General

Question 1

what is Osteoarthritis

Answer 1

progressive loss of articular cartilage and remodelling of the underlying bone

Question 2

pathophysiology of Osteoarthritis

Answer 2

degradation of cartilage and remodelling of bone due to active response by chondrocytes and inflammatory cells in the surrounding tissue

release of enzymes from these cells destroys the articular cartilage

the exposure of the underlying subchondral bone results in sclerosis, followed by reactive remodelling changes that lead to the formation of osteophytes and sunchondral bone cysts

the joint space is also progressively lost over time

Question 3

What are the typical radiological features in Osteoarthritis

Answer 3

osteophyte formation

subchondral bone cysts

reduced joint space

subchondral sclerosis

Question 4

risk factors for osteoarthritis

Answer 4

obesity

advancing age

female gender

manual labour jobs

Question 5

what are the most common joints affected by OA

Answer 5

small joints of the hands and feet

hip joint

knee joint

Question 6

clinical features/symptoms of OA

Answer 6

symptoms are chronic and gradually worsening

pain and stiffness in joints - worsened with activity and relieved by rest

pain that worsens throughout the day

bouchard nodes and heberden nodes

Question 7

heberden vs bouchard nodes

Answer 7

heberden = swelling of DIPJs

bouchard = swelling of PIPJs

Question 8

osteoathritis vs rheumatoid arthritis

Answer 8

OA = morning stiffness lasting less than 30 mins, pain worsens with activity, stiffness returns after resting joint for a long period of time, asymmetrical effect

RA = morning stiffness lasting longer than 30 mins, stiffness and pain improve with activity, symmetrical effect

Question 9

key differential to look out for (and what to look out for) when examining for OA

Answer 9

septic arthritis

hot, swollen, inflamed joint with rapid onset symptoms

Question 10

management of OA; conservative, medical and surgical

Answer 10

conservative = weight loss, physio, strengthening exercises

medical = analgesia and NSAIDs, intra-articular steroid injections

surgical = arthroplasty (replace joint)

Question 11

what 3 words form the basis of surgical fracture management

Answer 11

Reduce

Hold

Rehabilitate

Question 12

what is reduction of a fracture

Answer 12

reduction involves restoring the anatomical alignment of a fracture or dislocation of the deformed limb

the main principle of reduction is to correct the deforming forces that resulted in the injury

Question 13

what does reduction of a fracture allow for

Answer 13

the main principle is to correct the deforming forces that resulted in the injury

it allows for;

• tamponade of the bleeding
• reduction in the traction of surrounding soft tissues
• reduction in the traction on the traversing nerves
• reduction in the traction on the traversing blood vessels

Question 14

what does ‘hold’ mean when talking about fracture management

Answer 14

hold refers to the immobilisation of the fracture

Question 15

what are the most common ways to immobilise a fracture

Answer 15

simple splints

plaster casts

Question 16

when applying a plaster cast what are the 2 most important principles to remember

Answer 16

1. for the first 2 weeks - plasters are not circumferential
   - they need and area which is covered by only the overlying dressing to allow the fracture to swell, if not the fracture will swell and become very painful and tight, and if left the patient would be at risk of compartment syndrome
2. if there is axial instability (whereby the fracture is able to rotate along its long axis) e.g. combined radius/ulna and combined tibia/fibula fractures, the plaster should cross both the joint above and below

Question 17

when should an above elbow or above knee plaster cast be used

Answer 17

casts that cross both the joint above and below should only be used when the fracture is able to rotate along its long axis e.g. a combined radius/ulna fracture and a combined tibia/fibula fracture

Question 18

what important clinical points should you inform the patient of or think about regarding fracture immobilisation

Answer 18

weight bearing - depends on fracture

thromboprophylaxis - if a patient is immobilised and non-weight bearing, it is common to provide thromboprophylaxis

inform patient of symptoms of compartment syndrome and warn them that if they see any symptoms to immediately return to A&E

Question 19

what does rehabilitate mean in terms of fracture management

Answer 19

intensive period of physiotherapy following fracture management

Question 20

when faced with acute monoarthritis, what is the first differential you should immediately consider

Answer 20

septic arthritis

Question 21

what is key to obtain in the history of a patient presenting with an acutely swollen joint

