Disease Profiles 3 Flashcards
1
Q
Transient Synovitis
A
Self-limiting inflammation of the synovium of a joint
2
Q
Transient Synovitis: Most common joint affected
A
Hip
3
Q
Transient Synovitis: Most common aetiology
A
Following URTI - usually viral
4
Q
Transient Synovitis: Peak age of incidence
A
2-10 years old
5
Q
Transient Synovitis: Epidemiology of sexes
A
More common in boys
6
Q
Transient Synovitis: Clinical presentation
A
Limp or reluctance to bear weight on the affected side with reduced range of motion
Pain at the end range of hip movements - reduced ROM
7
Q
Transient Synovitis: What criteria is used for diagnosis?
A
Kochers Criteria - differentiated septic arthritis from transient synovitis in a child with an inflamed hip
8
Q
Transient Synovitis: Test to exclude Perthes Disease
A
X-Ray
9
Q
Transient Synovitis: Test to exclude septic arthritis
A
CRP
10
Q
Transient Synovitis: Test to exclude osteomyelitis of the proximal femur
A
MRI
11
Q
Transient Synovitis: Management
A
NSAIDs and Rest
12
Q
Septic Arthritis of the Hip: Why is it a surgical emergency? (3)
A
High bacterial load
Destruction of the joint occurs due to proteolytic enzymes
Potential for osteonecrosis of the hip due to increased pressure
13
Q
Septic Arthritis of the Hip: Aetiologies (4)
A
Direct inoculation due to trauma or surgery
Haematogenous seeding
Extension from adjacent bone osteomyelitis
Can develop from contiguous spread of osteomyelitis
14
Q
Septic Arthritis of the Hip: Most common cause
A
Haematogenous seeding
15
Q
Septic Arthritis of the Hip: What enables the spread?
A
Highly vascular metaphysis
16
Q
Septic Arthritis of the Hip: Why is this common in neonates?
A
Transphyseal vessels allow spread into the joint
17
Q
Septic Arthritis of the Hip: Causative organisms (4)
A
Staphylococcus aureus
Group B streptococcus
E. coli
Streptococcus pneumoniae
18
Q
Septic Arthritis of the Hip: Most common causative organism in first 2 years of life
A
Streptococcus pneumoniae
19
Q
Septic Arthritis of the Hip: Clinical Presentation (3)
A
Unable to weight bear
Severe hip or groin pain on passive movement
Pyrexial
20
Q
Septic Arthritis of the Hip: Kocher Criteria (5 criteria)
A
Fever - >38.5
Refusal to weight bear
ESR - 40mm/hour
Serum EBC - >12,000 cells
CRP - >2
21
Q
Septic Arthritis of the Hip: Management
A
Open surgical washout - takes an anterior approach
6 weeks of antibiotics via PICC line
22
Q
Perthes Disease
A
Idiopathic osteochondritis of the femoral head
23
Q
Perthes Disease: Peak age of incidence
A
4-9 years old
24
Q
Perthes Disease: Epidemiology of sexes
A
More common in men - more commonly active boys of short stature
25
Perthes Disease: What ethnicities are at greater risk?
Asian
Inuit
Central european
26
Perthes Disease: Pathophysiology
The femoral head transiently loses its blood supply resulting in necrosis with subsequent abnormal growth
27
Perthes Disease: Remodelling causes the formation of an incongruent joint, what impact may this have?
Increased risk of early onset arthritis
28
Perthes Disease: Symptoms (2)
Child presents with unilateral pain and a limp
29
Perthes Disease: Bilateral pain may represent what?
Underlying skeletal dysplasia or a thrombophilia
30
Perthes Disease: Impact on movement
Loss of internal rotation
Loss of abduction
Positive Trendelenburg Test - detects gluteal weakness
31
Perthes Disease: Growth pattern of these patients
Delayed bone age - retarded growth soon after diagnosis but later catch up
32
Perthes Disease: Why do some patients become Trendelenburg Positive?
The femoral head becomes aspherical, flattened and widened therefore weakens the lever arm of the abductor muscles
33
Perthes Disease: When may osteotomy of the femur or acetabulum be required?
When the femoral head subluxes - partially dislocates
34
Hallux Valgus
Deformity of the great toes due to medial deviation of the 1st metatarsal and lateral deviation of the toe itself
35
Hallux Valgus: Epidemiology of sexes
More common in females
36
Hallux Valgus: What would indicate a strong family history of this?
Presentation in late adolescence
37
Hallux Valgus: More common in those impacted by what?
Inflammatory Arthropathies - RA or Neuromuscular diseases e.g. MS or Cerebral palsy
38
Hallux Valgus: Extrinsic Risk Factors (2)
High heels
Narrow toe box shoes
39
Hallux Valgus: Pathophysiology
Valgus deviation of the phalanx promotes medial deviation of the metatarsal head
40
Hallux Valgus: Impact on the sesamoids
Lateral deviation
41
Hallux Valgus: Why are the sesamoids deviated laterally?
Due to attachment to the flexor hallucis brevis that attaches to the base of the proximal phalanx of the toe
42
Hallux Valgus: Is presentation normally unilateral or bilateral?
Bilateral
43
Hallux Valgus: Why may patients become unable to wear closed shoes? (2)
Bursa present
Nerve damage
44
Hallux Valgus: How could a bunion form?
