cast/splint in extension
71
How is a patellar tendon rupture managed?
Conservative for partial = immobilisation in extension with PT Surgical for complete - open repair
72
Give 3 risk factors for quadriceps and patellar tendon rupture
Previous tendon rupture Corticosteroid injections Steroid use Co-morbidities (SLE, RA, diabetes)
73
What is the commonest mechanism of injury for a meniscal tear?
Twisting the knee while weight bearing
74
What are the signs/symptoms of a meniscal tear?
``` Pain Instability (stairs) Swelling Tenderness Reduced ROM Locking +ve McMurray's test ```
75
What is McMurray's test?
Compressing and twisting knee joint reproduces pain (meniscal tears)
76
What imaging is most useful for meniscal tears?
MRI | Diagnostic arthroscopy
77
Injury to which ligament in the knee makes up 75% of haemarthroses caused by sport?
ACL
78
What other structures are likely to be injured in an ACL tear?
Medial meniscus | Medial collateral ligament
79
What is the mechanism of injury of an ACL tear?
Forced flexion or hyperflexion, twisting injury or direct blow behind upper tibia
80
What are the signs/symptoms of an ACL tear?
``` Snapping sound/sensation Large rapid haemarthrosis Tenderness +ve anterior drawer test +ve Lachman's test ```
81
Give 3 complications of ACL/PCL tears
Instability Loss of function Meniscal tears Early OA
82
What is the mechanism of injury of an PCL tear?
Hyperextension or forced displacement of upper tibia from femur Falling onto an object
83
What are the signs/symptoms of a PCL tear?
Large haemarthrosis Posterior sag Tenderness +ve posterior drawer test
84
What is the mechanism of injury of an MCL tear?
Twisting injury
85
What are the signs/symptoms of a MCL tear?
Bruising medially Swelling Tenderness Laxity on valgus stress
86
Are MCL or LCL tears more common?
MCL
87
What is the mechanism of injury of an LCL tear?
Stretching/tearing when varus force applied to knee
88
What are the signs/symptoms of a LCL tear?
Brusing laterally Swelling Tenderness Laxity on varus stress
89
What are the complications of a MCL injury?
Chronic valgus instability | Avulsion
90
What are the complications of a LCL injury?
Avulsion fracture at fibular head | Common peroneal nerve injury
91
What scoring systems are used for major trauma?
Injury severity score Abbreviated injury scale Revised trauma score
92
What is the golden hour in major trauma?
Period of time following an injury with the highest likelihood that prompt treatment will prevent death
93
How is c-spine stabilisation achieved in ATLS?
Triple immobilisation - hard collar, tape and blocks
94
Give 3 sources of major haemorrhage in trauma
``` Chest Abdomen Pelvis Retroperitoneum Long bones ```
95
What is shock?
A life-threatening condition of circulatory failure resulting in cellular injury and inadequate tissue function
96
Outline the features of a class I acute haemorrhage
Blood loss - <750cc (0-15%) | Fluids - crystalloids
97
Outline the features of a class II acute haemorrhage
``` Blood loss - 750-1500cc (15-30%) HR - increased PP - decreased Mental state - anxious Fluids - crystalloids ```
98
Outline the features of a class III acute haemorrhage
``` Blood loss - 1500-2000cc (30-40%) HR - increased PP - decreased BP - decreased Urine output - decreased Mental state - confused Fluids - crystalloids and blood ```
99
Outline the features of a class IV acute haemorrhage
``` Blood loss - >2000 (>40%) HR - increased PP - decreased BP - decreased Urine output - negligible Mental state - lethargic Fluids - crystalloids and blood ```
100
In general, how is a major trauma managed?
ATLS | Primary survery and secondary survey
101
What might be done as part of a secondary survey in major trauma?
Focused history Complete systematic examination Further imaging
102
Give 3 complications of major trauma
``` ARDS SIRS MOD Fat embolism syndrome Compartment syndrome ```
103
What causes fat embolism syndrome?
Pelvis/long bone fracture | Significant soft tissue injury
104
Give 3 symptoms of fat embolism syndrome
``` Hypoxia Low platelets Anaemia SOB Confusion Delirium Petechial rash ```
105
What is the mortality from fat embolism syndrome?
20%
106
What is a Volkmann's contracture?
Irreversible muscle and nerve damage caused by compartment syndrome
107
Why might colloids be unsuitable for a post-operative patient?
Variable effect on haemostasis | Some reduce platelet function
108
Give 3 signs/symptoms of a surgical site infection
Purulent discharge Erythema Pain Swelling
109
What is the difference between a superficial and deep surgical site infection?
Superficial - skin and subcutaneous tissue | Deep - fascia and muscle
110
What is the most common organism involved in hip arthroplasty infection?
Coagulase negative staphylococcus
111
What route of administration is best for post-operative analgesia?
Oral < IV < IM
112
Give 3 ways in which analgesia may be given post-operatively
Local anaesthetic Regional via nerve catheter Regional nerve block
113
What factors increase the risk of an AKI post-operatively?
Hypovolaemia Reduced vascular resistance Nephrotoxic agents Prophylactic antibiotics
114
How is AKI managed post-operatively?
Loop diuretics only if overloaded | Ensure fluid balance is adequate
115
What are the risk factors for compartment syndrome?
``` Crush injury Rhabdomyolysis Long bone fracture Vascular limb injury Tissue ischaemia Coagulopathy ```
116
In which 2 patient populations do you need to beware of compartment syndrome?
Ventilated ITU patients | Regional/spinal anaesthesia
117
Why are orthopaedic patients at risk of thromboembolic disease?
