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Musculoskeletal & Rheumatology > How to manage Orthapaedic conditions > Flashcards

How to manage Orthapaedic conditions Flashcards

1
Q

What are the different bone cells and their roles?

A
  1. Osteogenic cells “stem cells”
    precursors to the more specialized bone cells (osteocytes and osteoblasts)- found in the bone marrow
  2. Osteoblast “Bone forming”
    - secretes osteoid
    - Catalyse mineralisation of osteoid
  3. Osteoclast “Bone breaking”
    - dissolve and reabsorb bone by phagocytosis
    - Derived from bone marrow
  4. Osteocytes “mature” bone cell
    - Formed when an osteoblast becomes embedded in it’s secretions
    - sense mechanical strain to direct osteoclast and osteoblast activity
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2
Q

What are the 2 main bone types in the body?

A
  • flat bones
  • Long bones
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3
Q

What is the subdivision from flat/ long bones that can be used to describe it’s structure?

A

Flat and long bones can be either:
- cortical/compact (weight bearing)
- cancellous/ spongy (not weight bearing)

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4
Q

Describe the structure of compact/ cortical bone

A
  1. Compact bone have “osteons”
    - repeated structural units “osteons” provide protection, support and resists stresses produced by weight of movement
  2. “Osteons” are made up of:
    - concentric “lamellae” around a central “Haversian canal”
    - “Haversian canal”- contain blood vessels, nerves and lymphatics
  3. “Volkmans canal” these are transeverse perforating canals that connect the Haversian canals
  4. Lacunae- small paces containing osteocytes
    - tiny canaliculi radiate from lacunae filled with extracellular fluid
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5
Q

Describe the structure of long bones

A
  1. Periosteum: connective tissue covering
  2. Outer cortex: compact bone
  3. Cancellous/ spongy bone at the end (proximal epiphysis)
  4. Medullary cavity: contains yellow bone marrow
  5. Nutrient artery
  6. Articular cartilage: on surface of bone at a joint only
    (Diaphysis long stick part, metaphysis, physis/ epiphyseal line/ growth plate, epiphysis (end)
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6
Q

What are the different mechanisms that can cause a fracture?

A
  1. Trauma:
    - low energy
    - high energy
  2. Stress (bone breaking from a marathon)
    - abnormal stresses on normal bone
  3. Pathological (osteoporosis, cancers)
    - normal stresses on abnormal bone
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7
Q

What are the different pathologies that can cause fractures?

A
  • Osteoporosis (soft bone)
  • Malignancy (primary or bone mets)
  • Vit D deficiency (presents as Osteomalacia in adults or rickets in kids)
  • Osteomyelitis (bone infection)
  • Osteogenesis Imperfecta (genetic)
  • Pagets
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8
Q

What different things do you make note of when describe a fracture pattern?

A
  1. Soft tissue integrity:
    - open
    - closed
  2. Bony fragments:
    - Greenstick (not broken all the way)
    - Simple
    - Multifragmentary
  3. Movement:
    - displaced
    - undisplaced
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9
Q

What is the process for fracture healing?

A
  1. INFLAMMATION:
    - Haematoma formation
    - Release of Cytokines
    - Granulation tissue and blood vessel formation
  2. REPAIR:
    - Soft Callus formation
    (Type II Collagen - Cartilage)
    - Converted to hard callus
    (Type I Collagen - Bone)
  3. REMODELLING:
    - Callus responds to activity, external forces, functional demands and growth
    - Excess bone is removed
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10
Q

What is Wolff’s law?

A

Bone Grows and Remodels in response to the forces that are placed on it

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11
Q

What are the clinical features of a fracture?

A
  • Pain
  • Swelling
  • Crepitus (cracking of bone)
  • Deformity
  • Adjacent structural injury:
    Nerves/vessels/ligament/tendons
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12
Q

How are fractures investigated?

A
  • Radiograph
  • Bone scan
  • MRI scan
  • CT scan
    (need at least 2 different views perpendicular to each other to detect/ identify a fracture)
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13
Q

How do you describe a fracture image from a radiograph?

