Orthopaedics Flashcards
Describe lateral epicondylitis
Lateral epicondylitis: worse on resisted wrist extension/supination whilst elbow extended
also pain and tenderness localised to the lateral epicondyle
Typically house painting or playing tennis (‘tennis elbow’)
Describe causes of hip pain
- osteoarthritis
- inflammatory arthritis
- referred lumbar spine pain (positive femoral nerve stretch test)
- greater trochanteric pain (trochanteric bursitis)
- avascular necrosis
- pubic symphysis dysfunction (common in pregnancy)
- transient idiopathic osteoporosis (uncommon, pregnancy)
Describe osteomyelitis and its management
Osteomyelitis describes an infection of the bone
Classification
- haematogenous osteomyelitis
> vertebral osteomyelitis is the most common form of haematogenous osteomyelitis in adults
> risk factors: sickle cell anaemia, IVDU, immunosuppression, infective endocarditis - non-haematogenous osteomyelitis:
> contiguous spread of infection from adjacent soft tissues to the bone or from direct injury/trauma to bone
> risk factors: diabetic foot ulcers/pressure sores, diabetes mellitus, peripheral arterial disease
Microbiology
- Staph. aureus is the most common cause except in sickle-cell anaemia where Salmonella species are most common
Investigations: MRI
Management
> flucloxacillin for 6 weeks
> clindamycin if penicillin-allergic
Describe the pathophysiology and clinical features of compartment syndrome
can occur following fractures (or following ischaemia reperfusion injury in vascular patients)
characterised by raised pressure within a closed anatomical space
> raised pressure will eventually compromise tissue perfusion resulting in necrosis
> 2 main fractures carrying this complication: supracondylar fractures and tibial shaft injuries.
Features
> Pain, especially on movement (even passive)
> excessive use of breakthrough analgesia
> Paraesthesia
> Pallor
> Arterial pulsation may still be felt as the necrosis occurs as a result of microvascular compromise
> Paralysis of the muscle group may occur
describe the diagnosis and management of compartment syndrome
Diagnosis
> measurement of intracompartmental pressure via needle manometry
> Pressures >20mmHg are abnormal and >40mmHg is diagnostic
> no pathology on x-ray
Treatment: cut dressings down to skin
> prompt and extensive fasciotomies releasing all compartments
> Myoglobinuria may occur following fasciotomy leading to renal failure - aggressive IV fluids
> Where muscle groups are necrotic at fasciotomy - debridement +/- amputation
Death of muscle groups may occur within 4-6 hours
Describe the following knee problems:
- Infrapatellar bursitis
- Prepatellar bursitis
Infrapatellar bursitis- Clergyman’s knee
> Associated with kneeling
Prepatellar bursitis - housemaid’s knee
> Associated with more upright kneeling
Describe features and causes of cauda equina syndrome
Clinical features
> Urinary retention, bladder distension
> Reduced/absent anal tone, faecal incontinence
> Bilateral sciatica
> bilateral motor weakness in legs
> Saddle anaesthesia
> loss of perianal sensation (S2-S4)
causes
- disc prolapse in lumbosacral canal
investigations
- pre and post-voiding bladder scan (retention/incomplete bladder emptying)
- emergency MRI whole spine (within 4 hours)
Management
> Neurosurgery referral - decompression laminectomy within 24h
> Metastatic cancer: IV dexamethasone, radiotherapy
Complications
- urinary dysfunction requiring catheterisation
- sexual dysfunction
- chronic pain
- leg weakness
Describe the clinical features and causes carpal tunnel syndrome
caused by compression of median nerve in the carpal tunnel
History
> pain/pins and needles in thumb, index, middle finger
> unusually the symptoms may ‘ascend’ proximally
> patient shakes hand to obtain relief, classically at night
Examination
> weakness of thumb abduction (abductor pollicis brevis)
> wasting of thenar eminence
> Tinel’s sign: tapping causes paraesthesia
> Phalen’s sign: flexion of wrist causes symptoms
Causes
- idiopathic
- pregnancy
- oedema e.g. heart failure
- lunate fracture
- rheumatoid arthritis
- acromegaly
- hypothyroidism
- diabetes
- chronic renal failure
describe the diagnosis and management of carpal tunnel syndrome
Electrophysiology: motor + sensory: prolongation of the action potential
Treatment
- 6-week trial of conservative treatments mild-moderate
> wrist splints at night: particularly useful if transient factors present e.g. pregnancy
+/- corticosteroid injection
if severe symptoms or persistent:
> surgical decompression (flexor retinaculum division)
Describe sciatica
Causes
> Prolapsed lumbar disc
Clinical features
> Clear dermatomal leg pain associated with neurological deficits
> Leg pain worse than back pain
> Pain worse when sitting
Management
> analgesia, physiotherapy, exercises
> if symptoms persist >4-6 weeks, refer for MRI
Describe the presentation of scaphoid fractures
wrist fracture, typically due to fall onto an outstretched hand (FOOSH).