``` Blood stasis (immobilisation) Endothelial injury (surgical position/manipulation) Hypercoagulability (increased blood loss and thromboplastins) ```
118
Give 2 methods of mechanical VTE prophylaxis
Early mobilisation Graduated compression stockings Intermittent pneumatic compression devices
119
Give 2 methods of pharmacological VTE prophylaxis
Aspirin Warfarin Apixaban Clexane
120
How long after discharge can hypercoagulability last for a hip fracture?
6 weeks
121
What is the most common mechanism of injury of a clavicle #?
FOOSH | Direct blow to shoulder
122
How are clavicle # managed?
Usually conservative | ORIF if shortened/comminuted/Z pattern
123
Give 3 complications of clavicle #
``` Malunion Non-union Bump Stiffness Infection ```
124
How are clavicle # classified?
Lateral (15%) Middle (80%) Medial (5%)
125
What is the most common type of shoulder dislocation?
Anterior
126
What are proximal humerus # and brachial plexus injuries associated with?
Shoulder dislocation
127
How is shoulder dislocation managed?
Urgent reduction
128
Give 2 complications of anterior shoulder dislocation seen on x-ray
Bankhart lesion | Hill-Sachs lesion
129
What is a Bankhart lesion?
Anterior shoulder dislocation complication - injury to anterior glenoid
130
What is a Hill-Sachs lesion?
Anterior shoulder dislocation complication - depression in posterolateral head of humerus
131
What must be assessed in older patients who have a shoulder dislocation before discharge?
Rotator cuff injury
132
What is the most common mechanism of action of ACJ dislocation?
Direct blow to shoulder
133
How are ACJ dislocations classified?
Rockwood type 1-6
134
How are ACJ dislocations managed?
Grade 1-3 - conservative PT | Grade 4-6 - reconstruction/ORIF with hook plate
135
How are proximal humerus # classified?
Neer classification
136
How are proximal humerus # managed?
Depends on number of fragments and their displacement
137
In what type of # is axillary nerve palsy a complication?
Proximal humerus #
138
How are humeral shaft # classified?
Location - proximal, middle, distal
139
What is a Holstein-Lewis #?
Spiral fracture of distal 1/3 of humeral shaft associated with radial nerve palsy
140
How are humeral shaft # managed?
Usually conservative - humeral brace | Open, vascular injury, plexus injury, forearm fracture (floating elbow), polytrauma - ORIF
141
Is radial nerve palsy due to humeral shaft # an indication for surgery?
Only if palsy has occurred due to manipulation/intervention
142
What is the most common elbow #?
Radial head #
143
What is the most common mechanism of injury for radial head #?
FOOSH with pronated forearm
144
How are radial head # classified?
Mason types 1-4
145
What is an Essex-Lopresti injury?
Interossesous membrane disruption and distal radial ulnar joint (DRUJ) injury
146
How are radial head # managed?
Type 1 - conservative Type 2 - conservative unless block to rotation Type 3/4 - ORIF, excision or replacement
147
Give 2 complications of radial head #
Soft tissue injury - DRUJ, interosseous membrane, MCL, LCL, elbow dislocation Loss of forearm movements
148
What is the 'terrible triad' of radial head # complications?
Elbow dislocation Coronoid # Radial head #
149
What is the most common type of elbow dislocation?
Posterolateral
150
What is the most common mechanism of elbow dislocation?
Axial loading, supination and valgus force
151
How are elbow dislocations classified?
Location of olecranon in relation to humerus - simple or complex
152
What is the 'terrible triad' of elbow dislocation?
Elbow dislocation (lateral ulnar collateral ligament injury) Radial head # Coronoid process #
153
How are elbow dislocations managed?
Closed reduction or ORIF with soft tissue repair
154
Give 2 complications of elbow dislocation
Stiffness Instability Heterotrophic ossification Neurovascular injury
155
Give 3 features to look for on x-ray of an elbow dislocation
Alignment - anterior humeral line, radiocapitellar line Fat pads - anterior may be normal, posterior always abnormal Cortices
156
What is the most common mechanism for forearm (both bones) #?
Direct trauma
157
How are forearm (both bones) # managed?
Conservative - minimal displacement | ORIF
158
What is a Monteggia #?
Proximal 1/3 ulnar # with associated radial head dislocation/instability
159
At what age is a Monteggia # most likely to occur?
4-10 years
160
What is a Galeazzi #?
Distal 1/3 radial shaft # with associated DRUJ injury
161
Give 3 signs of DRUJ injury
Ulnar styloid # Widening of joint on AP view Dorsal/volar displacement on lateral view Radial shortening (>5 mm)
162
Give 2 upper limb # associated with osteoporosis
Proximal humerus # | Distal radius #
163
How are distal radius # classified?
Intra/extra-articular Shortened Displaced Comminuted
164
How are distal radius # managed?
Extra-articular, simple - MUA and plaster, K wires | Intra-articular, complex - ORIF
165
Give 2 complications of distal radius #
Complex regional pain syndrome Stiffness Extensor pollicis longus rupture
166
What is the most common type of scaphoid #?
Waist (65%) Proximal (25%) Distal (10%)
167
Describe the blood supply of the scaphoid and its significance
Retrograde blood supply from branches of radial artery - risk of AVN increases with proximity of fracture
168
How are scaphoid # managed?
Usually conservative | ORIF for proximal pole # or displaced waist #
169
How are scaphoid # imaged?
X-ray Repeat x-ray in 2 weeks if negative MRI for occult fracture
170
Give 2 complications of scaphoid #
Non-union SNAC wrist AVN
171
What is SNAC wrist?
Scaphoid non-union advanced collapse - progressive degenerative arthritic changes in the wrist
172
What is the mechanism of perilunate dislocation?