A widened forefoot may cause rubbing of the foot with the shows causing an inflamed bursa over the medial 1st metatarsal head
45
Hallux Valgus: How could ulceration develop?
The great toe and the second toe rubbing on each other
46
Hallux Valgus: Joint pain indicates what?
Osteoarthritis
47
Hallux Valgus: What does defunctioned 1st ray indicate?
Transfer metatarsalgia
Poor balance
48
Hallux Valgus: Defunctioned 1st Ray
Segment of the foot composed of the first metatarsal and the first cuneiform bones
49
Hallux Valgus: Conservative management
Wear wider and deeper shoes to prevent bunion formation
Spacer used to prevent ulceration
50
Hallux Valgus: What surgical procedure can be performed?
Osteotomies
51
Hallux Valgus: Function of Osteotomies
Realign bones and soft tissue to tighten slack tissues and release tight tissues
52
Hallux Valgus: Indications for surgery (5)
Failure of conservative management
Lesser toe deformities
Liftstyle limitation
Overlapping
Functional limitation
53
Hallux Valgus: Complications of surgery (2)
Pain in the metatarsal heads
Risk of recurrence of deformity in adolescents
54
Hallux Valgus: Aim of surgical management
Realign the hallux and decrease the HV angle
55
Hallux Rigidus
Osteoarthritis of the first Metatarsophalangeal Joint
56
Hallux Rigidus: Predisposing factors (2)
Acute trauma
Microtrauma
57
Hallux Rigidus: Symptoms (3)
Painful 1st Metatarsophalangeal Joint
Stiffness
Pain increases with activity or shoes
58
Hallux Rigidus: Signs (2)
Dorsal Exostosis - this is a bone spur
Interphalangeal Joint hyperextension
59
Hallux Rigidus: Diagnostic Test
X-Ray - Anteroposterior, Lateral and Oblique
60
Hallux Rigidus: Conservative management (3)
Weight loss
Analgesia or NSAIDs
Intra-articular injection
61
Hallux Rigidus: Surgical Management - For early cases with dorsal osteophytes impinging during dorsiflexion
Cheilectomy - removal of osteophytes
62
Hallux Rigidus: Surgical Management - Gold standard surgical management
Arthrodesis - fusion of the bones to remove diseased cartilage
63
Rheumatoid Foot
Inflammatory autoimmune disorder characterised by joint pain, swelling and synovial destruction of the foot
64
Rheumatoid Foot: Impacts what % of RA patients?
90%
65
Pes Planus: Alternate name
Flat feet
66
Pes Planus: Prevalence
1 in 5 adults
67
Pes Planus: Most people are born with flat feet, how is this changed over time?
Most individuals develop a medial arch once walking as the tibialis posterior strengthens
68
Pes Planus: Suggested pathophysiology for this (2)
Generalised ligamentous laxity or tightness of the gastrocsoleus complex, causing stretching
Tarsal Coalition - Underlying bone connection
69
Pes Planus
Loss of the medial longitudinal arch of the foot where it contacts or nearly contacts the floor
70
Pes Planus: Acquired flat foot may occur due to what? (4)
Tibialis posterior tendon stretch
Tibialis posterior tendon rupture
Rheumatoid arthritis
Diabetes with Charcot Foot - neuropathic joint destruction
71
Pes Planus: Mobile Flat Feet
Feet where the flattened medial arch forms with dorsiflexion of the great toe and forms an arch when patient is on tip toes
72
Pes Planus: Mobile Flat Feet - Management
This is normal in children - medial arch orthoses are not required
73
Pes Planus: Mobile Flat Feet - Cause in adults
Tibialis posterior tendon dysfunction
74
Pes Planus: Rigid Flat Feet
The arch of the foot remains flat regardless of load or great toe dorsiflexion
75
Pes Planus: Rigid Flat Feet - Implies what is present? (3)
Underlying bony abnormality - tarsal coalition where the bones of the hindfoot have an abnormal or cartilaginous connection
Inflammatory disorder
Neurological disorder
76
Pes Planus: Diagnostic test
Calf Tightness Assessment
77
Pes Planus: Complications
Higher risk of tendonitis of the tibialis posterior tendon
78
Tibialis Posterior Tendon Dysfunction: The Tibialis Posterior Tendon inserts where?
Onto the medial navicular
79
Tibialis Posterior Tendon Dysfunction: Tibialis Posterior Tendon serves what function?
Support the medial arch of the foot
80
Tibialis Posterior Tendon Dysfunction: Most common cause of what?
Acquire flat foot (pes planus) in adults
81
Tibialis Posterior Tendon Dysfunction: Most at risk patient group
Obese middle aged females
82
Tibialis Posterior Tendon Dysfunction: Correlation between incidence and age
Risk increases with age
83
Tibialis Posterior Tendon Dysfunction: Risk Factors (4)
Hypertension
Diabetes
Steroid injections
Seronegative Arthropathies
84
Tibialis Posterior Tendon Dysfunction: Pathophysiology
Under repeated stress the tendon is degenerated to develop tendonitis, elongation and then rupture
85
Tibialis Posterior Tendon Dysfunction: What is the result of this pathophysiology?
Loss of the medial arch with resulting valgus of the heel and flattening of the medial arch of the foot
86
Tibialis Posterior Tendon Dysfunction: Anatomy - Posterior to what?