A

Location: which bone and which part of bone?
Pieces: simple/multifragmentary?
Pattern: transverse/oblique/spiral
Displaced/undisplaced?
Translated/angulated?
X/Y/Z plane

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14
Q

How do you describe the X/Y/Z plane of a fracture?

A

in terms of
a) TRANSLATION:
X= Medial/ lateral
Y= Proximal/ distal
Z= Anterior/ posterior
b) ANGULATION:
X= Varus/ Valgus
Y= Internal/ external rotation
Z= Dorsal/ volar

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15
Q

What is the difference between varus and valgus angulation?

A

Varus= outward
Valgus= inward

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16
Q

What is the difference between dorsal and volar angulation?

A

Dorsal= angled upward
Volar= angled downward

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17
Q

Why do fractures differ in children?

A

ELASTICITY:
Children’s bone can bend – more elastic than adult
- Increased density of haversian canals

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18
Q

What are the types of fractures seen in children?

A
  1. Plastic deformity
    – bends before breaks
  2. Buckle fracture
    - One side of a bone bends, raising a little buckle, without breaking the other side of the bone.
  3. Greenstick
    – One cortex fractures but does not break the other side
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19
Q

What are the 3 general principles for managing fractures?

A
  1. REDUCE:
    - closed
    - open
  2. HOLD:
    - no metal
    - metal
  3. REHABILITATE:
    - move
    - physiotherapy
    - use
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20
Q

Describe how a fracture can be reduced

A

CLOSED:
- manipulated
- traction (on the skin or skeletal- pins in bone)
OPEN: (here nerve vessels can get tangled in the fracture)
- Mini-incision
- full exposure

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21
Q

Describe how a fracture is held in place

A

CLOSED:
- plaster
- Traction (skin or skeletal)
FIXATION

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22
Q

How is a fracture held with fixation?

A

Fixation=
INTERNAL:
- intramedullary (pins or nails)
- Extramedullary (plate/ screws or pins)
EXTERNAL:
- Monoplanar
- Multiplanar

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23
Q

How is a fracture rehabilitated?

A
  1. Use (pain relief and retrain)
  2. Move
  3. Strengthen
  4. Weight bear
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24
Q

What general complications can follow a fracture?

A

General (early or late):
- Fat embolus (hours)
- DVT (days-weeks)
- PE
- Infection/sepsis
- Prolonged immobility (UTI, chest infections, sores)

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25
Q

What are some urgent complications that follow a fracture?

A
  • Local visceral injury
  • Vascular injury
  • Nerve injury
  • Compartment Syndrome
  • Haemarthrosis
  • infection
  • Gas gangrene
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26
Q

What are some less urgent complications following a fracture?

A
  • Fracture blisters
  • Plaster sores
  • Pressure sores
  • Nerve entrapment
  • Myositis ossificans
  • Ligament injury
  • Tendon lesions
  • Joint stiffness
  • Algodystrophy
27
Q

What are some complications of fracture that is left untreated for long/ treated late?

A
  • delayed union
  • malunion
  • non-union
  • avascular necrosis
  • muscle contracture
  • joint instability
  • osteoarthritis
28
Q

What is fractured NoF?

A

“Fractrured Neck of Femur”

29
Q

What are the causes of FNoF?

A

“Fractrured Neck of Femur”
- Osteoporosis (older)
- Trauma (younger)
- Combination

30
Q

What kind of things do you ask about during a history for suspected FNoF?

A

“Fractrured Neck of Femur”
- Age
- Comorbidity: respiratory/cardiovascular/diabetes/cancer
- Preinjury:
mobility/ independent/shopping/walking/sports
- Social hx: relatives, stairs, etoh

31
Q

What are the types of NoF you can have?

A

“Fractrured Neck of Femur”
Can be categorized by location of fracture:
1. Subcapital (intracapsular)
2. Transcervical (intracapsular)
first 2 can affect blood supply to femoral head= necrosis
3. Intertrochanteric (extracapsular)
4. subtrochanteric
5. part intertrochanteric

32
Q

Do you fix or replace a fractured NoF?