Wrist extended with ulnar deviation = intercarpal supination Scapholunate ligament, capitolunate articulation and lunotriquetral articulation disruption -> failure of dorsal radiocarpal ligament -> lunate dislocates
173
How are perilunate dislocations classified?
Mayfield classification 1-4
174
How are perilunate dislocations managed??
Urgent reduction and fixation with K wires +/- ligament reconstruction +/- carpal tunnel release
175
What metacarpals are most commonly #?
5th MC | MC neck
176
How are metacarpal/phalanx # managed?
Conservative - good movement | ORIF or K wires - rotational deformity
177
Give 2 complications of metacarpal/phalanx #
Stiffness OA Deformity
178
How can major trauma and polytrauma be defined?
Major - injury with the potential to cause prolonged disability or death; injury severity score >15 Poly - multiple severe injuries which may cause dysfunction/failure of organs/systems
179
What scoring systems can be used for trauma?
Injury severity score Abbreviated injury scale Revised trauma score
180
What is a primary survey?
Initial assessment of trauma patient to detect and treat imminent threats to life A-E (with c-spine control as part of A and haemorrhage control as part of C)
181
Give 2 sources of major haemorrhage
``` Chest Abdomen Pelvis Retroperitoneum Long bones ```
182
What are the 3 types of pelvic fracture?
Lateral compression AP compression Vertical shear
183
How can the pelvis be stabilised in trauma?
Pelvic binder
184
Outline the major haemorrhage protocol
Assess - major haemorrhage Restore volume - wide bore cannulae, fluids, oxygen, monitor BP Summon help and stop bleeding - 2222 call for major haemorrhage, call surgery/anaesthetics Bloods - emergency crossmatch, FBC, clotting screen, calcium Give blood products as necessary
185
How is major haemorrhage defined?
50% blood loss in 3 hours OR rate of loss >150ml/minute
186
What is a secondary survey?
Complete head-to-toe systematic examination once patient is stable Focused history
187
What are the differential diagnoses for back pain?
``` Mechanical back pain Osteoarthritis of the spine Prolapsed intervertebral disc Spinal stenosis Spondylolithesis Discitis Inflammatory causes Malignancy Fracture Referred pain from - abdomen, hip, pelvis, SI joints ```
188
How should mechanical back pain be investigated?
No investigation unless more sinister cause suspected or history >6 weeks Check - FBC with differential WCC, EST, LFTs, bone profile, myeloma screen, CRP
189
How should mechanical back pain be managed?
Patient education Simple analgesia Early return to normal activities Self-referral to physiotherapy
190
Give 5 red flags for back pain
``` Thoracic pain Fever and unexplained weight loss Bladder or bowel dysfunction History of carcinoma Ill health or presence of other medical illness Progressive neurological deficit Disturbed gait, saddle anaesthesia Age of onset <20 years or >55 years Immunocompromised/prolonged steroid use Limb weakness Bilateral radicular pain ```
191
What is the most common cause of nerve root impingement causing back pain?
Intervertebral disc herniation (L4/5 or L5/S1)
192
What pattern does pain follow in nerve root impingement?
Radicular pain which extends below the knee, is equal to/worse than the back pain and follows the dermatome of the involved nerve root
193
Give 2 clinical signs of nerve root impingement
Leg pain in dermatomal distribution extending below the knee | Pain on straight leg raise
194
What imaging is used to diagnose nerve root impingement and what are the indications?
MRI Radicular pain >6 weeks and failure of conservative measures Neurologic deficit Bilateral lower limb deficit/peroneal symptoms (CES)
195
How is nerve root impingement managed?
Non-surgical - PT, NSAIDs, muscle relaxants, acupuncture | Surgical - decompression
196
What are the absolute and relative indications for surgical intervention in nerve root impingement?
Absolute - CES, progressive neurological deficit Relative - intractable radicular pain, neurological deficit not improving despite conservative measures, recurrent sciatica following successful conservative measures
197
What are the 3 main clinical features of cauda equina syndrome?
Bilateral parasthesia/muscle weakness Saddle parasthesia Bladder and bowel dysfunction
198
Give 2 red flags for cauda equina syndrome on history taking
``` Back pain with sciatica Lower limb weakness Altered perianal sensation Faecal incontinence Acute urinary retention/incontinence ```
199
Give 2 red flags for cauda equina syndrome on examination
Limb weakness Other neurological deficit/gait disturbance Hyper-reflexia/clonus/up-going plantars Urine retention DRE - saddle anaesthesia, loss of anal tone
200
How is CES managed?
History and examination (including DRE) Bladder scan pre and post void Urgent MRI Refer to neurosurgery for decompression
201
What are discitis and vertebral osteomyelitis?
Discitis - infection of the disc space | Vertebral osteomyelitis - infection of the vertebral body
202
What are discitis/vertebral osteomyelitis associated with?
IV drug use Sepsis from another source Post-spinal surgery
203
What organisms most commonly cause discitis/vertebral osteomyelitis?
Staphylococci and streptococci Strep and haemophilus in children Tuberculosis should also be considered
204
How does discitis/vertebral osteomyelitis present?
Fever Generally unwell Unrelenting back pain Spinal deformity (late)
205
How should discitis/vertebral osteomyelitis be investigated?
Bloods - WCC, ESR, CRP | Imaging - XR, MRI
206
How is discitis/vertebral osteomyelitis managed?
CT guided biopsy IV antibiotics (6 weeks) Surgical - stabilisation, abscess drainage
207
What is the most common type of spinal tumour?
Metastatic
208
How are spinal tumours investigated?
MRI spine Bone scan Serum calcium
209
What is malignant spinal cord compression?
Patients with spinal metastatic disease present with compression of the spinal cord - oncolocy/neurosurgery emergency
210
How is malignant spinal cord compression managed?