Medial malleolus
87
Tibialis Posterior Tendon Dysfunction: Anatomy - Attaches onto what?
Navicular tuberosity
Plantar aspect of the medial and middle cuneiforms
88
Tibialis Posterior Tendon Dysfunction: Anatomy - What elevates the arch?
Primary dynamic stabiliser of the medial longitudinal arch
89
Tibialis Posterior Tendon Dysfunction: Clinical Presentation - Specific symptom
Pain and/or swelling posterior to the medial malleolus
90
Tibialis Posterior Tendon Dysfunction: Clinical Presentation - Type I
Normal Arch - with swelling and tenderness over the posterior tibia with weak muscular power
91
Tibialis Posterior Tendon Dysfunction: Clinical Presentation - Type II
Flat foot with midfoot abduction - the arch is collapsed
92
Tibialis Posterior Tendon Dysfunction: Clinical Presentation - Management of Type II
Passively correctable
93
Tibialis Posterior Tendon Dysfunction: Clinical Presentation - What sign is present in Type II?
Too many toes sign - cannot single heel raise
94
Tibialis Posterior Tendon Dysfunction: Clinical Presentation - Type III
Flat foot with rigid forefoot with a collapses arch
95
Tibialis Posterior Tendon Dysfunction: Clinical Presentation - What pathologies are present in Type III?
Hindfoot deformities
Subtalar arthritis
96
Tibialis Posterior Tendon Dysfunction: Clinical Presentation - Type IV
Arch collapse with a talar tilt in ankle mortise
97
Tibialis Posterior Tendon Dysfunction: Clinical Presentation - What pathology is present in Type IV?
Subtalar arthritis
98
Tibialis Posterior Tendon Dysfunction: Tendonitis should be treated how?
Splint with a medial arch support to avoid rupture
99
Tibialis Posterior Tendon Dysfunction: Management - First line
Orthoses to accommodate foot shape and medial longitudinal arch
100
Tibialis Posterior Tendon Dysfunction: Management - Second line if orthoses fail
Surgical decompression and tenosynovectomy
101
Tibialis Posterior Tendon Dysfunction: Management - What must not be used?
Steroid injections
102
Tibialis Posterior Tendon Dysfunction: Management - Surgical options if no secondary osteoarthritis is present
A tendon transfer with a calcaneal osteotomy
103
Tibialis Posterior Tendon Dysfunction: Management - Surgical options if secondary osteoarthritis is present
Arthrodesis
104
Tibialis Posterior Tendon Dysfunction: Complications
Failure of static hind foot stabilisers, spring ligament, plantar fasciitis and plantar ligaments
105
Pes Cavus
Abnormally high arch of the foot
106
Pes Cavus: Often caused by what?
Neuromuscular conditions - Neuropathy, Cerebral palsy, Polio and Spinal cord tethering from the spina bifida occulta
107
Pes Cavus: Main symptom
Pain in the arch of the foot
108
Pes Cavus: What is an accompanying symptom of pes cavus?
Claw toes
109
Pes Cavus: Combined deformities (3)
Hindfoot varus
Forefoot adduction
Clawing of the toes
110
Pes Cavus: Investigation if tumour is suspected
MRI of the spine
111
Pes Cavus: Gold standard
X-ray of the foot
112
Pes Cavus: Management - If movement is easy
Soft tissue release and tendon transfer
113
Pes Cavus: Management - If rigid movement
Calcaneal osteotomy
114
Plantar Fasciitis
Degenerative condition of the plantar fascia that causes sharp pain on the bottom of the foot
115
Plantar Fasciitis: Aetiology
Repetitive stress or overload
Degenerative condition
116
Plantar Fasciitis: 5 Risk Factors
Physical overload - excessive exercise or weight
Diabetes
Increased age
Abnormal foot shape
Frequent walking on hard floors with poor cushioning in shoes
117
Plantar Fasciitis: Why does increased age increase risk?
The cushioning heel fat pad atrophies with age
118
Plantar Fasciitis: What abnormal foot shapes increase risk? (2)
Planovalgus
Cavovagus
119
Plantar Fasciitis: Clinical presentation
Pain after rest on the instep of the foot
120
Plantar Fasciitis: When is the pain worse?
After exercise
121
Plantar Fasciitis: Where is the pain mainly felt?
At the origin of the plantar aponeurosis on the distal plantar aspect of the calcaneal tuberosity
122
Plantar Fasciitis: Sign on the plantarmedial aspect of the heel
Fullness or swelling
123
Plantar Fasciitis: What test can be used and what result would it have?
Tinel's Test - lightly tap over the nerve to elicit a tingling sensation
Positive for Baxter's nerve
124
Plantar Fasciitis: Management - Risk of surgical release of the plantar fascia
Injury to the plantar nerves
125
Plantar Fasciitis: Management - General suggestion
Rest and NSAIDs
126
Plantar Fasciitis: Management - Suggested physiotherapy
Achilles and plantar fascia stretching exercises
127
Morton's Neuroma
Benign fibrotic thickening of a plantar digital nerve near the bifurcation
128
Morton's Neuroma: 2 Aetiologies
Repeated trauma of the plantar interdigital nerves from the medial and lateral plantar nerves overlying the intermetatarsal ligaments
Irritated nerves
129
Morton's Neuroma: Most commonly involved
Third interspace of the foot
130
Morton's Neuroma: Mean age
45-50 years old
131
Morton's Neuroma: Main 2 Risk factors
Obesity
Females
132
Morton's Neuroma: Epidemiology of sexes
More common in women - due to high heels
133
Morton's Neuroma: Main symptom
Burning pain and tingling that radiates to the affected toes
134
Morton's Neuroma: What is metatarsalgia?
