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Flashcards in T&O Deck (78):
1

What is syndesmosis

Immovable joint

2

Core signs of NPH

(NPH = Normal Pressure Hydrocephalus)

1) Dementia
2) Ataxia
3) Urinary incontinence

3

Signs of compartment syndrome

All the Ps...
Painful, Perishingly cold, pale, pulseless
Late signs- paraesthesia, paralysis

Abnormally painful when big toe is pulled forward

** SURGICAL EMERGENCY or can lose the limb due to nerve/muscle ischaemia

4

Causes of compartment syndrome

TRAUMA
Lower leg or radial/ulnar fractures
Crush injuries
Plaster of paris casts
Burns

Bonus: anabolic steroids can be associated

5

Pathophysiology of compartment syndrome

Muscle compartments enclosed by fascia. Fascia does not stretch... so bleeding/oedema causes increased compartmental pressure very easily. This reduces blood supply to the compartment and thus o2/nutrients.
The increased pressure also reduces lymphatic and venous return.
VISCIOUS CYCLE OF INCREASING PRESSURE

6

Consequences of missed compartment syndrome

Rhabdomyolysis = skeletal muscle breakdown, myoglobin release = acute renal failure

Limb ischaemia = loss of function/loss of limb

7

How many compartments between knee and ankle

4 !!!
- anterior
- lateral
- superficial posterior
- deep posterior

8

Mx of compartment syndrome

History
Examination
Pain management
GET HELP FROM SENIORS (fasciotomy)
Split cast

9

Ligament most likely to be damaged in an ankle strain (bonus point for mechanism)

anterior talofibular ligament
(also calcaneofibular)

Mechanism- excessive inversion/twisting injury

10

Types of ankle #

Open
Closed- displaced
Closed- non-displaced
(lateral/medial/posterior malleoli or bimallolar/trimalleolar (POTTS))

11

Mx of the # pt (generally)

1) History (inc PMH)
2) Examine
3) Investigate (XRAY either AP, lateral)
4) Bloods- FBC, U and Es, MRSA screen, G&S, clotting, calcium
5) ECG and CXR?

12

Most common organism isolated in osteomyelitis

Staph aureus

13

Best imaging tool for osteomyelitis

plain radiograph (XR)

14

Define osteomyelitis

Infection of the bone. Can be haematogenous or caused by contiguous spread of infection.

15

Presentation of osteomyelitis

Non-specific pain (with and without movement)
Tenderness
Swelling
Warmth of area/erythema
Malaise/Fatigue/Low grade fever
Typically weeks-months post trauma

16

Risk factors for osteomyelitis

Penetrating injuries (hx of)
IV drug abuse
HIV
Surgical contamination
Diabetes Mellitus

Bonus- Periodontitis (can cause osteomyelitis of the mandible)

17

Investigating osteomyelitis

Bloods- WCC, cultures, ESR, CRP,

Imaging- plain radiograph/XR of affected area (periosteal thickening or soft tissue swelling often seen)

Also want to culture aspirate or bone from debridement

18

Differentials for osteomyelitis

Metastatic bone cancer
Osteosarcoma
Old/new trauma

19

Mx osteomyelitis

Abx therapy (culture-directed)
Superficial or surgical debridement

20

What is cauda equina syndrome

Compression of terminal spinal nerve roots in the lumbosacral region (L1-S5)

** MEDICAL ORTHO EMERGENCY

21

Features of cauda equina

Bilateral leg pain
Bowel and bladder dysfunction
Saddle anaesthesia
Lower extremity sensorimotor changes
Back pain
Impotence

22

Causes of cauda equina

Disc herniation (most common)
Spinal stenosis
Tumours
Trauma
Spinal epidural haematoma
Epidural abscess

Associated with DVT post spinal trauma/surgery

23

Signs of cauda equina on physical examination

-palpate bladder for retention
-may see muscle fasiculations or atrophy (rare)
-lower extremity weakness
-decreased/absent lower limb reflexes
-reduced/absent sensation around perianal/perineum/post thigh
-decreased rectal tone on DRE
-diminished/absent bulbocavernosus reflex

24

What is the bulbocavernosus reflex

Squeeze penis/clitoris and external anal sphincter should contract
Tests S2-S4

25

Imaging for cauda equina

mri

26

Mx for cauda equina

urgent surgical decompression within 48 hrs (diskectomy or laminectomy)