Emergency radiotherapy or surgical decompression
211
What type of spinal fractures are stable/unstable?
Isolated anterior column fractures (wedge compression) tend to be stable Both column (burst fractures) or associated ligament injuries tend to be unstable
212
How should a patient with a suspected spinal injury be assessed?
Log roll with C-spine control Examination - bony midline tenderness, clinical deformity/palpable step, boggy swelling/bruising, neurological compromise ASIA chart documentation of neurological deficits Spinal shock - bradycardia, hypotension
213
How can different imaging modalities be used to investigate spinal injuries?
XR - c-spine, T and L spine CT - high energy, >1 column, SC or ligament injury MRI - SC or ligament injury
214
How should spinal injuries be managed?
Stable - cervical (collar, analgesia), thoracolumbar (early mobilisation, brace) Unstable - cervical (HALO, collar, ORIF), thoracolumbar (ORIF, brace, bed rest)
215
How are spinal cord injuries managed?
Surgical decompression and stabilisation
216
Define scoliosis
Lateral deviation/rotational deformity of the spine
217
What are the causes of scoliosis?
Idiopathic Neuromuscular Congenital Secondary
218
How is scoliosis managed?
Mild - conservative, brace if risk of progression | Moderate/severe - surgical correction
219
Give 2 common causes of shoulder pain?
Subacromial impingement Rotator cuff tears Dislocation Arthritis
220
What is subacromial impingement?
First stage of rotator cuff disease Most common cause of shoulder pain Inflammation of the subacromial bursa due to abutment of the greater tuberosity/RC and the acromion/coraco-acromial ligament/acromioclavicular joint
221
What 3 things are associated with subacromial impingement?
Hook shaped acromion Greater tuberosity fracture malunion Shoulder instability
222
How does subacromial impingement present?
Insidious onset shoulder pain Exacerbated by overhead activities Night pain
223
What signs of subacromial impingement can be seen on examination?
``` Positive painful arc test (60-120 degrees) Neer impingement sign (pain on passive forward flexion >90 degrees) Hawkins test (pain on passive forward flexion to 90 degrees and internal rotation) ```
224
What features may be seen on XR of a patient with subacromial impingement?
Type 3 hooked acromion ACJ osteoarthritis Sclerosis/cystic changes in greater tuberosity
225
How is subacromial impingement managed?
Non-operative - PT, NSAIDs, corticosteroid injections | Operative - arthroscopic subacromial decompression and acromioplasty
226
What are the risk factors for rotator cuff tears?
Age Smoking Hypercholesterolaemia Thyroid disease
227
How can rotator cuff tears be categorised?
Mechanism - chronic degenerative tear, acute traumatic avulsion Size - small, medium, large, massive (>=2 tendons)
228
What are the 2 main symptoms of rotator cuff tears?
Pain - acute/insidious, deltoid region, worse on overhead activities, night pain Weakness - loss of active ROM
229
What sign is seen on physical examination of rotator cuff tears if the supraspinatus is involved?
Jobe's/empty can test
230
What sign is seen on physical examination of rotator cuff tears if the infraspinatus is involved?
External rotation lag (Arm is placed in maximal ER; patients with a massive RC tear will be unable to maintain the arm in that position and the arm will swing toward neutral rotation)
231
What sign is seen on physical examination of rotator cuff tears if the teres minor is involved?
``` Hornblower sign (The patient is asked to bring the hands to the mouth; if teres minor is torn, will do it, but only with the elbow in a high position on the affected side) ```
232
What sign is seen on physical examination of rotator cuff tears if the subscapularis is involved?
Lift-off and belly-press tests
233
What imaging modalities are used for rotator cuff tears?
USS | MRI
234
How are rotator cuff tears managed?
Non-operative - PT, NSAIDs, steroid injections Operative - repair (young), debridement (elderly, irreparable), tendon transfer (young, irreparable), reverse total shoulder arthroplasty (massive tear with advanced arthritis)
235
What is the most common joint dislocation and why?
Shoulder - the head of humerus is larger than the shallow glenoid fossa
236
How are shoulder dislocations classified?
Anterior (95%) Posterior (4%) Inferior (1%)
237
What is the usual mechanism of injury in posterior shoulder dislocation?
Seizure | Electric shock
238
Give 2 clinical features of shoulder dislocation
Severe pain Inability to move Empty glenoid fossa (palpable lump) Arm held in external rotation and slight abduction
239
Give 2 complications of shoulder dislocation
``` Axillary nerve damage Brachial plexus injury Axillary artery/vein injury Avulsion fracture of tuberosities Recurrent shoulder instability (<30 years) Rotator cuff injury (>45 years) ```
240
What is a Bankhart lesion?
Injury of the anterior inferior lip of the glenoid labrum due to traumatic anterior shoulder dislocation
241
How are shoulder dislocations managed?
Emergency - sling immobilisation, analgesia Conservative - closed reduction Surgical - reduction of humeral head and repair of labrum
242
What are the indications for surgical management of shoulder dislocation?
Unsuccessful closed reduction Displaced Bankhart lesion Recurrent dislocation Young and active to prevent recurrence
243
What are the 2 types of shoulder OA?
Primary | Secondary - fracture/dislocation, RA/gout, AVN, massive RC tear leading to arthritis
244
What are the signs/symptoms of shoulder OA?
Shoulder pain Loss of ROM (especially external rotation - anterior capsule contraction), pain at night Crepitus
245
What are the XR features of shoulder OA?
Joint space narrowing Subchondral sclerosis Subchondral cysts Osteophytes Circumferentially at humeral head “goat’s beard” Posterior glenoid wear
246
How is shoulder OA managed?
