Unit 1: Joint Conditions

Question 1

What causes cruciate ligament lesions?

Answer 1

The cruciate ligament is commonly injured by either hyperextension or a twist, often in association with the foot being anchored in a studded boot or a ski

Question 2

Describe the management of meniscal lesions

Answer 2

Peripheral tears can be reattached with sutures. Tears within the substance of the meniscus have no apparent capacity to repair and so the torn peripheral part should be removed. Once clinical suspicion is raised, patients should be examined by arthroscopy. Most meniscal lesions can be removed via the arthroscope (arthroscopic meniscetomy)

Question 3

Describe the management of cruciate ligament lesions

Answer 3

In general, the ligament should be left untreated for a while and the knee muscles rehabilitated. Treatment should only be offered if symptoms interfere with daily life or if the patient wishes to return to sport. Treatment consists of replacing the torn ligament with a synthetic one

Question 4

Why do cruciate ligaments not heal spontaneously?

Answer 4

When a cruciate ligament is torn it loses its blood supply and therefore cannot heal spontaneously

Question 5

Which organism may cause septic arthritis a young adult, often with little constitutional upset?

Answer 5

Gonococcus

Question 6

Discuss the aetiology of gout

Answer 6

Gout is caused by urate crystal deposition. The most common cause in the West is overuse of diuretics

Question 7

Discuss the aetiology of inflammatory abnormalities seen in orthopaedics

Answer 7

Inflammatory abnormalities may be associated with bacterial infection causing inflammation of a joint or bone. Sometimes the cause of the inflammation is not known, e.g. rheumatoid arthritis

Question 8

Discuss the aetiology of congenital abnormalities seen in orthopaedics

Answer 8

Congenital abnormalities are defects associated with development in the womb. They may have a familial or genetic cause or they may be the result of something happening to the mother or to the child whilst in the womb

Question 9

Name two types of avascular necrosis

Answer 9

Two types of avascular necrosis are post-traumatic and Caisson’s disease

Question 10

Describe arthrodesis

Answer 10

Arthrodesis, or the surgical stiffening of a joint in a position of function, is an appropriate operation in a young person with a painful and limited range of movement

Question 11

What is a meniscectomy?

Answer 11

The surgical removal of a meniscus

Question 12

List the professionals involved in treating orthopaedic conditions

Answer 12

The orthopaedic surgeon is dependent on theatre nurses and porters, orthopaedic nurses, other doctors e.g. GPs, anaesthetists, and paramedical specialists e.g. physiotherapists

Question 13

What is a synovectomy?

Answer 13

A synovectomy is a surgical procedure used in the management of rheumatoid arthritis. It involves the removal of the diseased synovial tissue (synovium). It is a good operation for clearing up damage around extensor tendons, reducing pain and stiffness

Question 14

Name the important types of movement of the hip

Answer 14

Flexion, extension and abduction

Question 15

Describe the overall treatment objectives in the field of orthopaedics

Answer 15

The ideal outcome would be to return people to normal. However, in most orthopaedic cases we cannot achieve a cure but we may try to relieve the patient of their principle complaints - pain and stiffness

Question 16

What is the important difference between treating tuberculosis and acute septic arthritis?

Answer 16

The important difference between treating TB and acute septic arthritis is that surgery is rarely necessary in the treatment of TB

Question 17

Why are prosthetic knee ligaments liable to fail?

Answer 17

Prosthetic knee ligaments are liable to fail as they have no sensory receptors and so may be overstretched without the brain ‘knowing’. The brain is therefore unable to initiate protective muscle action

Question 18

Describe an osteotomy

Answer 18

Osteotomy consists of the surgical realignment of a joint, with the aim being to redirect forces across a joint so that they are more evenly distributed

Question 19

Name one principle difference between the requirements for an upper limb and lower limb joint replacement

Answer 19

An upper limb joint replacement must be capable of a larger range of movement than a lower limb joint replacement, but it does not require to withstand such large forces

Question 20

List and classify the causes of osteoarthritis

Answer 20

The classification starts by grouping patients into those whose arthritis has a known cause (secondary osteoarthritis) and those where the cause remains unknown (primary arthritis)

Question 21

Name the early problems which may occur after a joint replacement

Answer 21

Dislocation is a risk as in the immediate post-operative period the prosthesis will not be fully supported by the surrounding tissues. Deep vein thrombosis and infection are also risks

Question 22

Name the late problems which may occur after a joint replacement

Answer 22

Infection and loosening and wear

Question 23

Name the important types of movement of the knee

Answer 23

Flexion and extension

Question 24

What is the principal indication for operative treatment of arthritis?