27

Complications of cauda equina

sexual dysfunction
urinary dysfunction (needs catheter)
chronic pain
persistent leg weakness

28

What is non union and malunion

Non-union: bone does not heal properly, causing pain and instability in the limb

Malunion: fracture heals in a deformed position, commonly with shortening of the limb

29

Types of "wrist fracture"

Distal radial...
- Colles' (post displacement), extra-articular
- Smiths (ant displacement), extra-articular
- Barton's (dorsal or volar displacement), intra-articular

Radial styloid process...
- Chauffeur's fracture

30

What is discitis

Infection of intervertebral disc space...

Can result in epidural abscess or sepsis !!

31

Clinical features of discitis

Back pain
Rigors, fever, sepsis
Neuro features if an epidural abscess develops

32

Causes of discitis

Bacterial (staph aureus most common)
Viral
TB
Aseptic

33

Managing discitis

6-8 weeks IV Abx

34

Diagnosing discitis

MRI
Biopsy may be needed to guide Abx treatment

35

Triad seen in Leriche syndrome

Claudication of buttocks and thighs
Impotence (lose L1)
Atrophy of leg muscles

36

Pathophysiology of leriche syndrome

Atherosclerosis of iliac arteries and aorta. Iliac arteries supply buttocks etc

Typically treated with endovascular angiography and stent

37

Common cause of osteomyelitis in ...
children with sickle cell disease
T2DM
IVDU
immunosuppression/HIV
chronic alcohol abuse

Salmonella organisms!

Mx: flucloxacillin for 6 weeks (clindamycin if allergic to penicillin)

38

What is Finkelstein's test for

De Quervains Tenosynovitis

** thumb in a fist and then sharp ulnar deviation of the wrist

39

Risk factors for carpal tunnel syndrome

fat, female, 40
diabetes
pregnancy
post menopause
trauma
rheumatoid arthritis
repetitive flexing of the wrist
hypothyroidism
acromegaly

40

Testing carpal tunnel syndrome

tinnel's test (tapping)
phalen's test (reverse prayer sign)

41

What does hoffman's test for?

Bonus: other signs and symptoms for this condition

cervical myelopathy

** UMN signs... hyper-reflexia, + babinski, stiffness, clonus/hoffmans in upper limb, ataxia (+ rombergs)

42

Froment's sign?

ULNAR NERVE PALSY- loss of pinch grip (grab piece of paper between thumb and index finger)
Wastage in first web space as loss of adductor pollicus

43

Basic hand examination

Look
Feel over joints/bones
Move-
- Ulnar nerve (pinch grip and interossei spread fingers)
- Median nerve (ok sign, flex at DIPJ and PIPJ)
- Radial nerve (extension of fingers)
- Froment's sign
- Tinnel's/Phalen's sign
- Bring thumb across to little finger (opposition)
- Hoffman's

44

Causes of ulnar nerve palsy

cervical radiculopathy (pinched nerve in neck)
cubital tunnel syndrome

45

What is CTEV

Congenital Talipes Equinovarus

46

What is 'clubbed foot'

Congenital Talipes Equinovarus (CTEV)

47

What are the 4 deformities in CTEV

C - cavus (high arch, plantar flexed first ray)
A - Adductus (midfoot turns in)
V - Varus (hindfoot)
E - equinus (tight achille's tendon)

48

Mx of CTEV

Ponseti techniques! (followed by use of denis brown boots)

49

'Child with a limp' ... differentials

DDH
SUFE (10-16, male, obese)
Transient Synovitis
Septic arthritis
Perthe's disease (idiopathic osteonecrosis)

50

DDH findings on examination/tests

Ortolan's test (abduct and medially apply pressure to relocate)

Barlow's test (push femur backwards with leg flexed to dislocate)

Different patella heights when lying flat with bent knees

51

Mx of DDH

<6 mths = pavlik harness
6-18 mths = closed reduction and spica cast
>18 mths = open reduction and spica cast
> 2 y/o = reduction and femoral/pelvic osteotomy

52

What is perthe's disease

limp and pain in a child aged 4-8
idiopathic osteonecrosis of femoral head
femoral head becomes flattened
conservative management