NSAIDs, PT, steroid injections | Shoulder replacement
247
Give 3 common causes of elbow pain
``` OA RA Tennis elbow Golfer's elbow Olecranon bursitis ```
248
How is elbow OA managed?
NSAIDs, steroid injections | Debridement (removal of osteophytes and capsular release), arthroplasty
249
What is tennis elbow?
Overuse injury at origin of common extensor tendon (ECRB) leading to tendinosis and inflammation
250
What are the clinical features of tennis elbow?
Pain with gripping and resisted wrist extension Point tenderness at lateral epicondyle (ECRB origin) Exacerbation of pain on resisted extension of long finger
251
What feature of tennis elbow may be seen on XR?
Calcifications at extensor origin
252
How is tennis elbow managed?
NSAIDs, PT, steroid injections | Release and debridement of ECRB origin
253
Define golfer's elbow
Overuse of flexor-pronator origin - medial epicondylitis
254
What are the clinical features of golfer's elbow?
Pain on gripping and resisted wrist flexion Point tenderness distal to medial epicondyle Pain on resisted forearm pronation and wrist flexion
255
What features of golfer's elbow may be seen on XR/MRI?
XR - calcifications at flexor origin | MRI - rule out ulnar collateral ligament injury in overhead throwers
256
What is the main differential for golfer's elbow?
Ulnar collateral ligament injury
257
How is golfer's elbow managed?
NSAIDs, PT, steroid injection | Debridement and reattachment of flexor-pronator origin
258
What are the causes of olecranon bursitis?
``` Trauma Prolonged pressure Infection RA Gout ```
259
How does olecranon bursitis present?
``` Swelling Pain Redness Warmth Fever and malaise if infective ```
260
How is olecranon bursitis investigated?
``` FBC Uric acid level CRP XR - olecranon spur Aseptic needle aspiration - GS, C&S, crystals ```
261
How is olecranon bursitis managed?
Non-infective - ice, elevation, NSAIDs, treat cause Infective - broad spectrum antibiotics Recurrent - interval bursectomy
262
What is the differential diagnosis for tingling fingers?
Peripheral nerve entrapment (carpal tunnel syndrome or cubital tunnel syndrome) Central nerve entrapment Peripheral neuropathy
263
What are the 3 key features of peripheral nerve entrapment?
Pain/paraesthesia in the distribution of the nerve Altered sensation in the distribution of the nerve Reduced muscle function supplied by the nerve
264
What forms the carpal tunnel?
Bones of the carpus roofed by the transverse carpal ligament (flexor retinaculum)
265
What passes through the carpal tunnel?
``` 10 structures, 4 components Median nerve 4 x FDS (flexor digitorum superficialis) 4 x FDP (flexor digitorum profundus) 1 x FPL (flexor pollicis longus) ```
266
What conditions are associated with CTS?
``` Diabetes Hypothyroidism RA Acromegaly Wrist fracture Pregnancy Use of heavy vibrating machinery ```
267
How does CTS present?
Nocturnal waking with tingling (relieved by shaking/running under water) Altered/reduced sensation in median nerve distribution Difficulty manipulating small objects Clumsiness
268
What signs are seen on examination of CTS?
Reduced/altered sensation in median nerve distribution Reduced power of median nerve innervated muscles of the hand - thumb abduction Thenar muscle wasting Positive Tinel's test Positive Phalen's test
269
How is CTS managed?
``` Wrist splints (night) Steroid injections (pregnancy) Decompression surgery - division of flexor retinaculum longitudinally ```
270
What causes cubital tunnel syndrome?
Compression of ulnar nerve in cubital tunnel behind medial epicondyle of elbow
271
What forms the cubital tunnel?
Cubital tunnel retinaculum | Ulnar nerve travels underneath between 2 heads of FCU
272
How does cubital tunnel syndrome present?
Nocturnal wakening with tingling in ulnar nerve distribution Altered/reduced sensation in ulnar nerve distribution
273
What signs may be seen on examination of cubital tunnel syndrome?
Altered/reduced sensation in ulnar nerve distribution Reduced power of ulnar nerve innervated muscles - finger abduction Claw posture (severe) Hypothenar muscle wasting Interosseous muscle wasting Positive Tinel's sign at elbow
274
How is cubital tunnel syndrome managed?
Soft elbow splints (night) | Decompression surgery
275
Why are steroid injections not used to treat cubital tunnel syndrome?
Risk of ulnar nerve injury
276
What is the differential diagnosis for sticking fingers?
Trigger finger | Extensor tendon subluxation
277
What causes trigger finger?
Constriction and thickening of A1 pulley | Nodule on tendon
278
How does trigger finger present?
Finger stuck in flexion and clicks painfully when extended | Worse in morning
279
Patients with what condition are at higher risk of trigger finger?
Diabetes
280
How is trigger finger managed?
Splint Steroid injection Surgical release of A1 pulley
281
What causes extensor tendon subluxation?
Weakness of sagittal bands which hold extensor tendon centrally over MCPJ
282
Patients with what condition are at higher risk of extensor tendon subluxation?
RA
283
How does extensor tendon subluxation present?
On flexion, tendon subluxes into ulnar gutter and flicks back in extension so needs to be straightened manually
284
How is extensor tendon subluxation managed?
Splint | Surgical recontruction/repair
285
What is the differential diagnosis for stuck fingers?
Dupuytren's disease Radial nerve/posterior interosseous nerve injury Locked trigger finger Subluxed MCPs
286
What causes Dupuytren's disease?
Autosomal dominant genetic condition with variable penetrance Proliferation of myofibroblasts in palmar fascia producing nodules and cords
287
What are the ectopic manifestations of Dupuytren's disease?
