Orthopaedics + Trauma + Surgery Flashcards
Describe Plantar Fasciitis, it’s signs and symptoms, and management
Between 4-7% of people have heel pain at any given time and around 80% are due to plantar fasciitis.
Signs and symptoms: Sharp, unilateral (70%) heel pain, worse on bearing weight on the heel after long period of rest, usually improved on walking. Dorsiflexion of foot may cause pain, and Achilles’ tendon and calves muscles may be tight.
Management:
- around 90% are self-limiting and recover with conservative management within 6months
- NSAIDs, heat and ice, calf exercise may help
- steroid injections if non-resolving or severe pain may help
- If injections fail refer, extracorporeal shockwave therapy is a reasonable alternative
What are some causes of heel pain?
- Diseases of the calcaneum
- Rupture of calcaneal tendon
- Postcalcaneal bursitis
- Plantar fasciitis
- lymphoma in children
- arthritis of the subtalar joint
- calcaneal paratendinopathy
- Tender heel pad
- infection
What is the straight leg raise test and stretch?
A test to determine whether low back pain has an underlying herniated disc. Patient lies down, or sits (less sensitive) and examiner raise leg with knee extended and ankle dorsiflexion. Sciatic pain at 30-70 degrees indicates +ve test and suggest herniated disc
Stretch test = take lift leg to pain, stop lower slightly then dorsiflex foot if pain elicited sciatica likely.
Describe Benign Joint Hypermobility Syndrome, its symptoms, diagnostic criteria, and management.
Possible overlap with Ehlers-Danlos Type 3 (Hypermobility type), typically affects children and young adolescents.
Symptoms: Main features are joint Hypermobility, with exercise-related muscle and joint pain and some level of fatigue. Swelling, heat or redness are not present unless underlying injury. Extra-articulate symptoms include abdominal pain, headaches, and mood disturbance.
Diagnostic criteria: Beighton Hypermobility Score 1 point each for:
-left little finger passive dorsiflexion beyond 90degrees
-right little finger passive dorsiflexion beyond 90degrees
-left thumb passive dorsiflexion to flexor aspect of forearm
-right thumb passive dorsiflexion to flexor aspect of forearm
-left elbow hyperextends beyond 10degrees
-right elbow hyperextends beyond 10degrees
-left knee hyperextends beyond 10degrees
-right knee hyperextends beyond 10degrees
-trunk flexion with knees fully extended, palms and hands rest flat on floor.
4 or more entails a major criterion, arthralgia for more than 3 months in four or more joints also entails a major criterion.
Management:
- look for other hereditary connective tissue disorders or inflammatory joint conditions such as Ehlers-Danlos syndrome, Marfans, Juvenile idiopathic arthritis, RA, Ankylosing spondylitis, fibromyalgia.
- pain management and physiotherapy is needed
Describe low back pain, red flag symptoms, investigations.
Back pain is common. Most back pain is self-limiting. Pain brought on by activity and relieved by rest is rarely sinister.
Red flag symptoms:
- less than 20yrs or greater than 55yrs
- violent trauma
- alternating sciatica (both legs involved)
- bilateral sciatica
- weak legs
- weight loss
- fever or systemically unwell
- ESR greater than 25mm/hr
- oral steroids
- local bony tenderness
- previous neoplasia
- faecal/urinary incontinence
- perianal paraesthesia
Investigations:
- examine in underwear ideally, test forward flexion and extension, lateral flexion and rotation, straight leg test.
- if pain last more than 4 weeks do FBC, CRP(infection) ESR (if high think metastases or myeloma and do electrophoresis +/- bone aspirate), LFT (ALP is high in Paget’s disease and tumour), calcium. In absence of trauma MRI is gold standard investigation.
Describe Perthe’s disease, it’s presentation, investigations, and management.
This is osteochondritis of the femoral head and effects those aged 3-11yrs. It is bilateral in 10-15% and is 4 times more common in males. The disease is likely secondary to a vascular necrosis of the developing femoral head.
Presentation: pain in hip or knee that causes a limp. All hip movements are limited especially internal rotation and abduction.
Investigations: Early radiographs and MRIs show joint space widening. Later there is a decrease in femoral head with patchy density. Then there is collapse and deformity of femoral head with new bone formation. Initial X-RAY can be NORMAL
Management:
- if caught early bed rest and NSAIDs until pain free followed by radio graphic surveillance.
- If more severe joint replacement may be neccessary
Describe Transient Synovitis of the Hip and its management.