A

“fractured neck of femur”
depends on location/displacement and age:
1. Extracapsular: minimal risk to blood supply and AVN: fix with plate and screws (Dynamic hip screw)
2. Intracapsular: if undisplaced: less risk to blood supply: fix with screws
3. If displaced: 25-30% risk AVN: replace in older patients; fix if young

33
Q

Describe the management for a fractured NoF

A

“fractured neck of femur”
is it:
1. Extracapsular
(Internal fixation (plate and screws or nail))
2. Intracapsular
- displaced
Less than 55yrs: reduce and fixation with screws OR >65 yrs replace (Fit and mobile: total hip replacement or Less fit: hemiarthroplasty)
- undisplaced
Fixation with screws

34
Q

How do we classify joints?

A
  1. Fibrous (sutures, syndemosis, interosseous membrane)
  2. Cartilaginous (synchondroses- spine, symphyses- pubic)
  3. synovial (plane, hinge, condyloid, pivot, saddle, ball & socket)
35
Q

How are synovial joints stabilised?

A
  • muscles/ tendons
  • ligaments
  • bone surface congruity
36
Q

What are the components of a synovial joint?

A
  1. Articular cartilage: a thin layer of cartilage at the end of the bone in the joint
    - Type II collagen
    - Protecoglycan (aggrecan)
  2. Join cavity containing synovial fluid: “synovial fluid”=
    - hyaluronic acid- rich viscous fluid
  3. Synovium: a specialized connective soft-tissue membrane that lines the inner surface of synovial joint capsules:
    - 1-3 cell deep lining containing macrophage-like phagocytic cells (type A synoviocyte) and fibroblast-like cells that produce hyaluronic acid (type B synoviocyte)
    - Type I collagen
37
Q

What is cartilage?

A
  • Cartilage is composed of:
    1) specialized cells (chondrocytes)
    2) extracellular matrix: water, collagen and proteoglycans
    (mainly aggrecan)
  • Cartilage is avascular – it has no blood supply
38
Q

What is aggrecan?

A

Aggrecan is:
-a proteoglycan that possesses many chondroitin sulfate and keratin sulfate chains
-characterized by its ability to interact with hyaluronan (HA) to form large proteoglycan aggregates

39
Q

What is arthritis?

A

disease of the joints
- There are many different types of arthritis, but there are 2 major divisions:
1. Osteoarthritis (degenerative arthritis)
2. Inflammatory arthritis (main type is rheumatoid arthritis)

40
Q

What are the radiographic changes seen in RA vs ostoarthritis?

A

RA:
- Joint space narrowing
- No subchondral sclerosis
- No osetophytes
- osteopenia
- bony erosions

osetoarthritis:
- Joint space narrowing (indicates articular cartilage loss- can occur in both)
- Subchondral sclerosis
- Osetophytes (a.k.a Heberden’s nodes if at distal inter- phalangeal joints, and Bouchard’s nodes if at the proximal inter-phalangeal joints)
- No osteopenia
- No bony erosions

41
Q

What is osetoarthritis?

A

According to WHO:
OA: is a long-term chronic disease characterized by the deterioration of cartilage in joints which results in bones rubbing together and creating stiffness, pain, and impaired movement.
- Degenerative disease of chondral cartilage
- Inflammation occurs late in disease cf. rheumatoid
- Essentially cartilage wears away, bones rub togetther to cause damage and fluid comes out forming cysts
- Inflammatory mediators include proteinases, e.g., matrix metalloproteinases (MMPs) and aggrecanases, and inflammatory cytokines, including interleukin (IL)-1β and tumor necrosis factor α (TNFα), which enhance the synthesis of proteinases and other catabolic factors to degrade the articular cartilage membrane

42
Q

What are the main risk factors for osteoarthritis?

A
  • age
  • excess weight and obesity
  • mechanical constraints (intense sport, some professions)
  • Heredity
  • Female gender, menopause
  • Osteonecrosis
  • Leg bone malalignement
  • Estrogen deficiency
  • Metabolic syndrome
  • Advanced hip osetoarthritis
43
Q

What are the clinical features of osteoarthritis?

A
  • Pain (exertional/rest/night)
  • Disability: walking distance/stairs/giving way
  • Deformity

Previous history:
- trauma/infection
- Treatments given (physio/injections/operations)
- Other joints affected

44
Q

How do you assess suspected osteoarthritis?