53

Differentiating septic arthritis from transient synovitis

!! Unable to weight bear
!! WCC > 12,000
!! Fever >38.5
!! ESR > 40mm/h

54

Most common organism in septic arthritis in kids/adolescents

Neisseria Gonorrhoea (gram neg diplococci)

55

Risk factors for DDH

Breech
First born
female
Family history
oligohydraminos

56

What is DDH

Shallow/underdeveloped acetabulum in kids

57

What is transient synovitis

child with a limp and hip pain (2-5 y/o)
sudden onset
often associated with recent viral infection
hip will be flexed and externally rotated
self limiting - use NSAIDs

58

What is SUFE/SCFE

Slipped capital femoral epiphysis!

weakness in growth plate of the femoral head = neck slips from femoral head

59

Risk factors for SUFE

Obesity
Male
10-16 y/o
Endocrinopathy (hypothyroid/hypogonadism)

60

SUFE on imaging

Slipped Klein's line! (does not intersect femoral head when drawn from just below greater trochanter)

61

SUFE Mx

Singe screw into growth plate (pin in place)

62

Mx of septic arthritis (kid with a limp)

Surgical incision and drainage
Abx (cephalosporin)

63

Classify open Fractures

Gustilo and Anderson classification

1 - <1cm, min contamination, mild soft tissue damage, local coverage, simple #/minimal comminuition

2- >1cm, mod contamination, mod soft tissue damage, local coverage, more comminuted fracture

3 = 3a, 3b, 3c!
- All >10cm, severe contamination, severe soft tissue damage, periosteal stripping and severe comminution/segmental Fractures

A) adequate coverage
B) needs graft
C) needs graft and NVS damage (most likely amputate)

64

Factors to consider when assessing an open fracture

Size of wound
Soft tissue damage (is there local coverage)
Contamination
Comminution of fracture/complexity
+/- NVS injury

65

Mx of open Fractures (ed)

1) ABCDE
2) Stop bleeding, replace fluid/blood loss
3) analgesia
4) abx and tetanus
5) assess soft tissue damage and NVS status
6) remove obvious debris, TAKE A PHOTO
7) cover with saline gauze
8) splint/stabilise then REASSESS NVS STATUS
9) send for surgical debridement and # stabilisation

66

Red flags for back pain

Saddle anaesthesia
Outside 18-55 in age
Night pain
Weight loss
Steroid use
Prev malignancy
Thoracic pain
Loss of sphincter control
Muscle weakness

67

Presentation of a fat embolus

- Breathlessness
- Retinal Haemorrhages
- Fever
- Confusion
- Up to 3 days post trauma
- Petechial rash

68

Where does the psoas muscle insert and give the presentation of a psoas abscess (including organism)

T12-L5 - lesser trochanter of the femur
Often staphylococcus or streptococcus
May be primary or spread from pyelonephritis/IBD

Risk factors - IVDU, immunosuppression, TB, cancer, diabetes

Presentation: lying on back with knees slightly flexed, back tenderness over insertion region, non specific pain which increases over days, unable to weight bear

69

Gold standard for diagnosing a psoas abscess

MRI scan
(bloods for septic screen too, failure to detect can lead to multi organ failure)

70

MOA tetanus vaccine

artificial active immunity

dead/weakened version of disease enters body and causes an immune response to produce antibodies

71

Tetanus organism

Clostridium tetani

72

What is tetanus

Infection characterised by muscle spasms starting in the jaw and progressing over the body
Powerful and pain muscle contractions! Lead to fractures, muscle tears, suffocation, swallowing difficulties, heart attack, incontinence, drooling

73

What has a higher risk of infection? Cat or dog bite?

CAT

74

Most common organism in cat and dog bites

Most are polymicrobial
Most common organism in both = Pasteurella (gram neg anaerobe)

75

Dog bite organisms

Pasteurella canis (50%)
Staph aureus
Strep (alpha-haemolytic)
Corynebacterium
Capnocytophaga canimorsus (rare, deadly)

76

Cat bite organisms

Pasteurella multocida and pasteurella septica (70-50%)

77

Organism in rabies

Rhabdovirus (dogs, racoons, bat, fox)

78

Mx/Abx for cat and dog bites

Amoxicillin/clavulanic acid effective against pasteurella multocida
Cefuroxime
Ceftriaxone