It is the chief cause of hip pain in children, it is a diagnosis of exclusion after ruling out septic arthritis, Perthes’ disease and slipped upper femoral epiphysis. Examine the hip clinically and investigate with plain films, FBC, CRP, ESR.
Management:
- admission for observation, rest and analgesia e.g. Ibuprofen may be needed.
- if other joints are involved consider juvenile idiopathic arthritis
- Kochers can help rule out septic arthritis if unsure ( 1 point for each, non weight bearing, ESR over 40, WBC over 12, Fever over 38.5, 3 or 4 indicates 95% probability of sepsis).
- make sure to follow up child to ensure no missed Perthes etc. Irritable hip should resolve after 2-3wks
Describe Slipped Upper Femoral Epiphysis, its symptoms, and management.
Affects those aged 10-16years 20% are bilateral and it is 3x more common in males. About 50% of patients are obese. Hypothyroidism is a risk factor.
Symptoms: usually presents with limping and pain in the groin, anterior thigh or knee. Hip flexion abduction and internal rotation are limited.
Management:
-Reduction and stabilisation to reduce risk of Avascular necrosis.
Describe Still’s disease, its symptoms, tests and management.
Systemic-onset juvenile idiopathic arthritis.
Symptoms: It present with systemic upset e.g. In a prepubertal girl with Synovitis, cartilage erosion +/- fever , pericarditis, iridocyclitis, pneumonitis, lymphadenopathy, splenomegaly. It is cause of walking on tiptoes. 88% get arthritis (poly/oligo) often of the knee, wrist and ankle.
Tests: Raised WCC, raised ESR, Raised CRP (poor response), Low Hb, raised ferritin, Raised LFTs, low albumin.
Management:
- MDT approach between physio/OT and child to help achieve normal lifestyle/
- Mild excercise + Rest daily
- hot baths help morning stiffness.
- if severe consider tocilizumab, methotrexate, penicillamine, hydroxychloroquine.
Describe Varicoceles, theirs features and management.
Varicosities of the pampiniform plexus. Most commonly occurs on left because testicular vein drains into renal vein. May be a presenting feature of renal cell carcinoma. Affected testis may be smaller and bilateral Varicoceles may affect fertility, repair has little effect on pregnancy rates.
Features: Distended scrotal vessels, feel like a bag of worms, patient may complain of dull ache. Associated with Subfertility.
Management:
- conservatively
- surgery or embolisation may be used if concerns about testicular function.
Describe Epidymitis, its symptoms, and management.
An infection of the epididymis can spread to testes (orchitis).
Symptoms: Unilateral tesitcular pain and swelling, urethral discharge may be present. If patient less than 20, severe pain and acute onset consider testicular torsion.
Management:
- if unknown organism, ceftriaxone IM once plus doxycycline PO BD for 10-14 days
- US to exclude underlying structural abnormalities.
Describe Testicular torsion, its symptoms, and management.
Twist of the spermatic cord resulting in testicular ischaemia and necrosis. Most common in males aged 10-30.
Symptoms: severe sudden onset unilateral pain. Cremaster if reflex is lost and elevation of testis does not ease pain.
Treatment:
Surgical exploration and fixing of testes.
Describe the management of Head injury.
Assess all patients within 15 minutes of arrival documenting GCS. If GCS less than 8 consider stabilising the airway, treat pain with low dose IV opiates.
- Full spinal immobilisation if GCS less than 15, neck pain/ tenderness, paraesthesia extermities, focal neurological deficit, suspected c-spine injury
- If C-spine suspected 3 view C-spine X-ray is indicated, CT-spine is preferred if intubated, GCS less than 13
- Immediate CT head within 1 hr if GCS less than 13 on admission, GCS less than 15 2hr after admission, suspected open or depressed skull fracture, suspected basal skull fracture, focal neurology, vomiting, post traumatic seizure, coagulopathy.
- contact neurosurgeon if persistent GCS less than 8, unexplained confusion after 4h, reduced GCS post admission, progressive neurological signs, incomplete recovery post seizure, penetrating injury, cerebrospinal leak.
- CT head within 8 hours of injury if 65 or older, history of bleeding or clotting disorders, dangerous mechanism of injury e.g. RTA, more than 30 minutes retrograde amnesia of events before had injury.
Describe Pilonidal sinus and its management.
Obstruction of natal cleft hair follicles around 6cm above the anus. In-growing of hair excites a foreign body reaction and may cause secondary tracks to open laterally +/- abscesses, with foul smelling discharge. (Barbers get them between infers). 10 times more common in men.
Management:
- excision of the sinus tract +/- primary closure.