Forefoot pain
135
Morton's Neuroma: How is pain exacerbated?
Footwear
136
Morton's Neuroma: How is pain relieved?
Removal of a shoe
Massaging the foot
Changing footwear
137
Morton's Neuroma: Main Sign
Loss of sensation in the affected webspace
138
Morton's Neuroma: What test can be used?
Mulder's Click Test
139
Morton's Neuroma: What is the Mulder's Click Test?
Medio-lateral compression of the metatarsal heads by squeezing the forefoot in the hand may reproduce symptoms or a characteristic click
140
Morton's Neuroma: Diagnostic test
Ultrasound
141
Morton's Neuroma: What will an ultrasound show?
Swollen nerve
142
Morton's Neuroma: Problem with Diagnostic US
Poor specificity if <6 mm in diameter
143
Morton's Neuroma: Conservative management
RICE
Weight loss if appropriate
Activity modification
144
Morton's Neuroma: Management to relieve symptoms
Steroid and local anaesthetic injections
145
Morton's Neuroma: Indication for surgical intervention
Symptoms persisting after 2-3 months of footwear medication and metatarsal pads with an inadequate response to corticosteroid injection
146
Achilles Tendonitis
Inflammation of the achilles tendon
147
Achilles Tendonitis: What is the real name for the achilles tendon?
Calcaneal tendon
148
Achilles Tendonitis: Aetiology (2)
Repetitive microtrauma leads to peritendonitis
Degenerative processes
149
Achilles Tendonitis: What drugs are risk factors?
Quinolone antibiotics e.g. Ciprofloxacin
150
Achilles Tendonitis: What conditions are a risk factor? (3)
Rheumatoid Arthritis
Gout
Inflammatory Arthritis
151
Achilles Tendonitis: Pathophysiology - Can be due to failure of what?
Collagen repair - leads to loss of fibre alignments
152
Achilles Tendonitis: Pathophysiology - What can occur to the vascuature of surrounding tissue?
Hypovascular region 2-6cm proximal to the insertion
153
Achilles Tendonitis: Clinical Presentation (2)
Pain of the achilles tendon or at its insertion in the calcaneus
Morning stiffness
154
Achilles Tendonitis: Pathophysiology - What makes the pain better?
Walking
155
Achilles Tendonitis: Complication
Increased risk of tendon rupture
156
Achilles Tendonitis: What can be administered to prevent tendon rupture?
Steroid injection around the Achilles Tendon
157
Achilles Tendonitis: Management - Conservative
Activity modification
Analgesia
NSAIDs
158
Achilles Tendonitis: Secondary management to lifestyle and pain killer
Heel raise in a splint or boot to offload the tendon
159
Achilles Tendonitis: Management for resistant cases
Tendon decompression or resection of the paratendon
160
Achilles Tendon Rupture: Peak age of incidence
>40 years old
161
Achilles Tendon Rupture: Why is risk increased in those over 40?
Tendon degeneration
162
Achilles Tendon Rupture: What may cause tendon rupture? (3)
Single high energy event
Accumulation of recurrent minor tears
Following recent tendonitis
163
Achilles Tendon Rupture: Risk Factors (4)
Diabetes
Rheumatoid Arthritis
Steroid use
Pre-existing Tendonitis
164
Achilles Tendon Rupture: Common description of symptom
Like being kicked in the back of the leg
165
Achilles Tendon Rupture: Example of initiating event
Sudden deceleration with resisted calf muscle contraction
166
Achilles Tendon Rupture: What test can be done and what would it show?
Simmonds Test - No plantar flexion when the calf is squeezed
167
Simmonds Test - what is a normal result?
Patient is asked to kneel on a chair and each calf is squeezed individually
Normal - the foot will planterflex due to contraction of the gastrocnemius
168
Achilles Tendon Rupture: What will the patient be unable to do?
Stand on tip toes
169
Achilles Tendon Rupture: Shows weakness in what?
Plantar flexion
170
Achilles Tendon Rupture: What can be felt in these cases?
Palpable gap in the tendon
171
Achilles Tendon Rupture: What diagnostic test is used to distinguish between complete and partial tears?
US or MRI
172
Achilles Tendon Rupture: What are the two treatment options?
Suture repair of the tendon
Series of casts in the equinous position
173
Achilles Tendon Rupture: Problem with surgical suture repair of the tendon
Problems with wound problems
174
Achilles Tendon Rupture: How do serial casts work?
The ankle is plantarflexed with the toes pointing down to close the gap in the torn tendon over 8 weeks
175
Ankle Sprains: Most common cause
Twisted ankle - inversion or twisted forces on a planted foot
176
Ankle Sprains: Most common ankle sprains
Lateral ankle sprains
177
Ankle Sprains: Lateral Ankle Sprains - Most common cause
Inversion of plantar flexed foot leading to excessive supination of the rearfoot about an externally rotated leg
178
Ankle Sprains: Lateral Ankle Sprains - What is injured first?