Plantar fascia of feet (Ledderhose disease) Knuckle pads on dorsal aspect of PIPJs (Garrod’s disease Dartos fascia of penis (Peyronie’s disease)
288
How does Dupuytren's disease present?
Fixed flexion deformity of MCP and PIP joints | Difficulty with ADLs
289
How is Dupuytren's disease managed?
Needle aponeurectomy (hypodermic needle used to cut cords) Collagenase injections (digests collagen and allows snapping by extension 24-72 hours later) Fasciectomy (surgical excision of cords) Dermofasciotomy (as above including overlying skin and application of skin graft)
290
What are the causes of radial/interosseus nerve palsy?
Trauma RA elbow Compression neuropathy
291
How does radial/interosseus nerve palsy present?
Weakness of active wrist/finger and thumb extension Wrist drop Normal passive movement
292
How is radial/interosseus nerve palsy managed?
``` Repair nerve (laceration) Treat inflammation (synovitis) Surgical decompression (compression) ```
293
What causes subluxed MCPs?
RA
294
How do subluxed MCPs present?
Swollen painful MCPs Inability to extend Obvious deformity
295
How are subluxed MCPs managed?
Joint replacement
296
What are the differentials for radial sided wrist pain?
``` De Quervain's stenosing tenovaginitis Scaphoid fracture Radial styloid fracture Thumb CMC joint OA Scaphotrapezotrapezoid OA ```
297
What causes De Quervain's stenosing tenovaginitis?
Stenosis at 1st dorsal extensor compartment (APL and EPB tendons pass through)
298
How does De Quervain's stenosing tenovaginitis present?
Pain on wringing/removing stiff lids Pain on resisted abduction Positive Eichoff's test
299
What is Eichoff's test?
Positive if pain over De Quervain's tendons on ulnar deviation with thumb in fist
300
How is De Quervain's stenosing tenovaginitis managed?
Splint Steroid injection Surgical release of 1st dorsal compartment
301
Give 2 features of scaphoid fractures
Young people FOOSH Difficult to see on XR Treated with plaster cast
302
Give 2 features of radial styloid fracture
May be associated with other carpal injuries | Treated with immobilisation in splint or plaster cast
303
How does thumb carpo-metacarpal OA present?
Pain and stiffness Pain on wringing/removing stiff lids Positive grind test Often noticed after a fall
304
How is thumb carpo-metacarpal OA managed?
Analgesia, splint, steroid injection | Surgery - excise, fuse, replace
305
What are the differentials for lumps and bumps on the hand and wrist?
``` Ganglion Giant Cell Tumour Heberden’s and Bouchard’s nodes Skin lesions Gouty Tophi Rheumatoid Nodules Inclusion cysts Osteochondroma Enchondroma ```
306
What are the most common sites for ganglions in the hand?
Dorsal wrist Volar wrist Finger flexor sheath DIP joint
307
How are ganglions managed?
None - most will spontaneously regress | Can aspirate or excise
308
What is a giant cell tumour of the tendon sheath and how is it managed?
Benign but aggressive slow growing tumour which can become very large Excision
309
What are the 2 complications of gouty tophi?
``` Skin ulceration Tendon infiltration (difficult excision) ```
310
What is an enchondroma and how is it managed?
Commonest bony tumour in hand which is benign | Observation, curretage and bone graft
311
Define osteoporosis
Low BMD and microarchitectural deterioration of bone leading to increased risk of fractures
312
Give 3 risk factors for reduced BMD
``` Oestrogen deficiency in females Androgen deficiency in males Endocrine disease (diabetes, hyperthyroidism) Malabsorption (Crohn's, UC, coeliac disease) CKD COPD Immobiliry Low BMI ```
313
Give 3 risk factors for osteoporosis
``` Age Oral steroids Smoking Alcohol Previous fragility fracture RA Parental hip fracture Drugs - SSRIs, PPIs ```
314
What do T- and Z-scores show?
T - compares BMD with normal adult | Z - compares BMD with age-matched controls
315
How are T-scores used in diagnosis of osteoporosis
Normal > -1 Osteopenia between < -1 and > -2.5 Osteoporosis < -2.5
316
What is a fragility fracture?
Caused by low energy mechanism which would not normally cause a fracture (e.g. fall from standing height)
317
What 2 assessment tools can be used to determine fracture risk?
FRAX | QFracture
318
Who should undergo assessment of fragility fracture/osteoporosis risk, according to NICE?
All women 50-64 years and all men 50-74 years with: previous fragility fracture, current/frequent use of oral steroids, history of falls, low BMI, smoking, alcohol >14 units/week, secondary cause of osteoporosis All patient <50 years with: steroids, menopause, previous FF All patients <40 years with: steroids, previous/multiple FF
319
What conditions causing fragility fractures should be excluded in suspected osteoporosis?
Metastatic disease Myeloma Osteomalacia Paget's
320
How is osteoporosis managed non-pharmacologically?
Exercise (weight-bearing) Reduce fizzy drinks (phosphoric acid) HRT for menopause <40 years Vitamin D and calcium
321
What are the pharmacological options for managing osteoporosis?
Bisphosphonates (e.g. alendronate) - reduce resorption SERM (e.g. raloxifene) Calcitonin - inhibits resorption Monoclonal (e.g. denosumab) - inhibits formation Recombinant PTH (e.g. teriparatide) - anabolic
322
What is osteomalacia/Rickets?
Defective mineralisation of osteoid most commonly due to vitamin D deficiency Osteomalacia - after skeletal maturity Rickets - before (children)
323
How is bone morphology affected in Rickets?