- consider pre-op antibiotics
- offer hygiene and hair removal advice.
Describe Intraductal Papilloma, its symptoms, and management.
Growth of papilloma in a single duct. No increase risk of malignancy. Most common in women between 35-55.
Symptoms: Warty lump usually behind the nipple. Usually present with clear or blood stained discharge originating from a single duct. Ask the patient where and how many positions the discharge appears as if the nipple were a clock.
Management:
- history and examination
- reassure patient that most likely benign but all lumps should be referred urgently to breast one stop clinic.
Describe Duct Ectasia, its symptoms, and management.
Mammary duct ectasia may be seen in up to 25% of normal female breasts. It is a normal variant of breast involution and is not the same as Periductal mastitis.
Symptoms: Patients usually present with nipple discharge which may be from single or multiple ducts (usually present after age of 50), the discharge is often thick and green.
Management:
-should be referred to breast one stop clinic urgently.
Describe Ulnar Collateral Ligament Injury and its symptoms.
Can often occur due to falling onto an outstretched thumb. It of tens occurs due to falling while holding a skiing pole. It is therefore often referred to as skiers thumb.
Symptoms: the thumb will usually be painful, swollen, and bruised on the inside of the MCP joint. Movements that use the UCL (e.g. Pinching a key between the thumb and index finger) can induce pain.
Describe the symptoms associated with a fracture of the shaft of the humerus
Associated with radial nerve damage which is the most susceptible nerve here.
Describe the symptoms of a supracondylar fracture of the humerus.
Most commonly associated with ulnar nerve damage
Describe symptoms associated with fracture of the proximal humerus.
Most commonly associated with axillary nerve damage.
Describe Tennis Elbow, it’s symptoms, and management.
Lateral epicondylitis, there is inflammation when the common extensor arises from the lateral epicondylitis of the humerus.
Symptoms: Pain is worst when the tendon is most stretched (wrist and finger flexion with hand pronated). Ask patient to extend the wrist and then resists extension of the middle finger, is pain elicited?
Management:
- usual resolves with time, but some favour steroid injection.
- if this fails physiotherapy may help and surgery is reserved for severe resistant cases where excision of the disease part of the common extension origin and repair of the common extensor mechanism gives relief but there is a lack of evidence in this area.
Describe Carpal Tunnel Syndrome, it’s symptoms, causes, tests, and management.
The commonest mononeuropathy caused by compression of the median nerve.
Symptoms: Aching pain in hand and arm especially at night and paraesthesiae in the thumb index and middle fingers all relieved by dangling the hand over the edge of the bed and shaking it. There may be sensory loss and weakness of the abductor pollicis brevis and wasting of the thenar eminence
Causes: Myxoedema, enforced flexion (e.g. In a Colles splint), diabetic neuropathy, idiopathic, acromegaly, neoplasms, amyloidosis, pregnancy, sarcoidosis, RA.
Tests: Phalens and tinels, TFTs and ESR, HBa1c to exclude other causes.
Treatment: Splinting, steroid injection, decompression surgery
Describe ingrown toe nails and their management
Typically the big toe. Caused by incorrect nail cutting and pressure on shoes causing lateral nail to dig into flesh which becomes heaped and infection prone.
Management:
- conservative involves cotton wool soaked in surgical spirit until nail grows out of skin and then cut appropriately.
- antibiotics may help young.
- recurrent infection may need nail avulsion plus chemical matrixectomy
What type of injury causes the knee to ‘give way’?
Cruciate ligament injury
Describe Bakers Cysts and management
Fluid from a knee effusion escapes to form a popliteal cyst (often swollen and painful) in sub-gastrocnemius bursa. Usually secondary to degeneration. Must exclude DVT, Sarcoma.
Management:
-NSAIDs if painful
What antibiotics should be used in open fractures?t
Tetanus Ig, and co-amoxiclav
Describe a haematoma block, its indications, contradictions, and method.
A colles fracture can be manipulated after infiltration of LA into the fracture haematoma and around the ulnar styloid. It converts a closed fracture into an open one so there is theoretical risk of infection but is rare.
Contraindications: Fractures over 24hrs old, infection on skin over fracture, methaemoglobinaemia.
Dosage: 15mL of 1% plain lidocaine never used adrenaline solutions
Method: Use a 20mL syringe and a blue needle, full asepsis technique is needed. Insert the needle into the fracture haematoma and aspirate blood to confirm this. Inject slowly to minimise pain and reduce risk of high blood levels and toxicity. Step the needle to find fracture edge.
Describe Colles’ Fracture, its presentation, investigations, and management.
Presentation: Fracture of the distal radius within 2.5cm of the wrist, such that the distal fragment is angulated to point dorsally. Usually as a result of a fall onto an outstretched hand.
Investigations: X-ray include one or more of the following:
- posterior and radial displacement of the distal fragment
- angulation of the distal fragment to point dorsally
- angulation of the distal fragment to point more radially
- impaction leading to shortening of the radius in relation to the ulna.
Management:
- Analgesia
- backstab POP and elevate with sling for undisplaced fractures
- arrange fracture clinic follow up
- if displaced consider Manipulation under Anaesthetic with haematoma block
- seek advice if fracture is comminuted, or symptoms of nerve compression.
Describe Smiths fracture and its management.
An unstable distal radius fracture where the distal fragment is impacted and displaced volarly. Usually follows a fall onto a flexed wrist
Management:
- analgesia
- immobilise and refer for MUA or ORIF, often unlikely to hold in position after MUA contact orthopaedics first.
Describe Barton’s fracture and its management.
An intraarticular fracture involving only the dorsal (Barton’s) or ventral (Reverse Barton’s) portion of the distal radius. The resultant fragment tends to slip so the fracture is inherently unstable.
Management:
- provide analgesia
- most require ORIF.
Describe the Gustilo-Anderson open fracture classification system
Grade 1 = Open fracture, clean wound, less than 1cm in length
Grade 2 = Open fracture, wound between 1-10cm in length without extensive soft tissue damage, flaps, avulsions
Grade 3 = Open fracture with extensive soft-tissue laceration greater than 10cm or an open segmental fracture. Further split into 3 grades of which 3C is associated with arterial injury requiring repair.
What ages do the elbow ossification centres appear?
Capitellum: 1year Radial head: 3 years Internal (medial) epicondyle: 5years Trochlea: 7 years Olecranon: 9years Lateral epicondyle: 11years
Describe Deep Vein Thrombosis, its risk factors, symptoms, and management.
Abnormal clotting occurs in the veins of the leg or pelvis, untreated are associated with 1-2% mortality from PE. Around half of those with DVT will go on to develop post-thrombotic syndrome, with lifelong pain and swelling of the leg.
Risk factors: recent surgery, recent admission to hospital, current malignancy, bed bound, sepsis, IV drug use, pregnancy, previous DVT/PE, thrombophilia or FH of VTE, recent immobilisation e.g.fracture
Symptoms: Unilateral leg pain and swelling, warmth, tenderness, dilated superficial veins. Differentials include muscle tear, ruptured bakers cysts, cellulitis.
Management:
- Wells score
- FBC, U+E, glucose, CRP
- if high risk well score US scan
- treat with LMWH and follow up with anticoagulation service for warfarin 3months if provoked 6 months if unprovoked.
- If unprovoked investigate all for malignancy + Antiphospholipid antibodies. With CXR, FBC, Ca, LFTs, Urinalysis, If over 40 consider further imaging e.g. CT CAP
Describe Chest drain insertion, the techniques, indications and contraindication, risks, complication and management
There are two techniques seldinger technique and open blunt dissection. Seldinger technique is used for inserting a narrow bore chest drain usually 10-14F but up to 24F. It is a wire guided technique which requires a small incision and local anaesthetic. Open technique allows for insertion of a wide bore chest drain (above 24F), and requires blunt dissection to create a tract into the intrapleural space.
Indications for a seldinger: Pneumothorax, Pleural effusions, empyema
Contraindications for a seldinger: Traumatic pneumothorax, haemothorax, flail chest, sucking chest wounds.
Risk:
Related to insertion: Pain, placement outside of pleural cavity (e.g. Subcutaneous, intra-abdominal, solid organ), puncture of organ, bleeding (puncture of intercostal artery), surgical emphysema
Related to position: Pain, failure of the drain, re-expansion of pulmmmonary oedema, formation of bronchopleural fistula, pneumothorax
Related to infection: Wound infection, empyema.
Management:
- Check position with X-ray
- Ensure drain is bubbling and swinging.
- In the first hour after insertion a maximum of 1.5L should be drained after this you should apply a clamp for approximately 30 minutes before draining again.
Complications:
- Persistant bubbling may be sure to air leak.
- Persistant drainage of blood or fluid (structural damage)
- Blockage, never advance drain, flushing may help
- CXR after removal - problem may re occur
- Do no raise chest drain above chest height due to risk of reflux of contents
- Never clamp drain in pneumothorax.