Answer 24

Pain is the principle indication for operative treatment

Question 25

Which late complication of arthroplasty is possibly almost inevitable?

Answer 25

Loosening and wear

Question 26

What causes meniscal lesions?

Answer 26

The principal cause of meniscal lesions is twisting injury, often associated with skiing, or games where studs are worn on shoes or boots

Question 27

Discuss the reasons why goals for lower limb joint replacement differ from goals for upper limb joint replacement

Answer 27

The relationship between pain relief and function is quite different from that observed in the lower limb. In the upper limb, the loads involved are quite low but a large range of motion is required. Intrinsic stiffness can still be a problem after arthroplasty as soft tissue distortion of the capsule and ligaments remains after replacing the articular surfaces

Question 28

Define an effusion

Answer 28

An effusion is excess fluid in the joint

Question 29

Define the term 'acute'

Answer 29

An acute disease is one that strikes the patient suddenly. It is characterised by the production of polymorphonuclear leucocyte (polymorph for short)

Question 30

Which is more significant in arthritis - pain or stiffness?

Answer 30

Pain

Question 31

What role has the surgeon in the treatment of avascular necrosis?

Answer 31

The surgeon has NO role in the treatment of avascular necrosis until the joint requires replacement

Question 32

Define chronic septic arthritis

Answer 32

Joint tuberculosis is a bacterial infection resulting in chronic septic arthritis. It is mainly found in underdeveloped countries. AIDS patients are particularly prone to this illness

Question 33

Define arthroplasty

Answer 33

Surgery which creates a new joint or changes the shape of a joint

Question 34

Define primary arthritis

Answer 34

Primary arthritis is when there is no known cause. We have little insight into the causes of primary arthritis, but it has been suggested that it is linked to problems with the repair of joint damage

Question 35

Define acute septic arthritis

Answer 35

Acute septic arthritis is an infection caused by bacteria, which have spread to the joint via the blood from a site of trivial infection, such as a boil. It occurs very rarely from direct penetration of the joint by a sharp object. In adults, joint infection is rare unless the joint is already damaged, or the immune defence system is abnormal

Question 36

List the types of operative treatment available for osteoarthritis

Answer 36

For most forms of arthritis there are four surgical options: - Nothing - Arthrodesis - Osteotomy - Arthroplasty

Question 37

Define the term 'self-limiting'

Answer 37

Self-limiting means the condition is temporary and will get better

Question 38

Describe the origins of orthopaedics

Answer 38

Orthopaedics literally means 'straight children' as it has its origins in dealing with musculoskeletal abnormalities occurring at birth or in children as they grow. Nowadays the field of orthopaedics has grown to encompass the whole range of diseases affecting the musculoskeletal system

Question 39

Which is the most successful and common joint replacement?

Answer 39

Hip replacement

Question 40

Describe three general complications of surgery

Answer 40

General complications of surgery include chest infection, urinary tract infection, and pressure sores

Question 41

Describe how a doctor may treat arthritis before and after admission to hospital

Answer 41

Conservative treatment options include weight loss, use of a stick, rest and physiotherapy

Question 42

Discuss the aetiology of pseudogout

Answer 42

Pseudogout is caused by the deposition of pyrophosphate, the origin of which is unknown

Question 43

Describe the management of loose bodies

Answer 43

Loose bodies should be removed, preferably using the arthrosope. In the case of osteochondritis dissecans, the condition may settle spontaneously or may require removal of the loose bodies

Question 44

Define plication

Answer 44

Plication is a medial tightening of the vastus medialis muscle

Question 45

Discuss the aetiology of degenerative disorders seen in orthopaedics

Answer 45

Degenerative disorders are a group of conditions where the normal structure of the joint has been disturbed through deterioration and wear

Question 46

What is an excision arthroplasty?

Answer 46

An excision arthroplasty is a surgical procedure used in the management of rheumatoid arthritis. It involves a limited excision of the joint. This relieves pain but because some of the joint has been removed there can never be a full return of function

Question 47

List the common types of meniscal lesion

Answer 47

The parrot beak tear and the bucket handle tear are the most common types of meniscal lesion

Question 48

The deposition of which crystal causes gout?