Presentation
> Pain along radial aspect of wrist at the base of the thumb
> Loss of grip / pinch strength
Signs:
- maximal tenderness over anatomical snuffbox
- pain elicited by telescoping of the thumb (pain on longitudinal compression)
- tenderness of the scaphoid tubercle (volar aspect of the wrist)
- pain on ulnar deviation of the wrist
Investigations
- Plain film radiographs
- CT scan if ongoing clinical suspicion
- MRI is definite investigation
describe complications and management of scaphoid fractures
Management
- Immobilisation with a Futuro splint or standard below-elbow backslab
- referral to orthopaedics
> undisplaced fractures of the scaphoid waist - cast for 6-8 weeks
> displaced scaphoid waist fractures
- surgical fixation
proximal scaphoid pole fractures
- surgical fixation
Complications
non-union → pain and early osteoarthritis
avascular necrosis
> most of the blood supply is derived from the dorsal carpal branch (branch of the radial artery), in a retrograde manner. Interruption of the blood supply risks avascular necrosis
What’s the normal position of the wrist joint?
10 degrees of volar angulation
describe open fracture management
ATLS approach
- inspect and photograph wound
- cover wound with saline soaked swab
- early antibiotics - IV cefuroxime, consider tetanus
Investigations - X-ray for diagnosis
management
- temporary stabilisation
> thomas splint - femur
> backslab - tibia
- definitive debridement and stabilisation in theatre
describe the classification of open fractures
Gustilo Anderson Classification
Type I
- skin wound <1cm
- clean
- simple fracture pattern
Type II
- laceration >1cm but <10cm
- moderate soft tissue damage
- adequate bone coverage
Type III
- laceration >10cm with extensive soft tissue damage
> IIIA: adequate soft tissue cover of bone but segmental / severely comminuted wounds
IIIB: extensive soft tissue injury with periosteal stripping and bone exposure; major wound contamination
IIIC: open fracture with arterial injury requiring repair
describe causes and features of septic arthritis
most common organism overall is Staphylococcus aureus
young adults who are sexually active - Neisseria gonorrhoeae is the most common organism (disseminated gonococcal infection)
causes
- bacteraemia - haematogenous spread
- direct innoculation (trauma / surgery)
- contiguous spread (adjacent osteomyelitis)
Features
> acute, swollen joint
> restricted movement
> examination findings: warm to touch/fluctuant
> fever
describe investigations and management of septic arthritis
Investigations
- synovial fluid sampling: joint aspiration
> before Abx unless extreme
fluid often cloudy if septic
send fluid for gram stain, culture and crystal analysis
aspirate prosthetic joints in theatre
- blood cultures + bloods
- joint imaging (X-ray)
Management
- intravenous antibiotics: flucloxacillin or clindamycin if penicillin allergic for 4-6 weeks
- needle aspiration should be used to decompress the joint
- arthroscopic lavage may be required
can get irreversible joint damage due to release of proteolytic enzymes within 8 hours
describe investigations, management and complications of cauda equina syndrome
investigations
- pre and post-voiding bladder scan (retention/incomplete bladder emptying)
- emergency MRI whole spine (within 4 hours)
Management
> Neurosurgery referral - decompression laminectomy within 24h
> Metastatic cancer: IV dexamethasone, radiotherapy
Complications
- urinary dysfunction requiring catheterisation
- sexual dysfunction
- chronic pain
- persistent leg weakness / altered sensation
describe the contents of the carpal tunnel
tendons:
- flexor digitorum profundus (4)
- flexor digitorum superficialis (4)
- flexor pollicis longus (1)
nerve:
- median nerve
Describe the following eponymous fractures