Fraying and widening of metaphysis (cupping) Increased physeal width and cortical thinning/bowing Large physes most prominent (e.g. knee, wrist)
324
What are the causes of vitamin D dependent forms of osteomalacia/Rickets?
``` Low UV radiation exposure Low oral intake Low intestinal absorption (e.g. CF, pancreatitis, coeliac) Drugs Alcoholism Renal/hepatobiliary disease Tumours ```
325
What are the causes of vitamin D independent forms of osteomalacia/Rickets?
``` Renal dysfunction (e.g. renal tubular acidosis, Fanconi anaemia) Drugs - bisphosphonates, fluoride, antacids ```
326
Give 3 clinical features of Rickets
``` Bowed legs Rachitic rosary (ribs) Kyphosis Flattened skull Deformity and pain ```
327
How is osteomalacia/Rickets managed?
``` Vitamin D Calcium Calcitriol Phosphate Surgical correction ```
328
Give 3 clinical features of osteomalacia
Bone and muscle pain Waddling gait (proximal muscle weakness) Fractures Looser's zones, trefoil pelvis, biconcave vertebral fracture, protusio acetabuli on XR
329
What is Paget's disease? What are the 3 phases?
Disorder of bone remodelling in which there is increased osteoclast activity Phases - lytic, mixed, sclerotic
330
What are the clinical features of Paget's disease?
``` Localised pain and tenderness Increased temperature (hyperaemia) Increased bone size Bowing deformity Kyphosis of spine Decreased ROM 75% asymptomatic ```
331
What are the complications of Paget's disease?
``` Deformity Pathological fracture OA risk Hearing loss Neural compression Malignant transformation High output congestive cardiac failure Hyperparathyroidism Extramedullary haematopoeisis ```
332
What signs of Paget's disease can be seen on skull XR?
Osteoporosis circumscripta - a large, well-defined lytic lesion Cotton wool appearance - mixed lytic and sclerotic lesions of the skull Diploic widening - both inner and outer calvarial tables are involved, with the former usually more extensively affected Tam O'Shanter sign - frontal bone enlargement, with the appearance of the skull falling over the facial bones, like a Tam O'Shanter hat
333
What signs of Paget's disease can be seen on pelvic XR?
Cortical thickening and sclerosis of the iliopectineal and ischiopubic lines Acetabular protrusion Enlargement of the pubic rami and ischium
334
What signs of Paget's disease can be seen on long bone XR?
Blade of grass/candle flame sign - begins as a subchondral area of lucency with advancing tip of V-shaped osteolysis, extending towards the diaphysis Lateral curvature (bowing) of the femur Anterior curvature of the tibia - sabre
335
What signs of Paget's disease can be seen on spine XR?
Picture frame sign - cortical thickening and sclerosis encasing the vertebral margins Squaring - flattening of the normal concavity of the anterior margin of the vertebral body also adds to the rectangular appearance Vertical trabecular thickening
336
How is Paget's disease managed?
Bisphosphonates Calcitonin Surgical correction of deformities/fractures
337
What are the compartments of the leg?
Anterior - deep peroneal nerve, dorsiflexors Lateral - superficial peroneal nerve, evertors Superficial and deep posterior - tibial nerve, plantarflexors
338
Name 3 lesser toe deformities
Mallet toe Hammer toe Claw toe
339
What is metatarsalgia and what is the differential?
Pain under forefoot | Tight calf, fracture, Morton's neuroma, Freiberg's infraction
340
What conditions can affect the lateral and medial ankle?
Lateral - peroneal tendon pathology, lateral ligament, subtalar joint arthritis Medial - deltoid ligament injury, tibialis posterior tendinopathy, OA
341
What conditions can affect the anterior and posterior ankle?
Anterior - osteophyte impingement, OA, loose bodies | Posterior - Achilles tendon rupture/tendinopathy, os trigonum, sub talar OA
342
How is hallux valgus managed?
Accommodative shoes, orthotics | Osteotomy (failed non-operative management, pain, skin compromise)
343
What is hallux rigidus?
1st MTPJ OA | Pain, stiffness, prominent bump
344
How is hallux rigidus managed?
Accommodative shoes, Rocker sole, orthotics | Cheilectomy (mild, bump trimming), fusion (Gold standard)
345
How is ankle arthritis managed?
Analgesia, activity modification, splint, injection | Fusion, replacement
346
What are the signs/symptoms of a growing bone tumour?
``` Pain Swelling Joint swelling and stiffness Limping Fever Generally unwell Weight loss Anaemia ```
347
What basic investigations can be done in suspicion of bone/soft tissue lesions?
``` XR - appearance Bloods - alkaline phosphatase CT - size MRI - soft tissue Biopsy - definitive diagnosis ```
348
What is an osteoid osteoma?
Benign bone tumour arising from osteoblasts which tend to be <1.5cm in size and are more common in long bones
349
What is an osteochondroma?
Most common benign tumour | Cartilage capped bony projections/outgrowths on the surface of bones
350
What is an enchondroma?
Benign bone tumour of cartilage
351
What is a simple bone cyst?
AKA unicameral bone cyst (UBC) | Benign cavity filled with yellow fluid which may be active or latent
352
What is fibrous dysplasia?
Uncommon bone disorder in which fibrous tissue develops in place of bone which leads to weakness and deformity/fracture Commonly affects a single bone - skull or long bones
353
What is a lipoma?
Benign tumour made of fat tissue which may be superficial (back, thigh, buttocks, shoulders, arms) or deep (muscles)
354
What is osteosarcoma?
Most common malignant bone tumour which peaks during growth spurts Mostly from metaphysis of distal femur, proximal tibia or proximal humerus
355
What is chondrosarcoma?