Anterior Talo-fibular Ligament
179
Ankle Sprains: Lateral Ankle Sprains - What is injured second?
Calcaneofibular ligament
180
Ankle Sprains: Lateral Ankle Sprains - What ligament is least likely to be affected?
Posterior Talofibular Ligament
181
Ankle Sprains: Lateral Ankle Sprains - Grade I
Microscopic tear
182
Ankle Sprains: Lateral Ankle Sprains - Grade II
Partial tear
183
Ankle Sprains: Lateral Ankle Sprains - Grade III
Complete rupture
184
Ankle Sprains: Lateral Ankle Sprains - Chronic Sprain
Recurrent sprain or giving way that persists for more than 6 months
185
Ankle Sprains: Lateral Ankle Sprains - Initial management
Protection with RICE
186
Ankle Sprains: Lateral Ankle Sprains - Management for pain if physiotherapy does not work
Arthroscopy
187
Ankle Sprains: Lateral Ankle Sprains - First line management if functional instability is present?
Physiotherapy
188
Ankle Fractures: Main cause
Inversion injury with a rotational force applied. tothe planted foot
189
Ankle Fractures: Can affect what structures? (3)
Lateral malleolus
Medial malleolus
Posterior malleolus
190
Ankle Fractures: What type are often small avulsion fractures or undisplaced?
Solitary malleolar fractures
191
Ankle Fractures: What type are often associated with a tendency to instability?
Trimalleolar fracture
192
Ankle Fractures: What classification system is used?
Weber Classification System
193
Ankle Fractures: Weber A Classification
Fracture of the fibular distal to the syndesmosis
194
Ankle Fractures: Weber B Classification
Fracture of the fibular at the level of the syndesmosis
195
Ankle Fractures: Weber C Classification
Fracture of the fibular proximal to the syndesmosis
196
Ankle Fractures: What is the Lauge Hansen Analysis system?
Analyses the fracture based on. thefoot position and force applied
197
Ankle Fractures: Stable ankle fracture description
Distal fibula fracture with no medial malleolus fracture or deltoid ligament rupture
198
Ankle Fractures: Unstable ankle fracture description
Distal fibula fracture with medial malleolus fracture or deltoid ligament rupture
199
Ankle Fractures: X-Ray - How to locate the site of fracture?
Check for soft tissue swelling
200
Ankle Fractures: X-Ray - What does non-uniform ankle joint space indicate?
Instability often with ligamentous damage
201
Ankle Fractures: CT - What is a pilon fracture?
High energy fracture at the bottom of the tibia and involves the ankle joint
202
Ankle Fractures: Management - Conservative options (2)
Cast
Moon boot
203
Ankle Fractures: Management - Surgical option
Open Reduction Internal Fixation
204
5th Metatarsal Fracture: Main cause
Inversion injury
205
5th Metatarsal Fracture: 3 different types
Avulsion by the peroneus brevis tendon
Jones fracture
Proximal shaft
206
5th Metatarsal Fracture: Cause of jones fracture
Sudden force applied to the outside of the foot whilst the foot is twisted outwards
207
5th Metatarsal Fracture: The proximal shaft is a common site for what?
Stress fracture
208
5th Metatarsal Fracture: Concern with Jones fracture
Poor blood supply - risk of non-union
209
5th Metatarsal Fracture: Clinical presentation
Pain over the lateral border of the forefoot - increased when weight bearing
210
5th Metatarsal Fracture: Clinically resemble what other pathology
Lateral malleolar fracture
211
5th Metatarsal Fracture: Fractures are in what direction?
Transverse
212
5th Metatarsal Fracture: Fractures may be confused with what on X-ray due to transverse direction?
Normal longitudinal adolescent ossification centre
213
5th Metatarsal Fracture: Management
Immobilisation and protected weight bearing
Surgery may be required
214
Lis Franc Injury
Tarsometatarsal fracture dislocation characterised by traumatic disruption between the articulation of the medial cuneiform and base of the second metatarsal
215
Lis Franc Injury: Main cause
High energy injury
216
Lis Franc Injury: Clinical presentation
Severe midfoot pain - inability to bear weight
217
Lis Franc Injury: How to correctly assess the X-Ray
AP view - 1st and 2nd TMT joint congruity assessed
Oblique view - 3rd, 4th and 5th joint congruity assessed
218
Lis Franc Injury: What X-rays need to be taken?
AP and Oblique view
219
Lis Franc Injury: What clinical features is best shown on CT?
Multiple ligamentous avulsion fractures
220
Lis Franc Injury: Management
Requires fixation - Open Reduction Internal Fixation
221
Lis Franc Injury: Complications (2)
Can cause disability
Osteoarthritis
222
Calcaneus Fracture: Main cause
Axial compression e.g. falling from a height onto the heel
223
Calcaneus Fracture: Clinical presentation
Pain at the heel that. isunable to bear weight and has significant swelling
224
Calcaneus Fracture: Diagnostic testing (2)
X-ray
CT
225
Calcaneus Fracture: X-Ray presentation
Loss of central peak seen in a normal calcaneus
Increased bone density
226
Calcaneus Fracture: How is the central peak measured on X-Ray?
Bohler's angle
227
Calcaneus Fracture: Conservative management
Non-weight bearing for 6-12 weeks
228
Calcaneus Fracture: Why is surgery controversial?
High risk of infection and wound breakdown
229
Calcaneus Fracture: Complication
Compartment Syndrome
230
Talus Fracture: Main causes (2)
Forced dorsiflexion
Rapid deceleration
231
Talus Fracture: What is there a risk of?
AVN
232
Talus Fracture: Why is there a risk of AVN?
Reversed blood supply
233
Talus Fracture: What two bones form a ring with the talus?
Tibia
Fibula
234
Talus Fracture: Talar Dome Margin Fracutre is caused by what?
Excessive inversion or eversion
235
Bone Tumours: Terminology - Osteo is cancer of what?
Bone
236
Bone Tumours: Terminology - Chondro is cancer of what?
Cartilage
237
Bone Tumours: Terminology - Sacro is cancer of what?
Soft tissue
238
Bone Tumours: Examples of bone-forming tumours (4)
Osteoma
Osteoid Osteoma
Osteoblastoma
Osteosarcoma
239
Bone Tumours: Examples of cartilage-forming tumours (3)
Enchondroma
Osteochondroma
Chondrosarcoma
240
Bone Tumours: Can be secondary to what other cancers? (5)
Breast
Lung
Prostate
Kidney
Thyroid
241
Bone Tumours: Predisposing condition risk factors (3)
Paget's disease
Fibrous dysplasia
Multiple enchondromas
242
Bone Tumours: Genetic causes (2)
Li Fraumeni - p53
Familial Retinoma - RBI
243
Bone Tumours: Environmental risk factor
Previous radiotherapy
244
Bone Tumours: Sites of metastatic cancer in the bone (5)
Vertebra
Pelvis
Ribs
Femur
Skull
245
Bone Tumours: May not show on X-ray until what?
>50% of bone is depleted
246
Bone Tumours: Radiological features of Malignant Lesions (3)
Broad zone of transition
Periosteal reaction
Cortical destruction
247
Bone Tumours: 3 options for management
Neoadjuvant - Chemotherapy, Radiotherapy or Hormonal Treatment
Surgery - Reconstruction or Amputation
Adjuvant therapy - Chemotherapy or Radiotherapy
248
What is the most common primary sarcoma of the bone?
Osteosarcoma
249
Osteosarcoma: Impacts what patient groups?
Children and young adults
250
Osteosarcoma: 2nd peak occurs when and why?
Elderly due to Paget's Disease
251
Osteosarcoma: 2nd peak occurs when and why?
Elderly due to Paget's Disease
252
Osteosarcoma: Usually affects what bones?
Distal femur
Proximal tibia
253
Osteosarcoma: Common site of metastasis
Lung
254
Osteosarcoma: Management
Chemotherapy
Limb salvage
255
Ewing's Sarcoma: Found in what bones?
Diaphysis of long bones, distal femur or proximal tibia
256
Ewing's Sarcoma: Management
Chemotherapy with limb salavge +/- Adjuvant Radiation
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Chondrosarcoma
Malignancy of the chondrocytes
258
Chondrosarcoma: Peak age
40-75 years
259
Chondrosarcoma: May arise from what?
Benign lesions - Enchondroma and Osteochondroma
260
Chondrosarcoma: Most common locations (3)
Pelvis
Proximal femur
Distal femur
261
Chondrosarcoma: Histology
Lytic or blastic lesion with reactive cortical thickening
262
Osteoid Osteoma
Painful benign bone-forming tumour of long bones
263
Osteoid Osteoma: Peak age of incidence
5-25 years old
264
Osteoid Osteoma: Common sites (3)
Proximal femur
Diaphysis of long bones
Vertebrae
265
Osteoid Osteoma: Clinical presentation
Intense constant pain thayt worsens at night
266
Osteoid Osteoma: Why does the pain worsen at night?
Intense inflammatory response
267
Osteoid Osteoma: Appearance on CT
Central nodule of woven/immature bone with an osteoblastic rim that appears as an intense sclerotic halo
268
Osteoid Osteoma: What would bone scan show?
Intense local uptake
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Osteoid Osteoma: Management - of pain
NSAIDs
270
Osteoid Osteoma: Management of severe cases (2)
CT-guided radiofrequency ablation
En bloc excision
271
Osteochondroma
A benign lesion derived from aberrant cartilage from the perichondral ring
272
Osteochondroma: Peak age of incidence
10-20 years old
273
Can have what cause?
Trauma
274
Osteochondroma: Multiple osteochondromas can occur due to what?
Multiple Hereditary Exostosis - Autosomal dominant hereditary disorder
275
Osteochondroma: Pathophysiology
A bony outgrowth on the external surface with a cartilaginous cap
276
Osteochondroma: Common location (2)
Near the knee - Distal femur or proximal tibia
277
Osteochondroma: Clinical presentation
Painless hard lump that may produce pain or numbness with activity
278
Osteochondroma: Pain may generate from where?
Tendons
279
Osteochondroma: Numbness may develop due to what?
Nerve compression
280
Osteochondroma: Diagnostic test
X-Ray
281
Osteochondroma: X-ray appearance
Carilage capped ossified pedicle
282
Osteochondroma: When is excision required?
Growth of the lesion
Pain caused
283
Osteochondroma: Complication
Progression to Chondrosarcoma as pelvic lesions
284
Enchondroma
Intramedullary cartilaginous cancer caused by failure of normal enchondral ossification at the growth plate
285
Enchondroma: Usually occurs where?
Metaphysis
286
Enchondroma: Peak age of incidence
20-50 years old
287
Enchondroma: Can occur in what bones? (5)
Femur
Humerus
Tibia
Small bones of the hands and feet
288
Enchondroma: Increased risk of what developing?
Fracture - due to weakening of the bone
289
Enchondroma: Appearance on X-ray
Lesion is typically lucent - can undergo mineralisation with a patchy sclerotic appearance
290
Enchondroma: Management - If healed fracture or risk of impending fracture
Curettage and filled with bone graft
291
Knee Ligament Injuries: Most common cause
Rotational movement of the knee joint
292
Knee Ligament Injuries: Grade I
Sprain - some fibres are torn but macroscopic strctures are intact
293
Knee Ligament Injuries: Grade II
Partial Tear with some fascicles disrupted
294
Knee Ligament Injuries: Grade III
Complete tear
295
Knee Ligament Injuries: MCL Rupture may lead to what?
Valgus instability
296
Knee Ligament Injuries: ACL rupture may lead to what?
Rotatory instability
297
Knee Ligament Injuries: PCL rupture can lead to what?
Recurrent hyperextension
Instability on descending stairs
298
Knee Ligament Injuries: Posterolateral corner rupture leads to what? (2)
Varus
Rotatory instability
299
Knee Ligament Injuries: Multiligament injuries can result in what?
Gross instability
300
Knee Ligament Injuries: MCL Injury - Mechnism of Injury
Valgus stress with possible external rotation
301
Knee Ligament Injuries: MCL Injury - Clinical presentation (3)
Knee swelling with pain, bruising, deformity and instability
Medial joint line tenderness over the origin or insertion of the MCL
Medial joint laxity and pain on valgus stress
302
Knee Ligament Injuries: MCL Injury - Primary management
Brace with early motion and physiotherapy
303
Knee Ligament Injuries: MCL Injury - Acute tear management
Hinged knee brace
304
Knee Ligament Injuries: MCL Injury - Chronic instability management
MCL tightening or MCL reconstruction with a tendon graft
305
Knee Ligament Injuries: ACL Injury - Mechanism of injury
High rotational force turning the upper body laterally on a planted foot
306
Knee Ligament Injuries: ACL Injury - ACL function
Main stabiliser of the tibia
307
Knee Ligament Injuries: ACL Injury - Epidemiology of sexes
Higher incidence in females
308
Knee Ligament Injuries: ACL Injury - Clinical presentation
Audible pop followed by deep knee pain and swelling within 1 hour of injury
309
Knee Ligament Injuries: ACL Injury - Impact on long term movement
Rotatory instability - gives way on turning on a planted foot due to excessive internal rotation of the tibia
310
Knee Ligament Injuries: ACL Injury - What tests can be conducted?
Anterior Drawer Test
Lachman Test
311
Anterior Drawer Test
Patient is positioned in supine with knee flexed to 90 degrees
The hands are wrapped around the proximal tibia with the fingers at the back of the knee joint
The forearm is rested down on the patients lower leg to fix position
Position the thumbs over the tibial tuberosity
Pull the tibia anteriorly whilst the hamstrings are relaxed and feel for any anterior movement of the tibia
312
Lachman's Test
Flex the patients knee to 30 degrees
Hold the lower leg with your dominant hand with your thumb on the tibial tuberosity and your fingers over the calf
With the non-dominant hand, hold the thing just above the patella
Use the dominant hand to pull the tibia forwards on the femur whilst the other hand stabilises the femur
313
Knee Ligament Injuries: ACL Injury - Diagnostic Tests
Joint aspiration
MRI to confirm
314
Knee Ligament Injuries: ACL Injury - Join aspiration will show what?
Haemarthrosis
315
Knee Ligament Injuries: ACL Injury - Complications
Arthritis within 10 years
316
Knee Ligament Injuries: ACL Injury - ACL reconstruction indicated when? (3)
Rotatory instability not responding to physiotherapy
Multi-ligament reconstruction
Professional athletes
317
Knee Ligament Injuries: ACL Injury - Options for ACL reconstruction (3)
Autograft - from the patellar tendon or hamstrings tendon
Allograft from the achilles tendon
Synthetic graft
318
Knee Ligament Injuries: ACL Rupture - Rule of Thirds
1/3 compensate and function well
1/3 avoid instability by avoiding certain activities
1/3 do not compensate and have frequent instability
319
Knee Ligament Injuries: LCL Injury - Mechanism. of injury
Varus stress
Hyperextension
320
Knee Ligament Injuries: LCL Injury - Clinical presentation
Knee swelling with the ecchymosis, pain, deformity and instability
321
Knee Ligament Injuries: LCL Injury - Presentation on examination
Lateral joint line tenderness
Varus stress test shows lateral joint laxity
322
Knee Ligament Injuries: LCL Injury - Can have what complication?