Answer 48

Urate

Question 49

Define secondary arthritis

Answer 49

Secondary arthritis refers to arthritis where there is a known cause e.g. congenital, metabolic, trauma

Question 50

Discuss the aetiology of dislocation of the patella

Answer 50

Dislocation of the patella is usually associated with a malformation of either the patella or the lateral femoral condyle. This leads to the patella moving abrasively on the femur (maltracking)

Question 51

What causes loose bodies in the knee?

Answer 51

Small fragments of cartilage and bone (osteochondral fragments) may be sheared off in an injury. These fragments are often not resorbed but floats in the synovial fluid Osteochondritis dissecans a condition seen very rarely in adolescence where osteochondral fragments occur spontaneously

Question 52

Discuss the principles of knee replacement

Answer 52

The functional range of movement of the knee is surprisingly small, although ideally ninety degrees of flexion must be achieved to get up and down stairs. Stability in extension is essential so that we can support the full weight of the body whilst standing on a single straight leg

Question 53

Define rheumatoid arthritis

Answer 53

Rheumatoid arthritis is a chronic disease of many systems of the body, manifesting itself as joint pain

Question 54

What is the principle difference between primary and secondary arthritis?

Answer 54

The cause of secondary arthritis is known, whereas the cause of primary arthritis is unknown

Question 55

Describe the management of dislocation of the patella

Answer 55

Minor degrees of maltracking are dealt with by surgical splitting of the vastus lateralis muscle insertion into the patella. If maltracking is recurrent and severe, then a medial tightening (plication) of the vastus medialis muscle may be required. In adulthood, the patellar tendon may be re-sited more medially

Question 56

Name the four cardinal symptoms of knee disorders

Answer 56

The four main symptoms of knee disorders are swelling, locking, giving way and pain

Question 57

Discuss the aetiology of metabolic disorders seen in orthopaedics

Answer 57

Metabolic disorder is a term indicating a group of illnesses which usually cause inflammation, but the cause can be traced back to some abnormality in body metabolism

Question 58

Which joints are most commonly affected in rheumatoid arthritis?

Answer 58

The joints of the fingers, wrists, feet, and ankles are most commonly affected by rheumatoid arthritis

Question 59

Name the two principle symptoms in orthopaedics

Answer 59

Pain and stiffness

Question 60

What is a loose body?

Answer 60

A loose body is a fragment of cartilage and bone free in the joint

Question 61

Discuss the aetiology of trauma seen in orthopaedics

Answer 61

Trauma is where the musculoskeletal system has suffered damage from an outside physical agent

Question 62

What happens to the menisci in knees affected by pseudogout?

Answer 62

In knees affected by pseudogout the menisci become calcified

Question 63

How does the surgeon ensure stability in extension after a knee replacement?

Answer 63

The surgeon must balance the collateral ligaments by cutting tight parts of the ligaments and then putting in artificial surface replacements of sufficient thickness to re-tighten the ligaments so that the medial and lateral collateral ligaments are under equal tension

Question 64

Define the term 'chronic'

Answer 64

A chronic disease takes a long time to develop and may last a long time. It is characterised by the production of lymphocytes

Question 65

Name three requirements of any joint replacement

Answer 65

Functional and pain-free range of movement, stability and resistance to forces, wear and loosening

Question 66

Describe the management of acute septic arthritis

Answer 66

Treatment consists of surgery and IV antibiotics. The 'first guess' antibiotic should be an anti-staphlococcal agent

Question 67

Describe the role of surgery in rheumatoid arthritis

Answer 67

The role of the surgeon is to ensure that the patient is as comfortable as possible whilst retaining as much function as possible. Soft tissue surgery involves synovectomy. This may be combined with an excision arthroplasty of the joint

Question 68

What kind of cells would you expect the immune defence system of the body to produce in response to tuberculosis?

Answer 68

As it is a chronic disease you would expect the body to produce lymphocytes

Question 69

What is an arthrotomy?

Answer 69

The surgical opening of a joint

Question 70

Describe the management of chronic septic arthritis

Answer 70

Treatment is by drugs and only rarely is surgery necessary. Combinations of antibiotics such as streptomycin, ethambutol and rifampicin are given for many months

Question 71

What is the possible long-term consequence of crystal arthropathy?

Answer 71

Chronic degeneration and secondary arthritis is the possible long-term consequence of crystal arthropathy

Question 72

Discuss the principles of hip replacement

Answer 72

Although the hip joint has tremendous demands placed upon it, the loads are largely offset by the generally stable configuration of a ball and socket joint. The functional range of hip motion is in practice fairly limited

Question 73

Define a bacteraemia

Answer 73

A bacteraemia is the presence of bacteria in the bloodstream