Malignant tumour of cartilaginous origin arising from diaphyseal-metaphyseal region of long bones most commonly in males aged 30-50 Mostly femur, pelvis or scapula
356
What is Ewing's sarcoma?
Highly malignant tumour occurring in children which arises from mesenchymal cells of medullary cavity Mostly diaphysis of long bones or pelvis
357
What is the most common cause of a destructive bone lesion in an adult?
Metastatic bone disease
358
What cancers commonly spread to bone?
``` Breast Prostate Thyroid Renal Lung ```
359
Give 3 things to consider regarding fluid management and blood loss in orthopaedic patients
``` Type of injury (trauma cases) Amount of fluid loss during operation Type of fluid loss (blood, insensible, third space) Level of dehydration/overload Age Comorbidities ```
360
How is fluid balance assessed?
Clinical examination Urine output (CVP monitoring)
361
What are the 3 types of post-operative infection?
Surgical site Superficial - within 30 days, skin and subcutaneous tissue Deep - within 30 days (no implant) or 90 days (implant), fascia/muscle involved
362
What are the 3 most common organisms causing post-operative infection in hip arthroplasty?
Coagulase negative staphylococcus (67%) Staphylococcus aureus including MRSA (13%) Streptococcus (9%) E.coli (6%)
363
What are the risk factors for post-operative infection?
``` Trauma case Open wounds Diabetes Obesity Vascular disease Prolonged procedure time Older patients Immune impairment Nutritional deficiencies (e.g. low albumin) ```
364
How should post-operative infection be managed?
Refer to treating team/on call orthopaedics Take wound swab, tissue culture and bloods Do not commence antibiotics without swabs/cultures and senior input
365
Why should antibiotics not be given until adequate samples and senior input obtained?
Prosthetic joint infection can be difficult to identify and organisms difficult to culture Best chance to isolate infection is at first presentation before antibiotic therapy
366
Give 2 considerations for pain management in post-operative patients
``` Pre-operative education Use oral over IV administration Avoid IM administration IV patient controlled analgesia recommended if parenteral route needed Monitor sedation Local infiltration is useful Regional anaesthesia (e.g. nerve catheter or regional nerve block) can be effective but may hide signs of compartment syndrome Be aware of toxicity ```
367
Define AKI
Elevated creatinine | Reduced urine output
368
How does AKI occur in post-operative patients?
Hypotension leads to pro-inflammatory state --> increase in vasoconstrictive mediators --> tubular ischaemia and injury
369
What are the procedure related risk factors for AKI in post-operative patients?
Hypovolaemia Reduced systemic vascular resistance (anaesthesia) Nephrotoxic agents (NSAIDs, contrast) Prophylactic antibiotics (gentamicin, flucloxacillin)
370
What are the patient related risk factors for AKI in post-operative patients?
``` Older patients Pre-existing CKD Diabetes Liver disease Hypertension ACEi ```
371
How should post-operative AKI be managed?
Loop diuretics only for fluid overload | Aim to maintain optimal haemodynamic state to perfuse kidneys
372
What is compartment syndrome?
Occurs when the pressure within a fascial compartment exceeds the capillary perfusion pressure of that compartment leading to a state of ischaemia Orthopaedic emergency that requires immediate attention.
373
What are the risk factors for compartment syndrome?
Trauma cases with crushing injury to tissues Trauma cases with long lie (rhabdomyolysis) Long bone fractures Patients with vascular injury to limb Ischaemia of tissues (eg prolonged tourniquet time) Patients with coagulopathy
374
What are the clinical features of compartment syndrome?
``` Pain (disproportionate to injury) Paraesthesia Pallor Pulselessness Paralysis Perishingly cold ```
375
What 3 features make orthopaedic patients at higher risk of thromboembolic disease?
Virchow's triad Blood stasis - immobilisation, tourniquet Endothelial injury - surgical position, limb manipulation Hypercoagulability - trauma increases thromboplastins, blood loss
376
What are the risk factors for thromboembolic disease?
``` Older patients Obesity Varicose veins Family history of VTE Thrombophilia Combined OCP / HRT Immobility Immobility due to travel Lower limb fracture Spinal cord injury Lower limb surgery ```
377
What are the options for VTE prophylaxis?
Mechanical - early mobilisation, graduated compression stockings, intermittent pneumatic compression devices Pharmacological - aspirin, vitamin K antagonists (warfarin), unfractionated heparin (clexane), newer oral anticoagulants (rivaroxaban/apixaban)
378
For how long does hypercoagulability persist after hip fracture?
Up to 6 weeks
379
How should hand amputations be assessed?
``` Level - tip, distal to FDS, proximal to FDS, hand, forearm, arm Vascularity Time from injury Bone, tendon and nerve injury Nail and skin loss ```
380
How are partial and complete finger tip amputations managed?
Partial - preserve and suture back on if viable Complete - usually not suitable for replant Try to preserve as much length as possible and insertion of FDP
381
How are finger tip injuries managed?
Dressing only or trimming of bone and dressing Primary closure Local advancement or transposition flap
382
How does amputation in relation to FDS change management?
Distal to FDS but proximal to DIPJ - ideal for replant | Proximal to FDS - unlikely to be replanted
383
What structures are at risk in self-harm?
Palmaris longus | Median nerve
384
How should tendon and nerve injuries be assessed?
Vascular assessment - CRT, pulses, emergency if able to replant Neurological assessment - radial and ulnar Tendon assessment - FDS and FDP tendons
385
How should tendon and nerve injuries be managed in A&E?
Local anaesthetic and irrigation Tetanus Dressing and back slab Low threshold for surgical exploration
386
How should tendon and nerve injuries be managed in theatre?
Exploration and repair Balance mobilisation and immobilisation Tendon and nerve repair

Year 5 (10 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions