Surgery - Orthopaedics (too much to learn for me) Flashcards
(332 cards)
1
Q
In the major haemorrhage protocol, what baseline bloods should be taken pre-transfusion?
A
FBC
Group and save
Clotting
Clauss fibrinogen assay (measures function of fibrinogen)
2
Q
In which major haemorrhage scenarios can tranexamic acid be given, and how should it be prescribed?
A
If trauma within 3 hours
Dose is 1g bolus over 10 mins followed by 1g infusion over 8 hours
3
Q
When examining a joint, what 3 things should you assess for?
A
Pain
Effusion
Temperature
4
Q
What are the 3 main tests to do when examining any joint?
A
Look
Feel
Move
5
Q
Describe the tests for each muscle of the rotator cuff
A
Supraspinatus tendon: Empty can test
Infraspinatus: External rotation against resistance
Teres minor: Hornblower test
Subscapularis: Internal rotation against resistance
6
Q
What 2 special tests can be doe on examination for carpel tunnel syndrome? Describe them
A
Tinel’s test: tap along nerve from index finger down through wrist towards antecubital fossa, is positive if tingling or paraesthesia down median nerve as is tapped
Phalen’s test: put hands in like a downwars pray position with backs of hands together, positive if tingling/ paraesthesia in distribution of median nerve
7
Q
What does the Trendelenburg test assess?
A
Abductor (gluteus medius and minimus) abnormality
8
Q
What is a positive trendelenburg test?
A
Dip in hip when lifting GOOD side leg
9
Q
How do you perform Thomas’ test, and what does it assess?
A
Ask pt to lie down, and to bring their knee up to their chest to ‘hug’ it
Positive test = other leg lifts off bed
Tests for fixed flexion deformities eg iliopsoas tightness, ACL tear, osteoarthritis…
10
Q
How can you identify if leg shortening is tibial or femoral in nature?
A
Galeazzi test
Get pt to lie down, flex hips to 45 degrees and knees to 90 degrees
Test is positive when knees are a different heights
If lower knee displaced towards foot = shortened tibia, if displaced towards body = shortened femur
11
Q
What can you do on examination to test for Achilles tendon rupture?
A
Simmond’s test
Calf squeeze –> foot movement
12
Q
What can you do on examination to test for Morton’s neuroma?
A
Mulden’s test
Clasp metatarsals and poke plantar side of foot - positive test will be pain/ tingling
13
Q
After an orthopaedic examination in PACES, what can you say you would like to do to finish your examination?
A
Assess neurovascular status
Assess joints above and below
Test the contralateral joint
14
Q
What % of bone matrix is organic vs inorganic?
A
40% osteoid (organic matrix)
60% inorganic
15
Q
What is osteoid matrix made up of?
A
Protein mix secreted by osteoblasts
16
Q
Recall the 2 subtypes of lamellar bone
A
Cortical (compact)
Trabecular (cancellous)
17
Q
What is woven bone?
A
Disorganised bone that forms the embryonic skeleton and fracture callus
18
Q
What are the 2 types of bone formation?
A
- Intramembranous ossification - direct ossification of mesenchymal bone models formed during embryonic development (skull bones, mandible and clavicle for example)
- Endochondral ossification - mesenchyme –> cartilage –> bone: most bones ossify this way
19
Q
What are the 4 stages of fracture healing and how long does each one last?
A
- Reactive: first 48 hours
Reparative phase = 2 days - 2 weeks - Proliferation (reparative phase part 1)
- Consolidation (reparative phase part 2)
- Remodelling = 1 week - 7 years
20
Q
Describe the reactive phase of fracture healing
A
Bleeding into the fracture site –> haematoma
Inflammation –> cytokine release –> recruitment of leukocytes and fibroblasts –> granulation tissue
21
Q
Describe the reparative phase of fracture healing
A
Proliferation of osteoblasts/ fibroblasts –> cartilage and woven bone forms –> callus formation
Consolidation = endochondrial ossification of woven bone to turn it into lamellar bone
22
Q
Recall the approx healing time for different types of fracture
A
Closed/ paediatric/ metaphyseal/ upper limb = 3 weeks
Open/ adult/ diaphyseal/ lower limb = 6 weeks
23
Q
Recall some examples of traumatic, stress and pathological fracture
A
Traumatic: direct (assault with metal bar), Indirect (fall on outstretched hand, clavicle #), avulsion
Stress: Foot fracture in marathon runners (particularly 2nd metatarsal)
Pathological: local (tumours), general (osteoporosis, Cushing’s, Paget’s)
24
Q
What is an avulsion fracture?
A
When small chunk of bone attached to a tendon/ligament gets pulled away from the main part of the bone. Common in young athletes
25
What radiographs do you need to image a fracture properly?
Orthogonal radiographs (at right angles) --> request AP and lateral films
26
What is an open vs closed fracture?
Open breaks the skin, closed doesn't
27
What is an extraarticular fracture?
One that doesn't cross the surface of a joint
28
What is fracture angulation?
Where the normal axis of the bone has been altered such that the distal portion of the bone points off in a different direction
29
What is fracture translation?
Movement of the fractured bones away from each other
30
What are the 4 elements of fracture 'deformity' you might comment on?
Translation ('translocation')
Angulation
Rotation
Impaction
31
What are the 'four Rs of fracture management?
Resuscitation
Reduction
Restriction
Rehabilitation
32
Recall the principles of resuscitation in fracture management
1. ATLS - Trauma assessed in primary survey (C spine, chest, pelvis) with secondary survey addressing #
2. Assess neurovascular status and look for dislocations
3. Stabilise BEFORE imaging
33
Recall the '6 As' of managing open fractures
Analgesia
Assess: NV status, soft tissues, photograph
Alignment: align # and splint
Anti-sepsis: wound swab, copious irrigation, cover with betadine-soaked dressing
Anti-tetanus: check status (booster lasts 10 years)
Antibiotics: flucloxacillin 500mg IV/IM, benzylpenicillin 600mg IV/IM)
34
What system can be used to classify open fractures?
Gustilo classification
35
Differentiate the 3 types of fracture in the Gustilo classification in terms of size
Type 1: <1cm
Type 2: 1-10cm
Type 3: >10cm
36
Which of the Gustilo classifications of fracture might involve periosteal stripping?
Type 3
37
If a fracture has been exposed to salt/fresh water, what extra antibiotic coverage will be needed and why?
Ciprofloxacin for pseudomonas exposure
38
Recall the principles of reduction in fracture management
- Displaced fractures should be reduced unless no effect on outcome (eg ribs)
- Aim for anatomical reduction (especially if articular surfaces involved)
- Alignment is more important than opposition
39
What are the principles of restriction in fracture management
Based on Wolff's law
Tissue formed at fracture site depends on strain it experiences
Fixation --> less strain --> bone formation
Also
Fixation --> less pain --> increased stability --> ability to fx
40
What is the difference between internal and external fixation?
Internal: Physically reconnecting bones with screw/plates etc
External: Fragments held in place by pins/ wires connected to an external frame
41
For open soft tissue injuries, which sort of fixation is best?
External
42
When describing the possible complications of fracture management, under what sub-headings can you classify them? Name some complications under each subheading
Anaesthetic - anaphylaxis, damage to teeth, aspiration
Intra-operative - bleeding, damage to local structures (eg neurovascular injury), treatment failure
Early post-operative - compartment syndrome, infection (surgical site, UTI, bed sores), VTE, ABx colitis
Late post-operative - scarring, fx loss, neuropathy, pain, myositis ossificans
43
What is myositis ossificans?
A condition where bone tissue forms inside muscle or other soft tissue after an injury at sites of haematoma formation
44
Recall 3 possible neurological complications of fracture surgery
Neuropraxia (axon preserved, conduction interrupted)
Axonotomesis (Wallerian degeneration of axon, interruption of axon)
Neurotmesis (axon transected - requires surgery)
45
What is Wallerian degenration?
An active process of retrograde degeneration of the distal end of an axon that is a result of a nerve lesion
46
Describe how compartment syndrome develops
Oedema from fracture --> increased pressure --> decreased venous drainage --> increased pressure --> ischaemia
47
What are the signs and symptoms of compartment syndrome?
Pain on passive stretching
| Warmth, erythema, swelling, weak pulses, increased CRT
48
Recall 2 fracture sites that are most associated with compartment syndrome
Suprachondylar fractures
| Tibial shaft fractures
49
How should compartment syndrome be managed?
Elevate limb, remove all bandages/ splint etc -- fasciotomy
50
Recall the '5 Is' that may cause non-union
```
Ischaemia (poor blood supply/ AVN)
Interfragmentory strain
Intercurrent disease (eg malignancy)
Infection
Interposition of tissue between fragments
```
51
Into what 2 types can non-union fractures be classified?
Hypertrophic (bone end rounded, dense + sclerotic)
| Atrophic (osteopaenic bone)
52
What is Pelligrini-Stieda disease?
A form of myositis ossificans where the superior MCL attachment on knee calcifies following trauma
53
How should myositis ossificans be managed?
Excision
54
What are the previous names for the 3 different types of complex regional pain syndrome?
Type 1 = Reflex Sympathetic Dystrophy/ Sudek's atrophy
Type 2 = Causalgia (persistent pain following injury to a nerve)
Type 3 = Type NOS
55
Recall 2 criteria that can be used to diagnose complex regional pain syndrome
Budapest criteria
| IASP criteria
56
What are the signs and symptoms of complex regional pain syndrome?
Affects a NEIGHBOURING area to the area affected by trauma
Hyperalgesia
Allodynia
Vasomotor disturbance (may be hot + sweaty or cold + cyanosed)
Swollen, atrophic and shiny skin
Hyperreflexia/ contractures/ dystonia
57
Recall some medical and surgical options for managing complex regional pain syndrome
Medical: amitriptyline + gabapentin
Surgical: regional nerve block
58
Recall the signs and symptoms of fat embolism
Looks like a PE but with neurological signs
Onset of dyspnoea, hypoxia and tachypnoea within 24 hours of multiple fractures
CNS signs: confusion, agitation, retinal haemorrhage
Dermatological: 25-50% develop a petechial rash
59
How should fat embolism be managed?
DVT prophylaxis
60
What is the Salter-Harris classification used for, and what are the criteria?
```
It's used to classify the degree of disruption to the growth plate caused by a fracture
SALT-C
Straight across
Above
Lower
Through
CRUSH
Type 1-5 = increasing risk of growth plate injury
```
61
What are the Ottawa rules used for?
To decide if an x ray is needed
62
Recall the 4 criteria of the Ottawa knee rule
- Over 55 years old
- Isolated patellar tenderness
- Cannot flex to 90 degrees
- Inability to weight bear both immediately and in A&E for >4 steps
63
Recall the Ottawa ankle rule (much more complicated than knee!)
LMN FUN
Malleolar zone pain +
- Lateral malleolus posterior edge tenderness
- Medial malleolus posterior edge tenderness
- No weight bearing - both immediately and for 4 steps in A&E
Mid foot zone +
- Fifth metatarsal base pain
- Unable to weight bear immediately or for 4 steps in A&E
- Navicular tenderness
64
Recall the risk factors for #NOF
```
SHATTERED
Steroids
Hyperthyroidism/hyperparathyroidism
Alcohol/ smoking
Thin (BMI<22)
Testosterone LOW
Erosive bone disease (eg RhA, MM)
Renal failure
Early menopause
Dietary calcium low, DM
```
65
What is the key examination finding in #NOF?
Leg is shortened with external rotation
66
What is the most common form of intracapsular #NOF?
Sub-capital NOF#
67
What is the most common form of extracapsular #NOF?
Intertrochanteric NOF#
68
If someone's leg is shortened and internally rotated, what is this indicative of?
Posterior dislocation of the hip
69
What are the 3 types of intracapsular NOF#?
Subcapital
Transcervical
Basicervical
70
What are the 3 types of extracapsular NOF#?
Intertrochanteric
Subtrochanteric
Reverse oblique
71
What is the best analgesia for a #NOF?
Iliofascial nerve block
72
What is the surgical management of intertrochanteric #NOF?
Dynamic hip screw
73
How should extracapsular NOF# be managed?
ORIF (although intertrochanteric # can be managed with a DHS)
74
How can the degree of displacement of an intracapsular NOF# be classified?
Using Garden classification (grades I-IV)
75
How should intracapsular NOF# be managed?
Garden 1 + 2 = ORIF with cancellous or cannulated screws
Garden 3 + 4 =
- <55 years: ORIF with cancellous or cannulated screws
- 55 - 75 years: total hip replacement
- >75 years: hemiarthroplasty
76
What is the difference between a total hip replacement and a hemiarthroplasty?
```
THR = replaces femoral head and acetabulum
Hemiarthroplasty = replaces femoral head
```
77
What is the 1 year mortality for NOF#?
30%
78
What type of NOF# is most likely to be complicated by osteonecrosis and why?
Transcervical fracture
| Retinacular artery is disrupted from medial circumflex femoral artery
79
What are the signs and symptoms of osteonecrosis of the hip?
Anterior hip pain on climbing the stairs
| Insidious onset
80
What imaging needs to be requested in suspected osteonecrosis of the hip?
XR (AP, frog-lateral, contralateral)
MRI (double density appearance)
Bone scan
81
How can osteonecrosis of the hip be medically managed?
Bisphosphonates
82
Recall some surgical options for managing osteonecrosis of the hip
```
Core-decompression
Rotational osteotomy
Free-fibula transfer
Total hip resurfacing/ replacement
Hip arthrodesis
```
83
What is the 'modified Kerboul angle' used to determine?
Risk of femoral head collapse in osteonecrosis of the hip
84
How should femoral shaft fractures be managed?
Immediately: traction
1st line: intramedullary nailing
2nd line: ORIF
85
Recall 4 options for managing humeral fracture and the general indications for each one
Collar & cuff: 2 parts, minimally displaced, high surgical risk
ORIF: >2 parts but not highly comminuted
Arthroplasty: large displacement of humeral head and high risk of non-union
Reverse arthroplasty - irreprable rotator cuff/ previous unsuccessful replacement
86
What is the most common type of paediatric elbow fracture?
Suprachondylar humeral #
87
How will a suprachondylar humeral # appear on examination?
Elbow swollen and hand semi-flexed
88
What is the difference between the extension and flexion types of suprachondylar humeral #?
```
Extension = distal fragment displaces posteriorly (most common)
Flexion = distal fragment displaces anteriorly
```
89
What is the most likely artery to be severed by a suprachondylar humeral #?
Brachial artery (by sharp edge of proximal humerus)
90
What is the most likely nerve to be damaged by a suprachondylar humeral #?
Median nerve
91
Recall the principles of reducing a suprachondylar humeral # if it is undisplaced vs if it is displaced
Undisplaced: Collar and cuff with fully flexed arm
Displaced: Manipulation under anaesthetic + K-wire fixation THEN collar and cuff for 3 weeks with fully flexed arm
92
What is the most common early sign of compartment syndrome following a suprachondylar humeral #?
Pain on passive extension of fingers
93
What is the aetiology of subluxation of the humeral head?
In children the distal attachement of the annular ligament covering the radial head is weaker so is at higher risk of subluxation
94
What are the signs and symptoms of subluxation of the humeral head?
Elbow pain and limited supination and extension of the elbow
95
How should subluxation of the humeral head be managed?
Analgesia
| Passively supinate elbow joint whilst elbow flexed
96
What is the 'dinner fork' deformity associated with?
Colle's #
97
What is Colle's #?
Posterior displacement and angulation of the distal radius fragment
98
What is Smith's #?
Anterior displacement and angulation of the distal radius fragment
99
What is the typical history of Colle's vs Smith's #?
Colle's = fall on an extended wrist
| Smith's fall on a flexed wrist
100
What are the Barton's and Reverse Barton's fractures?
Both are oblique intra-articular #s with dislocation at the radio-carpal joint
Barton's: Dorsal (posterior)
Reverse Barton's: Volar (anterior)
101
A Monteggia # is a type of fracture of which bone?
Ulnar
102
A Galeazzi # is a type of fracture of which bone?
Radius
103
Describe how the location of a radius/ulnar fracture guides how the cast should be applied
Proximal #: supination
Mid-shaft #: neutral
Distal #: pronation
104
How are intraarticular fractures of the radius/ulnar managed?
ORIF
105
How are extraarticular fractures of the radius/ulnar managed?
MUA + k wire
| If unsuitable for k wire --> ORIF
106
Recall 5 signs of scaphoid fracture
```
[1] Pain in the anatomical snuffbox
[2] Wrist joint effusion
[3] Pain on telescoping thumb
[4] Tenderness on scaphoid tubercle
[5] Pain on ulnar deviation of wrist
```
107
Why are scaphoid fractures particularly vulnerable to avascular necrosis?
Retrograde blood supply
| 80% is from the dorsal carpal branch of the radial artery
108
What is the use of CT in tibial plateau #?
To assess whether non-operative management can be used
109
What is the most common long bone fracture?
Tibial
110
Which bone articulates with the tibia and fibula at the ankle joint?
Talus
111
What is Pott's fracture?
Bimalleolar #
112
What is a Cotton's fracture?
Trimalleolar #
113
What is a pilon fracture?
A fracture of the distal tibia involving the articular surfaces
114
What classification system is used to assess the extent of syndesmotic ligament damage at the tibiotalar joint?
Weber
115
Name 2 techniques that can be used to repair syndesmotic tears at the ankle
Syndesmotic screws
| Tightrope technique
116
What is a Lisfranc injury?
An injury of the foot in which one or more of the metatarsal bones are displaced from the tarsus
117
Recall some signs and symptoms of Lisfranc injury
Medial plantar bruising
Unable to weight bear
Gross midfoot swelling with severe pain
118
What is the most common metatarsal to be fractured in children vs adults?
Children: 1st
Adults: 5th
119
Into which 3 categories can pelvic fractures be places?
1. Lateral compression (hit from side)
2. AP compression (Dashboard injury)
3. Vertical shear (falling from height)
120
Recall 3 signs/symptoms of fractured patella
1. Palpable patellar defect
2. Significant haemarthrosis
3. Loss of straight leg raise
121
What 3 x ray views are recommended to image a patellar fracture?
AP
Lateral
Skyline (inferior-superior)
122
How should patellar # be managed if the # is comminuted and ORIF is not possible?
Partial patellectomy, or total patellectomy if no salvage potential
123
How is ORIF performed for patellar fractures?
Tension Band Wiring
Cerclage wiring
Screw fixation
124
What is compartment syndrome?
Raised pressure in closed space --> compromised tissue perfusion
125
What are the main signs and symptoms of compartment syndrome?
Excessive use of breakthrough analgesia due to significant pain
126
Why might arterial pulses still be palpable in compartment syndrome?
Necrosis occurs as a result of microvascular compromise
127
How can a manometer be used to help diagnose compartment syndrome?
Can use to measure intracompartmental pressure (ICP)
Normal pressure = 0-10mmHg
Delta pressure <30mmHg = compartment syndrome
Absolute pressure >30mmHg = compartment syndrome
128
What is the 'delta pressure' of a compartment?
Diastolic pressure - measured intracompartmental pressure
129
Recall some non-operative options for managing compartment syndrome
- Fluid resuscitation to ensure normotension (as hypoperfusion accelerates tissue injury)
- Remove circumferential bandages and casts
- Maintain limb at level of heart
130
How can compartment syndrome be managed operatively?
Fasciotomy
131
Which tendon is impinged in 'subacromial impingement'?
Supraspinatus tendon
132
What is Hawkin's test used to diagnose, and how is it performed?
For shoulder impingement
90 degrees shoulder and elbow flexion
Passive internal rotation of the arm --> pain
133
Recall some differentials for subacromial impingement
Adhesive capsulitis
Supraspinatus tear
Osteoarthritis/ Rheumatoid/ Septic arthritis
Gout/ Pseudogout
134
Which x ray views are needed to investigate the aetiology of a subacromial impingement?
True AP
30 degrees caudal tilt (subacromial spurring)
Supraspinatus outlet (acromial morphology)
135
Recall some management options for subacromial impingement under the headings of 'conservative', 'medical' and 'surgical'
Conservative: rest, phyisio
Medical: NSAIDs, subacromial bursa steroid
Surgical: athroscopic acromioplasty
136
Describe the aetiology of subcoracoid impingement
Narrowing at the coracohumeral interval impinges the ligaments of:
- Subscapularis
- Long head of biceps
- Middle glenohumeral ligament
137
What are the signs and symptoms of subcoracoid impingement?
Pain at the anterior shoulder when arm held adducted/ extended
Maximal pain at 120 degrees flexion + internal rotation
138
What are the 3 stages of calcific tendonitis of the shoulder?
1. Pre-calcific (pain-free fibrocartilaginous metaplasia of tendon)
2. Calcific (phases of varying levels of pain)
3. Post-calcific
139
What imaging is useful in calcific tendonitis of the shoulder?
XR (shows deposits on AP)
| US (shows extend of calcification and targets therapy)
140
Recall some non-operative and operative options for managing calcific tendonitis of the shoulder
Non-operative: analgesia, physio, extra-corporeal shockwave therapy, US-guided injections
Operative: Surgical decompression
141
What are the 4 muscles of the rotator cuff?
Supraspinatus
Infraspinatus
Subscapularis
Teres minor
142
Recall 4 risk factors for a rotator cuff tear
Age >60
Smoking
Family history
Hypercholesterolaemia
143
Recall some possible causes of a rotator cuff tear
Chronic degeneration
Chronic impingement
Acute avulsion injury
144
How can you differentiate between a partial and complete rotator cuff tear?
Partial --> painful arc
Complete --> shoulder tip pain, FULL RANGE of passive movement but with inability to abduct arm. Active abduction IS possible following passive abduction to 90 degrees. 'Drop arm' sign (lowering arm beneath 90 degrees abduction --> sudden drop)
145
Recall some operative options for managing rotator cuff tears
Shoulder arthroscopy (to debride rotator cuff and subacromial decompression)
Rotator cuff repair (can be open or laparoscopic)
Tendon transfer
Reverse total shoulder arthroplasty
146
What is the aetiology of rotator cuff arthropathy?
Rotator cuff tear --> loss of joint congruence --> abnormal glenohumeral wear --> specific degeneration
147
Describe the signs and symptoms of rotator cuff arthropathy
Night pain with weakness and stiffness
Supra/infraspinatus atrophy
Limited ROM +/- crepitus and inability to abduct
148
Recall which muscles are involved in each stage of arm abduction
0-15 degrees = supraspinatus
15-90 degrees = deltoid
>90 degrees = serratus anterior + trapezius
149
In which direction does the humeral head migrate in rotator cuff arthropathy?
Superiorly
150
What test can be used to test teres minor and how is it performed?
Hornblower's test
Shoulder in 90 degrees abduction and elbow in full flexion
Positive test = pain/ inability to maintain
151
What is adhesive capsulitis?
Condition characterised by loss of active AND passive movement with no clear cause
152
Recall the stages of adhesive capsulitis
Stage 1: Freezing - gradual onset of diffuse pain
Stage 2: Frozen - decreased ROM
Stage 3: Thawing - gradual return of ROM
153
What is the main associated condition with adhesive capsulitis?
Diabetes
154
What score is used to assess hypermobility syndrome?
Beighton score
155
What % of shoulder dislocations are anterior vs posterior vs inferior?
Anterior: 90%
Posterior: 6%
Inferior: 2-4%
156
Which direction of shoulder dislocation is associated with seizures?
Posterior
157
How does acromioclavicular joint dislocation appear on examination?
'Step' deformity and prominent clavicle
158
What are the signs of glemohumeral dislocation on examination?
Shoulder contour lost ('square shoulder')
| Bulging infraclavicular fossa
159
What must you assess before manipulating a glenohumeral dislocation?
Neurovascular status - especially axillary nerve in chevron area
160
What is the management of glenohumeral dislocation?
Reduction with sedation
Rest in sling for 3-4 weeks
Physio
161
What is a Hill Sachs defect?
Damage to humeral head following shoulder dislocation
162
Where do the short and long tendons of the biceps attach?
Long tendon: glenoid
| Short tendon: coracoid process
163
Which tendon of the biceps is much more likely t get ruptured?
Long
164
What is a 'popeye deformity'?
Caused by proximal biceps tendon rupture - muscle bulk results in a bulge in the middle of the upper arm
165
How can you test for biceps tendon rupture on examination?
Biceps squeeze test --> supination if tendon is intact
166
What is the best form of imaging for initial assessment of a proximal biceps tendon rupture?
USS
167
What is the best form of imaging for initial assessment of a distal biceps tendon rupture?
MRI - it's a difficult clinical diagnosis and requires surgery
168
What are the 2 forms of traumatic anterior shoulder instability?
TUBS - Traumatic Unilateral dislocations with a Bankart lesion - often requires Surgery
AMBRI ("born loose") = atraumatic Multidirectional Bilateral shoulder dislocation is treated with Rehabilitation, but may require Inferior capsular shift
169
What are the colloquial names for lateral vs medial epicondylitis?
```
Lateral = tennis
Medial = golfer's
```
170
What is the aetiology of lateral epicondylitis?
Microtear at origin of ERB +/- ERCL and ECU from repetitive wrist extension/ forearm pronation
171
What is the aetiology of lateral epicondylitis?
Microtear at insertion of flexor-pronators from repetitive wrist activity
172
Which movements will worsen pain in lateral vs medial epicondylitis?
Lateral: worse on wrist extension
Medial: worse on wrist flexion
173
What is the best form of imaging to investigate epicondylitis?
USS
174
Is there a better success rate for conservative management of lateral or medial epicondylitis?
Lateral (95%)
175
What is the main symptom of olecranon bursitis?
Swelling over posterior aspect of elbow
176
Which nerve is compressed in radial tunnel syndrome, and what symptoms does this nerve compression produce?
Posterior interosseous branch of radial nerve
Symptoms very similar to lateral epicondylitis (pain in lateral epicondyle, worse on wrist extension, decreases grip strength)
177
Recall 6 associations with carpal tunnel syndrome
People who play DA HARP
Diabetes
Acromegaly
Hypothyroidism
Amyloidosis
Rheumatoid arthritis
Pregnancy
178
Which nerve is entrapped in carpal tunnel?
Median
179
Which digits get paraesthesia in carpal tunnel syndrome?
1st, 2nd and medial half of 3rd
180
What is the best investigative test for carpal tunnel syndrome?
EMG
181
Which muscles are supplied by the median nerve (and are weakened in carpal tunnel syndrome)?
Lateral 2 lumbricals
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis
182
How can carpal tunnel be managed conservatively?
Wrist splints at night
183
How can carpal tunnel be managed if conservative management is unsuccessful?
Corticosteroid injection --> surgical decompression
184
What are the contents of the carpal tunnel?
Median nerve
| FPL, FCR, FDP and FDS tendons
185
What is cubital tunnel syndrome?
Ulnar nerve entrapment at elbow
186
What is Guyon canal syndrome?
Ulnar nerve entrapment at wrist
187
Recall some risk factors for both Cubital Tunnel Syndrome and Guyon Canal Syndrome
Cubital tunnel: cycling, ganglion cyst pressure
| Guyon canal: leaning on elbow
188
What are the signs and symptoms of ulnar nerve entrapment?
Pins and needles in 4th and 5th digit
| Claw hand
189
How should suspected ulnar nerve entrapment be investigated?
Nerve conduction studies
190
Recall some conservative and surgical options for managing ulnar nerve entrapment
Conservative: wrist splints at night
Surgical: Corticosteroid injection --> surgical decompression
191
What is the aetiology of De Quervain's Tenosynovitis?
Sheath containing extensor pollicis brevis + abductor pollicis longus tendons becomes inflamed
192
Recall some signs and symptoms of De Quervain's Tenosynovitis
Tenderness over radial styloid and radial side of wrist
Abduction of thumb is painful
193
What is Finkelstein's test used to investigate and how is it performed?
Used to investigate De Quervain's Tenosynovitis
Examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction --> pain in the radial styloid and along the length of EPB and APL
194
How can De Quervain's Tenosynovitis be managed?
Analgesia + activity modification
Steroid injections + thumb splint --> surgery (if conservative measures have failed after 6 months)
195
What is Dupuytren's contracture?
Progressive, painless and fibrotic thickening of the palmar fascia
196
What is the aetiology of Dupuytren's contracture?
Fibroblasts replaced by myofibroblasts which produce a contractile element
197
Recall the associations of Dupuytren's contracture
BAD FIBRES
Bent penis (Peyronie's)
AIDS
Diabetes mellitus
```
Family history
Idiopathic (most common)
Booze (ALD)
Riedel's thyroiditis
Epilepsy and anti-epileptics
Smoking
```
198
Recall some options for managing Dupuytren's contracture
1. Percutaneous needle fasciotomy
2. Collagenase injection followed by MUA 24 hours later
3. Partial fasciectomy (if hand can't be placed flat on table)
199
What is a trigger finger?
Tendon nodule which catches on proximal side of tendon sheath --> triggering on forced extension
200
How can a trigger finger be managed?
```
Steroid injection (high recurrence)
Surgical release of 1st pulley
```
201
What is a ganglion?
Smooth, multilocular cystic swellings
202
What is the aetiology of ganglions?
Mucoid degeneration of joint capsule / sheath which may communicate with joint capsules/ tendons
203
What are the signs and symptoms of ganglion?
Subdermal swellings, fixed to deeper structures + limits planes of movement +/- pain on nerve pressure symptoms
204
How should ganglions be managed?
50% disappear spontaneously
Aspiration +/- steroid and hyaluronidase injection
Surgical excision
205
If someone has the symptom of knee locking, what are the differentials?
Obstructive causes:
- Meniscal/ cruciate tear
- Osteochondritis dissecans
- Osteophytes
206
What is the O'Donoghue Unhappy Triad?
Describes 3 soft tissue injuries that commonly occur together following a lateral blow to the knee on a fixed foot (eg football/ rugby)
- Ruptured ACL
- Ruptured MCL
- Damaged medial meniscus
207
Describe the typical presentation of ACL rupture
Rotational sports injury
Loud crack with pain
Rapid swelling due to haemarthrosis
208
Recall 2 signs of PCL rupture
1. Tibial lies posterior to femur
| 2. Paradoxical anterior draw test
209
What is the key sign of MCL rupture
Knee unstable in valgus stress test
210
What are the signs and symptoms of a torn meniscus in the knee?
- DELAYED knee swelling (immediate more likely to be ACL rupture)
- Joint locking
- Recurrent pain/ effusions
- McMurray's test positive
211
What cause of knee pain typically affects teenage girls?
Chondromalacia patellae
212
What classification system is used for tibial plateau fractures?
Schatzker system
213
Why would a visible fluid level in the knee (lipohaemarthrosis) on X ray lead you to perform an MRI?
It is either a # or a cruciate ligament tear
214
How should an isolated cruciate ligament tear be managed?
Specialised quadriceps physiotherapy
215
If a cruciate ligament tear is paediatric or concurrent, how can it be managed?
Reconstruction
| Gold standard is an autograft repair
216
What is the best conservative management for a medial/ lateral cruciate ligament tear?
Hinged knee brace
217
What is the most obvious sign on examination of a medial/ lateral cruciate ligament tear
Extreme valgus/ varus
218
What movement produces the most pain in a meniscal tear?
When loading knee in flexion (going downstairs)
219
What imaging should be done for a meniscal tear?
XR to exclude # followed by MRI
220
How can meniscal tears be managed?
Arthroscopic debridement or repair (depends on site)
221
How does site of meniscal tear affect nanagement?
Lateral 1/3 tears might be able to be managed conservatively as they have a very rich blood supply
Medial tears 2/3 tears may need a meniscectomy as poor supply of blood
222
What is Osgood-Schlatter's disease?
Tibial tuberosty apophysitis and patellar tendonitis
223
Can Osgood-Schlatter's disease be bilateral?
Yes, it is in 25-50%
224
How is Osgood-Schlatter's disease diagnosed?
Clinical diagnosis + XR
225
What would an X ray show in Osgood-Schlatter's disease?
Fragmentation of tibial tubercle and overlying soft tissue swelling
226
What are the signs and symptoms of osgood schlatter's?
Knee pain after exercise with gradual onset
Localised tenderness and swelling over the tibial tuberosity
Hamstring tightness
227
How should Osgood-Schlatter's disease be managed?
Analgesia, ice packs
| Reassure --> should resolve at end of growth spurt
228
What is meralgia paraesthetica?
Syndrome of paraesthesia/ anaesthesia in distribution of the lateral femoral cutaneous nerve
229
What is the aetiology of meralgia paraesthetica?
As the lateral femoral cutaneous nerve curves medioinferiorly around the ASIS it may be subject to repetitive trauma --> compression leads to symptoms
230
In what age group does meralgia paraesthetica typically develop?
30-40y
231
What are the signs and symptoms of meralgia paraesthetica?
Upper lateral thigh burning, tingling, coldness or shooting pain
NO MOTOR WEAKNESS
Symptoms usuallya ggravated by standing and relieved by sitting
232
How can you reproduce symptoms of meralgia paraesthetica on examination?
Deep palpation beneath ASIS
233
What is the main symptom of chondromalacia patellae?
Patellar aching after prolonged sitting or climing stairs
234
How can you investigate for chondromalacia patellae?
Clarke's test
| Pain on patellofemoral compression
235
What would be seen on XR in chondromalacia patellae?
Normal film
236
How can symptoms of chondromalacia patellae be improved?
Vastus medialis strengthening
237
What is a 'Baker's cyst'?
Popliteal extensions of the gastrocnemius-semimembranosus bursa (not a true 'cyst')
238
If Baker's cysts are secondary, what are they likely to be secondary to?
Osteoarthritis
239
What are the signs and symptoms of Baker's cysts?
Swelling in popliteal fossa
240
What is the cause of bipartite patella?
Congenital failure of patella to fuse
241
What are the 3 classifications of bipartite patella, and which is most common?
Type 1: inferior pole
Type 2: lateral margin
Type 3: superloateral (most common)
242
What are the 3 elements of the ankle syndesmosis?
1. Anterior inferior tibiofibular ligament
2. Posterior inferior tibiofibular ligament
3. Interosseous ligament and membrane
243
What is the mainstay of management for low ankle sprain?
RICE (rest, ice, compression, elevation)
244
What is the most common type of low ankle sprain?
Inversion injury affecting the ATFL
245
How can high ankle sprains be managed?
If there is diastasis (separation of fibula and tibia) --> surgical fixation
OR
No diastasis --> non weight-bearing orthosis
246
Which prescription drug is highly associated with achilles tendon rupture?
Quinolones (eg ciprofloxacin)
247
What is Simmond's triad?
100% sensitive in combination for picking up an Achilles' tendon rupture
- Thomas test does not elicit plantarflexion
- Angle of declination (greater dorsiflexion of injured foot)
- Gap in tendon path
248
Which type of imaging is diagnostic of Achiles tendon rupture?
USS
249
What are the signs and symptoms of Morton's neuroma?
'Walking on a marble'
Shooting pain in the ball of the foot
Numb toes
250
Where is the most common site of Morton's neuroma?
Between 3rd and 4th tarsal bones
251
What form of imaging can confirm a diagnosis of Morton's neuroma?
USS
252
What is the management of Morton's neuroma?
Orthotics --> steroid injections --> surgical resection
253
What is plantar fasciitis?
Inflammation of the plantar aponeurosis
254
What would make plantar fasciitis better or worse?
Exercise makes it better
| Inactivity makes it worse
255
What test on examination can be used to identify plantar fasciitis?
Windlass test
256
What is the management for plantar fasciitis?
```
Orthotics
Physiotherapy
Analgesia
Steroid injection
Refer to orthopaedics
```
257
What is the proper name for a bunion?
Halux valgus
258
How can bunions be manages conservatively?
Bunion pads
| Plastic wedge between great and 2nd toes
259
What surgery can be used to fix bunions?
Metatarsal osteotomy
260
What are the signs and symptoms of charcot foot?
```
Deformity
Debris
Density change
Destruction
Dislocation
```
261
What are the signs and symptoms of cervical spondylosis?
Neck pain and headaches
262
What are the signs and symptoms of lumbar spine stenosis?
```
Back pain that is worse when standing
Leaning forward relieves it
Neuropathic pain
Neurogenic claudication
Preserved distal pulses
```
263
What is the most common pathogen implicated in discitis?
Staph aureus
264
What is the most common pathogen implicated in iliopsoas abscess?
Staph aureus
265
What is the difference between the investigation of choice for discitis vs iliopsoas abscess?
Discitis: MRI (if S aureus --> echo)
| Iliopsoas abscess: CT
266
What is the difference between the management of choice for discitis vs iliopsoas abscess?
Discitis: IV Abx
| Iliopsoas abscess: Abx and percutaneous drain
267
What is Brown-Sequard syndrome?
Hemisected spinal cord
268
What are the signs and symptoms of Brown-Sequard syndrome?
Ipsilateral paralysis
Ipsilateral loss of proprioception & fine touch
Contralateral loss of pain & temperature
269
A prolapsed disc at which levels could cause quadriceps weakness?
L3 and L4
270
What are the 1st and 2nd line pain management for non-specific lower back pain?
1st line: NSAID and PPI
| 2nd line: codeine + paracetamol
271
What is the management of developmental dysplasia of the hip in a child <6 months old?
Pavlik harness for 6 months
272
What is Perthes' disease?
Avascular necrosis of the proximal femoral epiphysis from interruption of supply --> revascularisation and reossification over 18-36 months
273
What test can you perform on examination to test for Perthes?
Roll test
| Roll affected hip internally and externally --> guarding or spasm
274
Recall the management protocol for Perthes disease
If <6 years: analgesia, traction, crutches, physio to improve ROM
If >6 years: pelvic/ femoral osteotomy
275
What is SCFE?
Slipped Capital Femoral Epiphysis
| Displaced of epiphysis of femoral head postero-inferiorly
276
What are the 2 main key examination findings in SCFE?
Loss of internal rotation of a flexed hip
| Trendelenburg gait positive
277
How is SCFE managed?
Percutaneous internal fixation at growth plate
278
Recall some 5 prescription drug classes that can predispose to osteoporosis
```
Steroids
SSRIs
PPIs
Glitazones
Anti-epileptics
```
279
Which prognostic scoring systems are useful in osteoporosis?
FRAX
QFracture
Estimate a patient's 10 year risk of developing a fragility fracture
280
When assessing osteoporosis risk, what would count as 'long term steroids'?
>7.5mg/day for >3months
281
Recall the treatment indications for bisphosphonates
- Fragility fracture + age >75
| - Fragility fracture + T score 65y and on/ about to start longterm steroids
282
When should you give immediate bisphosophonates to patients who are on or about to start longterm steroids?
- If they are over 65
| - If under 65 then do a DEXA - give bisphosphonates if
283
What treatments should you give alongside bisphosphonates?
Always vitamin D
| Calcium supplements IF low levels
284
What are some contrainidications to bisphosphonates?
eGFR <30
Severe GORD
Recurrent gastric ulcer
285
Recall the instructions for administration of PO bisphosphonates
Take on empty stomach in the morning
Full glass of water
Stay upright for 30 minutes
286
If PO bisphosphonates are not tolerated, what alternative is there?
Annual IV zoledronate
287
What is the 2nd line for bisphosphonates if they are not contra-indicated?
SC denosumab
288
Recall some abnormalities that might be seen in the hands in osteoarthritis?
Heberden's nodes (DIPJ)
| Bouchard's nodes (PIPJ)
289
WHat are the 4 indications of osteoarthritis on X ray?
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchindral cysts
290
Recall some options for managing osteoarthritis
Wt loss
Physiotherapy
1st line: PO paracetamol w/ topical NSAID
2nd line: PO NSAIDs + PPI or weak opioids or capsaicin cream
3rd line: intra-articular corticosteroids
Surgical: joint replacement
291
What is the most likely (i) vascular and (ii) nerve injury caused by a knee replacement?
Vascular: superficial femoral artery
Nerve: common peroneal
292
Recall some immediate, early and late complications of T knee replacements
Immediate: vascular/ nerve injury
Early: DVT, prosthesis infection
Late: Loosening, instability from los ACL
293
Recal some possible complications of anterolateral vs posterior approaches for THR
Anterolateral: superior gluteal nerve injury --> Trendelenburg gait
Posterior: sciatic nerve injury --> foot drop
294
What is osteochondritis?
Idiopathic condition in which bony centres of paediatric bones become temporarily softened due to osteonecrosis
295
What would be seen on X ray in osteochondritis?
Increased density/ sclerosis --> patchy appearance
296
Which variation of osteochondritis affects the vertebral ring epiphyses?
Scheuermann's disease
297
Which variation of osteochondritis affects the navicular bone in toddlers?
Kohler's disease
298
Which variation of osteochondritis affects the lunate bone in adults?
Kienbochs disease
299
Which variation of osteochondritis affects the 2nd and 3rd metatarsals at puberty?
Friedberg's disease
300
Which variation of osteochondritis affects the capitulum of the humerus?
Panner's disease
301
What is the aetiology of osteochondritis dissecans?
Reduced blood flow --> cracks in articular cartilage and subchondral bone --> AVN --> fragmentation of bone and cartilage with free movement of fragments --> activity-related joint pain
302
What is the management for osteochondritis dissecans?
Arthroscopic removal
303
What is necrotising fasciitis?
Life-threatening infection that spreads across soft-tissue planes
304
What is pre-patellar bursitis?
It's an infection of the potential space in front of the patella
305
What should you ask about in the history if you are querying pre-patellar bursitis?
History of kneeling (eg builders)
306
How should pre-patelllar bursitis be managed?
Analgesia, compression, aspiration
307
Recall the risk factors for septic arthritis, and split them into modifiable and non-modifiable
Modifiable:
crystal arthropathies
Non-modifiable:
Age >90, rheumatoid arthritis, chronic renal failure, prosthetic joints
308
What investigations should be done to investigate septic arthritis?
XR
USS and MC&S joint aspirate
Bloods
Blood cultures
309
How should septic arthritis be managed?
IV antibiotics
| Joint washout
310
Recall some risk factors for osteomyelitis
Vascular disease, trauma, SCD, immunosuppression
311
What is the investigation of choice in suspected osteomyelitis?
MRI
312
What is the management for osteomyelitis?
IV antibiotics and radical debridement to living bone
313
What is the most likely pathogen in a prosthetic joint infection within 6 weeks of infection and after that?
<6 weeks: S. aureus
| >6 weeks: S. epidermidis
314
What is the gold-standard management of prosthetic joint infection?
Two-stage revision
Antibiotics whilst joint spacer is in
Re-implant with antibiotic-impregnated cement
315
What are the 2 main types of non-neoplastic bone tumours?
Fibrous dysplasia
| Simple bone cyst
316
Which bone tumour produces a 'shepherd's crook deformity' on X ray?
Fibrous dysplasia
317
Recall the names of 3 types of benign cartilaginous neoplasms
Osteochondroma
Endochondroma
Chondroblastoma
318
What is the most common benign bone tumour?
Osteochondroma
319
What is the most likely location of an osteochondroma?
Knee
320
What is a chondrosarcoma?
A malignant cartilaginous neoplasm
321
What are the most common sites of chondrosarcomas?
Pelvis
| Axial skeleton
322
Which form of tumour produces the appearance of 'popcorn calcification' on x ray?
Chondrosarcoma
323
Recall the 4 main different types of benign bone-forming neoplasms
Osteoma
Osteoid osteoma
Osteoblastoma
Osteoclastoma (giant cell tumour)
324
Which bone tumour typically produces severe nocturnal pain in young adults?
Osteoid osteoma
325
Which bone tumour produces a 'soap bubble' appearance on X ray?
Giant cell tumour/ osteoclastoma
326
What are the 2 main forms of malignant bone-forming neoplasms?
Osteosarcoma
| Ewing's sarcoma
327
What is the most common malignant primary bone tumour?
Osteosarcoma
328
Which bone tumour is associated with onion-skinning of the periosteum on X ray?
Ewing's sarcoma
329
In which dermatomes is sensation lost in Erb's palsy?
C5 C6
330
In which dermatomes is sensation lost in Klumpke's?
C8 T1
331
What muscle groups would be paralysed in Erb's palsy?
Abductors and external rotators --> waiter's tip
332
What muscle groups would be paralysed in Klumpke's?
Small muscles of hand --> claw hand