- Colles’
- Bennett’s
- Pott’s
- Smith’s
- Monteggia’s
- Galeazzi
- Barton’s
- Colles’ - dinner fork deformity
FOOSH resulting in transverse fracture of radius 1 inch proximal to radiocarpal joint with dorsal displacement and angulation - Bennett’s - intra-articular fracture of first CMC joint from fist fight, triangular fragment at ulnar base of metacarpal on X-ray
- Pott’s - bimalleolar ankle fracture on forced foot eversion
- Smith’s: (reverse Colles’) volar angulation of distal radius fragment, caused by falling backwards onto palm of outstretched hand
- Monteggia’s: dislocation of proximal radioulnar joint due to ulna fracture due to FOOSH with forced pronation
- Galeazzi: radial shaft fracture with dislocation of distal radioulnar joint (direct blow)
- Barton’s - distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation (fall onto extended and pronated wrist)
Describe the classification of ankle injuries and their management
Weber classification of ankle fractures
- type A: below level of ankle joint
> syndesmosis intact
> usually stable
> remain weight-bearing as tolerated in CAM boot for 6 weeks - type B: at the level of ankle joint
> syndesmosis intact or torn
> medial malleolus may be fractured
> deltoid ligament may be torn
> variable stability - type C: above ankle joint
> syndesmosis disrupted
> medial malleolus fracture and deltoid ligament rupture
> open reduction and external fixation (ORIF)
Maisonneuve fracture: spiral fibular fracture that leads to disruption of the syndesmosis with widening of the ankle joint
> surgery is required
Management
> prompt reduction of ankle fractures (before X-ray if neurovascular compromise)
> young patients with unstable/high velocity/proximal injuries - surgical repair with compression plate
> elderly patients - conservative management
List the Ottawa ankle rules
Ottawa ankle rules (to determine need for X-rays): if pain in malleolar zone and
> inability to weight bear for 4 steps
> tenderness over distal tibia
> bone tenderness over distal fibula
describe scheuermann’s disease
epiphysitis of the vertebral joints
predominantly affects adolescents
symptoms: back pain, stiffness
X-ray changes
- epiphyseal plate disturbance
- anterior wedging
clinical features
- progressive kyphosis
management
- physiotherapy
- analgesia
- severe cases may require bracing, surgical stabilisation
describe a ganglion cyst
cyst arising from a joint or tendon sheath
most commonly seen on dorsal aspect of wrist
features
- firm and well-circumscribed mass that transilluminates
management
- often disappear spontaneously within months
- surgical excision is indicated if severe symptoms or neurovascular manifestations
list late radiological features of avascular necrosis
- crescent sign: subchondral collapse
- osteochondral fracture
- flattening of femoral head
- joint space narrowing
describe the following tumours
- osteoma
- giant cell tumour
- osteosarcoma
- chondrosarcoma
osteoma
- benign overgrowth of bone, typically on the skull
- associated with Gardner’s syndrome (variant of familial adenomatous polyposis)
giant cell tumour
- tumour of multinucleated giant cells within fibrous stroma
- peak incidence: 20-40 years
- usually in epiphyses of long bones
- X-ray: double bubble or soap bubble appearance
chondrosarcoma
- malignant tumour of cartilage
- most commonly affects axial skeleton
- more common in middle age
Describe hip fractures and their management
Features
> pain
> shortened and externally rotated leg
Classification
> intracapsular (subcapital)
> extracapsular: these can either be trochanteric or subtrochanteric
Garden classification system also used to classify NOF fractures
Management
- Intracapsular hip fracture
> Undisplaced: internal fixation, or hemiarthroplasty if unfit.