Common peroneal nerve palsy
323
Knee Ligament Injuries: LCL Injury - Diagnosis
Clinical diagnosis - X-rays and MRI can rule out associated injuries
324
Knee Ligament Injuries: LCL Injury - Management of LCL rupture with early (2-3 weeks) diagnosis
Urgent repair
325
Knee Ligament Injuries: LCL Injury - Management of LCL rupture with late diagnosis
Reconstruction with tendon graft
326
Knee Ligament Injuries: LCL Injury - Complications
Early osteoarthritis in the knee
Common fibular nerve palsy
327
Knee Ligament Injuries: PCL Injury - Mechanism of injury (2)
Direct blow to the anterior tibia
Hyperextension injury
328
Knee Ligament Injuries: PCL Injury - Clinical presentation
Popliteal knee pain and bruising
329
Knee Ligament Injuries: PCL Injury - Presentation on examination
Positive posterior drawer test
Positive sag sign - gravity pulls the tibia downward greater than 10mm
330
Knee Ligament Injuries: PCL Injury - Management if instability present
Consider reconstruction
331
Knee Ligament Injuries: PCL Injury - Management if part of a multi-ligament injury
Reconstruction
332
Meniscal Tears: Aetiology - Young patients (2)
Twisting force on a loaded knee
Getting up from a squat position
333
Meniscal Tears: Aetiology - Older patients
Meniscus weakening with age can cause spontaneous tears
334
Meniscal Tears: Probably represents the first stage of what in older patients?
Knee osteoarthritis
335
Meniscal Tears: Aetiology - Pain in older patients causes what? (2)
Bone marrow oedema
Synovitis
336
Meniscal Tears: What type is more common?
Medial meniscal tears
337
Meniscal Extrusion
Meniscus is pushed slightly out of the knee joint due to root tear or degeneration
338
Meniscal Tears: Clinical Presentation - Examination for medial meniscus tear
Medial joint line tenderness
339
Meniscal Tears: Clinical Presentation - Examination for lateral meniscus tear
Lateral joint line tenderness
340
Meniscal Tears: Clinical Presentation (3)
Pain and tenderness localised to the joint line
Knees feel like they will give way if a loose meniscal fragment is caught in the knee
Catching or locking sensation
341
Meniscal Tears: Clinical Presentation - Signs present on examination
Positive meniscal provocation tests
342
Meniscal Tears: Clinical Presentation - What does an acute locked knee signify?
Displaced bucket handle mechanism tear
343
Meniscal Tears: Clinical Presentation - What is a Bucket Handle Meniscal Tear?
Large meniscal fragment is able to flip out of its normal position and displace anteriorly or into the intercondylar notch when the knee locks and is unable to fully extend due to mechanical obstruction from the trapped meniscal fragment
344
Meniscal Tears: Bucket Handle Mechanism - Presentation on extension
15 degree springy block to extension
345
Meniscal Tears: Bucket Handle Mechanism - What indicates a fixed flexion deformity?
Heel height asymmetry
346
Meniscal Tears: Degenerative Meniscal Tear - Presentation
Pain due to bone marrow oedema and synovitis
Inflammation from initial outset
347
Meniscal Tears: Diagnosis
MRI
348
Meniscal Tears: Management - Why is there limited healing potential?
Only has arterial blood supply to the outer third
349
Meniscal Tears: Management - What types of tear do not heal?
Radial tears
350
Meniscal Tears: Management - Younger Patients with acute peripheral or bucket handle meniscal tears
Arthroscopic repair
351
Meniscal Tears: Management - Acute traumatic peripheral meniscal tears in young patients
Arthroscopic repair
352
Meniscal Tears: Management - If meniscal repair fails, what is required?
Arthroscopic menisectomy
353
Menisectomy
Surgical removal of a torn meniscus
354
Meniscal Tears: Management - Young patients with irreparable tears with recurrent pain, effusion or mechnical symptoms that fails to settle within 3 months
Arthroscopic meniscectomy
355
Meniscal Tears: Management - Knees with degenerate changes on X-ray or MRI in young patients should avoid what treatment?
Arthroscopic menisectomy - as removal of meniscal tissue may increase stress on the changed surface of the joint
356
Meniscal Tears: Management - Degenerative tear symptomatic control in the early period
Corticosteroid injection
357
Meniscal Tears: Management - When is arthroscopic menisectomy appropriate for degenerative tears?
Only for unstable tears with mechanical symptoms
358
Meniscal Tears: Management - Bucket Handle Tears when irreparable
Partial menisectomy to unlock knee and prevent further damage
359
Meniscal Tears: Management - Bucket Handle Tears when knee remains locked
Develop permanent fixed flexion deformity
360
Meniscal Extrusion Two Types
Traumatic
Degenerative
361
Knee Dislocation: Aetiology
Serious high energy injury
362
Knee Dislocation: Potential directions of dislocation
Posterior
Anterior
Medial
Lateral
Rotatory
363
Knee Dislocation: Clinical Presentation
Pain and instability of the knee
364
Knee Dislocation: Primary investigation
Check the neurovascular status
365
Knee Dislocation: Investigation if concern on neurovascular status
CT angiogram
366
Knee Dislocation: Investigation if no concern on the neurovascular status
MRI
367
Knee Dislocation: Definitive Management
Sequential ligamentous repair
368
Knee Dislocation: Immediate Management
Emergency reduction under sedation with reassessment of neurovascular status
369
Knee Dislocation: When may a theatre reduction be required?
If the medial condyle has button-holed through the medial capsule
370
Knee Dislocation: What may be required if there is neurovascular injury?
Vascular stenting or bypass
371
Knee Dislocation: Reperfusion of the joint may result in what complication?
Compartment syndrome
