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Orthopaedics > Orthopaedics Part 3 > Flashcards

Orthopaedics Part 3 Flashcards

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1
Q

What is Leriche syndrome?

A
  • atheromatous disease involving iliac vessels
  • blood flow to pelvic viscera compromised
  • buttock claudication and impotence
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2
Q

Diagnosis Leriche syndrome:

A
  • angiography

- iliac occlusions usually treated with endovascular angioplasty and stent insertion

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3
Q

Red flags for lower back pain:

A
  • <20yo or >50yo
  • history previous malignancy
  • night pain
  • history trauma
  • systemic symptoms
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4
Q

Spinal stenosis onset, symptoms, examination and diagnosis:

A
  • gradual
  • unilateral or bilateral leg pain (with or without back pain)
  • numbness, weakness worse on walking and resolves when sitting
  • relieved by sitting, leaning forwards and crouching
  • examination normal
  • MRI diagnosis
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5
Q

Presentation of ankylosing spondylitis:

A
  • young man with LBP and stiffness
  • worse in morning and improves with activity
  • peripheral arthritis
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6
Q

Peripheral arterial disease lower back pain presentation:

A
  • pain on walking, relieved by rest
  • absent or weak foot pulses
  • limb ischaemia
  • past history: smoking and other vascular disease
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7
Q

Back pain management:

A
  • NSAIDs
  • co-prescribe PPI for >45yo
  • exercise and manual therapy
  • epidural injections of local anaesthetic and steroid for acute and severe sciatica
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8
Q

Investigation lower back pain:

A
  • lumbar spine x-ray
  • MRI if non-specific back pain and malignancy, infection, fracture, cauda equina or ankylosing spondylitis suspected
  • no other imaging can see neurological/soft tissue structures
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9
Q

L3 nerve root compression features:

A
  • sensory loss anterior thigh
  • weak quadriceps
  • reduced knee reflex
  • positive femoral stretch test
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10
Q

L4 nerve root compression features:

A
  • sensory loss anterior knee
  • weak quadriceps
  • reduced knee reflex
  • positive femoral stretch test
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11
Q

L5 nerve root compression features:

A
  • sensory loss dorsal of foot
  • weakness in foot and big toe dorsiflexion
  • reflexes intact
  • positive sciatic nerve stretch test
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12
Q

S1 nerve root compression features:

A
  • sensory loss posterolateral leg and lateral foot
  • weakness plantar flexion of foot
  • reduced ankle reflex
  • positive sciatic nerve stretch test
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13
Q

Management prolapsed disc:

A
  • analgesia, physio, exercises

- if symptoms persists, referral for consideration MRI

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14
Q

Motor and sensory supply of femoral nerve:

A

motor: knee extension, thigh flexion
sensory: anterior and medial aspect of thigh and lower leg

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15
Q

Typical mechanism of injury femoral nerve:

A
  • hip and pelvic fractures

- stab/gunshot wounds

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16
Q

Motor and sensory supply of obturator nerve:

A

motor: thigh adduction
sensory: medial thigh

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17
Q

Typical mechanism of injury of obturator nerve:

A

anterior hip dislocation

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18
Q

Motor and sensory supply of lateral cutaneous nerve of thigh:

A

no motor

sensory: lateral and posterior surfaces of thigh

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19
Q

Typical mechanism of injury of lateral cutaneous nerve of thigh:

A

compression of nerve near the ASIS - meralgia paraesthetica, condition characterised by pain, tingling and numbness in distribution of lateral cutaneous nerve

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20
Q

Motor and sensory supply tibial nerve:

A

motor: foot plantar flexion and inversion
sensory: sole of foot

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21
Q

Typical mechanism of injury of tibial nerve:

A

not commonly injured as deep

popliteal lacerations, posterior knee dislocation

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22
Q

Motor and sensory supply common peroneal nerve:

A

motor: foot dorsiflexion and eversion, extensors hallucinate longus
sensory: dorsal of foot and lower lateral part of leg

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23
Q

Typical mechanism of injury common peroneal nerve:

A
  • injury at neck of fibula
  • tightly applied lower limb plaster cast
  • foot drop
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24
Q

Motor and sensory supply superior gluteal nerve:

A

motor: hip abduction
sensory: none

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25
Typical mechanism injury superior gluteal nerve:
- misplaced IM injection - hip surgery - pelvic fracture - posterior hip dislocation - positive Trendelenburg sign
26
Motor and sensory supply inferior gluteal nerve:
motor: hip extension and lateral roatation sensory: none
27
Typical mechanism of injury inferior gluteal nerve:
- association with sciatic injury - difficulty rising from seated position - can't jump, can't climb stairs
28
Muscles of anterior compartment and innervation:
-tibialis anterior -extensor digitorum longus -peroneus tertius -extensor hallucis longus all supplied by deep peroneal nerve
29
Action of tibias anterior:
- dorsiflexion ankle | - inversion
30
Action of extensor digitorum longus:
- extends lateral four toes | - dorsiflexes ankle joint
31
Action of peroneus tertius:
- dorsiflexes ankle | - eversion
32
Action of extensor hallucinate longus:
- dorsiflexion ankle | - extends big toe
33
Muscles of peroneal compartment and innervation:
-peroneus longus -peroneus brevis supplied by superficial peroneal nerve
34
Action of peroneus longus:
- eversion | - assists in plantar flexion
35
Action of peroneus brevis:
plantar flexion ankle
36
Muscles of superficial posterior compartment and innervation:
-gastrocnemius -soleus innervated by tibial nerve
37
Action of gastrocnemius:
plantar flexion foot (may also flex knee)
38
Action of soleus:
plantar flexor
39
Muscles of deer posterior compartment and innervation:
-flexor digitorum longus -flexor hallucis longus -tibialis posterior tibial nerve
40
Action of flexor digitorum longus:
flexes lateral four toes
41
Action of flexor hallucis longus:
flexes great toe
42
Action of tibialis posterior:
- plantar flexor | - inversion
43
Presentation lumbar spinal stenosis:
- back pain - neuropathic pain - symptoms mimicking claudication - sitting better than standing and may find it easier to walk uphill rather than downhill
44
Most common underlying cause of lumbar spinal stenosis:
- degenerative disease - begins in intervertebral disc where cell death and loss of proteoglycan and water content leads to progressive disc bulging and collapse - increased stress transfer to posterior face joints - cartilaginous degeneration, hypertrophy, osteophyte formation - thickening and distortion of ligaments flavum
45
Diagnosis and treatment lumbar spinal stenosis:
- MRI scanning | - laminectomy
46
What is meralgia paraesthetica:
- entrapment mononeuropathy of lateral femoral cutaneous nerve - can also be iatrogenic post surgery or neuroma
47
What nerve is affected in meralgia paraesthetica and how?
- lateral femoral cutaneous nerve - originates from L2/3 - runs beneath iliac fascia as it crosses surface of iliac muscle and exits through or under lateral inguinal ligament - as it passes inferiorly to anterior superior iliac since, repetitive trauma or pressure
48
Risk factors meralgia paraesthetica:
- obesity - pregnancy - tense ascites - trauma - iatrogenic - sports - idiopathic
49
Symptoms meralgia paraesthetica:
- burning, tingling, coldness, shooting pain - numbness - deep muscle ache - aggravated by standing and relieved by sitting - can be mild and resolve spontaneously
50
Signs of meralgia paraesthetica:
- may be reproduced by deep palpation below ASIS and extension of hip - altered sensation upper lateral thigh - no motor weakness
51
Investigations meralgia paraesthetica:
- pelvic compression test highly sensitive - injection with local aesthetic abolishes pain - US - nerve conduction studies
52
Which metatarsal is most and least commonly fractured?
- 5th most common | - 1st least common
53
5th metatarsal fractures:
- proximal avulsion fractures (Pseudo-Jones) - proximal tuberosity, associated with lateral ankle sprain often follow inversion injuries of anlke - Jones fractures - less common, transverse fracture at metaphysical-diaphyseal junction
54
Metatarsal stress fractures:
- healthy athletes | - most common site of metatarsal stress fractures is 2nd metatarsal shaft
55
Features and investigations of metatarsal fractures:
- pain and bony tenderness, swelling, antalgic gait - x-rays to distinguish between displaced and non-displaced fractures (periosteal reaction seen 2-3weeks later) - isotope scan or MRI
56
What is Morton's neuroma?
- benign neuroma affecting inter metatarsal plantar nerve - most commonly 3rd metatarsophalangeal space - more common female
57
Features Morton's neuroma:
- forefoot pain - worse on walking - Mulder's click - loss of sensation distally in toes
58
Diagnosis and management of Morton's neuroma:
- clinical diagnosis but US helpful - metatarsal pad - referral if persistent for >3 months - corticosteroid injection and neurectomy of involved interdigital nerve and neuroma
59
What is Froment's sign?
- asses for ulnar nerve palsy - adductor pollicis muscle function - hold piece of paper between thumb and index finger - object then pulled away - if palsy, unable to hold paper and will flex flexor pollicis longus to compensate
60
What is Phalen's test?
- assess carpal tunnel syndrome - more sensitive than Tinel's - hold wrist in maximum flexion and test positive if numbness in median nerve distribution
61
What is Tinel's sign?
- assess for carpal tunnel syndrome | - tap median nerve at wrist and test positive if tingling over distribution of median nerve
62
What is an open fracture defined as?
- disruption of bony cortex | - associated with breach in overlying skin
63
Features osteoarthritis of the hand:
- bilateral - carpometacarpal joints, distal interphalangeal joints affected more than proximal interphalangeal joints - episodic joint pain - stiffness worse after inactivity, only few minutes in morning compared to RA - painless nodes: Heberden's at DIPJ and Bouchard's at PIPJ - squaring of thumbs - fixed adduction
64
X-ray findings of osteoarthritis in hands:
osteophytes and joint space narrowing
65
Most common location of OA:
knee
66
Second most common location OA:
hip
67
Features osteoarthritis of hip:
- chronic history groin ache relieved by rest | - red flag: rest pain, night pain, morning stiffness >2 hours
68
What scoring system is used for OA of hip?
Oxford hip score
69
Management OA of hip:
- oral analgesia - intra articular injections - total hip replacement definitive treatment
70
Complications OA of hip and reasons for total hip:
- VTE, intraoperative fracture, nerve injury | - total hip: aseptic loosening, pain, dislocation, infection
71
Patients who have had a hip replacement operation should receive basic advice to minimise the risk of dislocation:
- avoid flexing hip >90 degrees - avoid low chairs - no leg crossing - sleep on back for 6 weeks
72
Complications joint replacement:
- wound and joint infection - thromboembolism (LMWH for 4 weeks) - dislocation
73
What is osteochondritis dissecans?
- pathological disease affecting subchondral bone - most often knee - also effects on joint cartilage, pain, oedema, free bodies and mechanical function - affects children and adolescents with open growth plates (juvenile OCD) and adults with closed (adult OCD)
74
Risk factors OCD:
- trauma - male - genetic
75
Features OCD:
- knee pain and swelling, typically after exercise - knee catching, locking and/or giving way - feeling a painful clunk when flexing or extending knee - involvement of lateral femoral condyle
76
Signs OCD:
- joint effusion - full range movement without signs of ligamentous instability - external tibial rotation when walking - tenderness on palpation of cartilage of medial femoral condyle when knee flexed - Wilson's sign
77
What is Wilson's sign?
- for detecting medial condyle lesion - with knee at 90 degrees and tibia internally rotated, gradual extension leads to pain at 30 degrees (external rotation of tibia relieves)
78
Investigations OCD:
- x-ray: subchondral crescent sign or loose bodies - MRI: to evaluate cartilage, loose bodies, stage and assess stability of lesion - CT: preoperative planning - scintigraphy: sign of osteoblastic activity
79
2 types osteomyelitis:
- haematogenous | - non-haematogenous
80
What is haematogenous osteomyelitis?
- from bacteraemia - monomicrobial - most common in children - vertebral most common from in adults - risk factors: sickle cell, IV drugs, immunosuppression due to meds or HIV, infective endocarditis
81
What is non-haematogenous osteomyelitis:
- contiguous spread of infection or from direct injury - polymicrobial - most common in adults - risk factors: diabetic foot ulcers/pressure sores, diabetes, peripheral arterial disease
82
Most common organism in osteomyelitis:
- staph aureus | - sickle cell: salmonella
83
Investigation and management of osteomyelitis:
- MRI - flucloxacillin for 6 weeks - or clindamycin
84
Typical presentation osteoporotic vertebral fractures:
- asymptomatic - acute back pain - breathing difficulties - gastrointestinal problems due to compression of organs - minority have history of trauma
85
Signs and investigation of osteoporotic vertebral fracture:
- loss of height - kyphosis - localised tenderness on palpation of spinous processes at fracture site - x-ray of spine first line - wedging of vertebra due to compression (old fractures have sclerotic appearance)
86
How to calculate 10-year risk of osteoporotic fracture:
QFRacture tool or FRAX

Orthopaedics (4 decks)

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