A

Look (deformity: varus? valgus? scars?)
Feel (fluid in the knee)
Move (test flexion and extension)
Special tests (anterior drawer suggesting ACL injury, Lachmanns again for ACL injury

45
Q

What is meant by “weight bearing view” on image?

A
  • when the patient is standing vs sitting for the scan
46
Q

How is Osteoarthritis managed?

A
  1. Conservative:
    - Analgesics
    - Physiotherapy
    - Walking aids
    - Avoidance of exacerbating activity
    - Injections (steroid/viscosupplementation)
  2. Operative: (last resort)
    - Replace (knee/hip) “total knee replacement”
    - Realign (knee/big toe)
    - Excise (toe)
    - Fuse (big toe) “ankle fusion”
    - Synovectomy (Rheumatoid)
    - Denervate (wrist)
47
Q

What type of bone infection can you have?

A
  1. Bone: osteomyelitis:
    Refer to pathology lectures
    Acute or chronic
    Primary or secondary
    Pain/swelling/discharge
    Systemic signs:
    Fevers, sweats wt loss
  2. Joint: septic arthritis:
    Pain
    Joint swelling/stiffness
    Fevers, sweats, wt loss
48
Q

What causes septic arthritis?

A

Bacterial infection of a joint (usually caused by spread from the blood)
- Common organisms:
Staphylococcus aureus, Streptococci, Gonococcus

49
Q

What are the risk factors for septic arthritis?

A

immunosuppressed, pre-existing joint damage, intravenous drug use (IVDU)

50
Q

What is septic arthritis?

A

Serious type of joint infection:
- Septic arthritis is a medical emergency
-> Untreated, septic arthritis can rapidly destroy a joint
- Usually only 1 joint is affected* (monoarthritis)
- gonococcal septic arthritis is an exception:
-It often affects multiple joints (polyarthritis)
-It is less likely to cause joint destruction

51
Q

What are the symptoms of septic arthritis?

A

Consider septic arthritis in any patient with an acute painful, red, hot, swelling of a joint, especially if there is fever

52
Q

How do you diagnose septic arthritis?

A

Diagnosis is by joint aspiration (aspiration of pus from the joint- should wear gloves). Send sample for urgent Gram stain and culture

53
Q

How is septic arthritis treated?

A
  • Surgery: joint washout and drainage (repeated if required)
  • Iv antibiotics (days/weeks)
  • Immobilise joint in acute phase
  • Physiotherapy once over acute phase
54
Q

What tools are used to investigate septic arthritis?

A
  1. Radiology:
    Plain films
    MRI scans: bony architecture/collections
    CT if MRI not available
    Bone scans: multifocal disease
    Labelled White cell scans
  2. Bloods:
    CRP: acute marker
    ESR slower response
    WCC
    TB culture/PCR
55
Q

How is osetomyelitis treated?

A

“infection in a bone”
- Antibiotics: iv weeks
- Surgical drainage: especially collections/sequestrum
- Chronic: antibiotic suppression/dressings
- Possibly amputation

56
Q

What shoulder conditions are common from the ages 15-45 yrs ?

A

Dislocation
fractures

57
Q

What shoulder conditions are common from the ages 45-60 yrs?

A

Impingement
Dislocation
ACJ OA
Rotator cuff tears
fractures

58
Q

What shoulder conditions are common from the ages > 60 yrs?

A

Glenohumeral OA
Impingement
Cuff tears
Fracture

59
Q

What hip conditions are common from the ages 15-45 yrs?

A

Developmental dysplasia
Leg length discrepancy
Impingement

60
Q

What hip conditions are common from the ages 45-60 yrs?

A

OA
Avascular necrosis
impingement

61
Q

What hip conditions are common from the ages > 60 yrs?

A

OA
Post Total hip replacement

62
Q

What knee conditions are seen from the ages 15-45 yrs?

A

Patellofemoral maltracking
ACL/PCL
Meniscal tears
fractures

63
Q

What knee conditions are seen from the ages 45-60 yrs?

A

OA
Patellofemoral maltracking
ACL/PCL
Meniscal tears
Fractures

64
Q

What knee conditions are seen from the ages > 60 yrs?

A

OA

Musculoskeletal & Rheumatology (6 decks)

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