Answer 21

onset, site and timeframe

any precipitating factors e.g. trauma

any systemic symptoms e.g. fever, rigors, lethargy

relieving or aggravating factors

previous joint problems in this area (acute exacerbation of chronic issue)

ability to weight bear

past medical history

Question 22

what framework is used when examining affected joints

Answer 22

look, feel, move

Question 23

what investigations should be carried out in a patient presenting with an acutely swollen joint

Answer 23

routine bloods - FBC, CRP for infection + ESR (rheumatological cause) + serum urate (gout)

X-ray - especially if history of trauma to evaluate any fracture

joint aspiration

Question 24

what is the most important investigation to do in a patient with acute monoarthritis - and what specific investigations should it be sent for

Answer 24

joint aspiration

visually inspect it first for opacity, colour and presence of frank pus

then the aspirate can be sent for white cell count, microscopy, culture and sensitivity and light microscopy (for crystals)

Question 25

briefly describe the difference in aspirate appearance and composition (white cell count and neutrophils) in non-inflammatory, inflammatory and septic arthritis

Answer 25

non-inflammatory = clear/straw coloured, normal white cell count and low neutrophils

inflammatory = clear or cloudy yellow, moderate white cell count and moderate neutrophils

septic = turbid, very high white cell count and high neutrophils

Question 26

what is gout and what is it caused by

Answer 26

gout is an inflammatory arthritis caused by the collection of monosodium urate crystals in a joint

caused by hyperuricemia leading to crystilisation of the urate in the joint space

Question 27

clinical features/symptoms of gout

Answer 27

affects the first MTP joint

often episodic with flare ups lasting days or weeks, usually brought on by triggers including stress, illness and dehydration

Question 28

what investigations are used to confirm the diagnosis of gout and what is the management

Answer 28

investigations = joint aspiration and light microscopy - to determine the presence of monosodium urate crystals in the synovial fluid

management = acute gout treated with NSAIDs, patients who have had multiple episodes can be prescribed prophylactic agents such as allopurinol for prevention

Question 29

what is pseudogout and how is it different to gout

Answer 29

inflammatory arthritis caused by deposits of calcium pyrophosphate crystals

more likely to affect proximal joints with the knee and wrist being most commonly affected

risk factors include hyperparathyroidism, advanced age and hypophosphataemia

Question 30

presentation of rheumatoid arthritis

Answer 30

swollen, painful joints with stiffness that is usually worse in the morning

pain improves on activity

associated fatigue, lethargy, pyrexia or weight loss

Question 31

in patients with an acutely swollen joint following a trauma, what should initially be suspected

Answer 31

haemarthrosis - bleeding into a joint cavity

Question 32

when a fracture is referred to as an ‘open’ fracture, what does this mean

Answer 32

when there is direct communication between the fracture site and the external environment

Question 33

what are the 4 main important things to think about when a patient requires surgery for an open fracture

Answer 33

skin - is the skin loss significant to the point where it will require the aid of plastics surgery

soft tissues - is there significant muscle/tendon/ligament loss such that it requires reconstructive surgery

neurovascular injury - are any blood vessels or nerves compressed or have been transected all together

infection - risk of infection is very high

Question 34

what classification is used when looking at open fractures

Answer 34

Gustillo-Anderson classification

Question 35

describe the Gustillo-Anderson classification

Answer 35

Type 1 = <1cm and clean

Type 2 = 1-10cm and clean

Type 3A = >10cm wound and high-energy, but with adequate soft tissue coverage

Type 3B = >10cm wound and high-energy, but with inadequate soft tissue coverage

Type 3C = all injuries with vascular injury

***simple summary is;
3A = managed by orthopaedics alone
3B = requires plastics input
3C = requires vascular input

Question 36

investigations into open fractures

Answer 36

routine bloods + clotting screen

group and save

X-ray of affected areas

for comminuted fractures a CT scan may aid management

Question 37

management of an open fracture

Answer 37

following suitable resuscitation, urgent realignment and splinting of the limb is required

broad spectrum antibiotics and tetanus injection then given

photograph the wound and remove any gross debris

then definitive surgical management required - debridement and washed with copious amounts of saline

if there is vascular compromise it requires immediate surgical exploration by vascular surgeons