> displaced: replacement arthroplasty (total hip replacement or hemiarthroplasty)
- Extracapsular hip fracture
> stable intertrochanteric fractures: dynamic hip screw
> reverse oblique, transverse or subtrochanteric fractures: intramedullary device
List red flags in back pain
Age <18 or >50
Immunosuppression
Waking from pain
night sweats, fever, weight loss
recent trauma
progressive neurological deficit
worst at night or at rest
thoracic back pain
bladder or bowel dysfunction
history of malignancy
Describe cubital tunnel syndrome
due to compression of the ulnar nerve as it passes through the cubital tunnel
> ulnar nerve travels between two heads of FCU in cubital tunnel retinaculum
clinical features
- tingling and numbness of the 4th and 5th fingers
- weakness of finger abduction
- hypothenar wasting
- pain worse on leaning on the affected elbow
- +ve Tinel’s at elbow
- history of OA / prior trauma
investigations: clinical diagnosis but nerve conduction studies may be used
management
- avoid aggravating factors
- physio
- soft elbow splints
- surgery in resistant cases
Describe necrotising fasciitis and its management
classification:
- type 1: mixed anaerobes and aerobes (often occurs post-surgery in diabetics) - most common
- type 2: Streptococcus pyogenes
Risk factors
> skin factors: recent trauma, burns or soft tissue infections
> diabetes mellitus
> intravenous drug use
> immunosuppression
The most commonly affected site is the perineum (Fournier’s gangrene).
Features
> acute onset
> pain, swelling, erythema at the affected site
> rapidly worsening cellulitis with pain out of keeping with physical features
> extremely tender over infected tissue with hypoaesthesia to light touch
> skin necrosis and crepitus/gas gangrene are late signs
> fever and tachycardia may be absent or occur late in the presentation
Management
> urgent surgical referral debridement
> intravenous antibiotics
Prognosis - average mortality of 20%
describe shoulder dislocation
humeral head dislodges from glenoid cavity of scapula
anterior dislocation: FOOSH
posterior dislocation: seizures, electric shock
inferior dislocation
management: reduction
- if recent reduction may be attempted without analgesia/sedation
- some patients may require analgesia or sedation to relax rotator cuff muscles
describe achilles tendinopathy
risk factors
> quinolone use e.g. ciprofloxacin
> hypercholesterolaemia (xanthomata)
achilles tendinitis
- gradual onset of posterior heel pain that is worse following activity
- morning pain and stiffness
management
- rest, ice, analgesia
- reduction in precipitating activities
- calf muscle eccentric exercises
achilles tendon rupture
- audible pop in the ankle while playing a sport or running
- sudden onset significant pain in the calf or ankle
- inability to walk or continue the sport
simmond’s
- abnormal angle of declination
- greater dorsiflexion than uninjured side
- palpate for gap in tendon
- squeeze muscles to check integrity of tendon
imaging: US first-line
acute referral to orthopaedics if rupture
management:
> RICE immediately
> non-surgical: immobilisation
> surgical: reattachment
describe achondroplasia
AD disorder caused by mutation in FGFR-3
this results in abnormal cartilage
- short limbs (rhizomelia) with shortened fingers (brachydactyly)
- large head with frontal bossing and narrow foramen magnum
- midface hypoplasia with flattened nasal bridge
- trident hands
- lumbar lordosis
mostly a sporadic mutation, risk factor is increasing parental age
describe subacromial impingement
first stage of rotator cuff disease, most common cause of shoulder pain
clinical features
- pain exacerbated by overhead activities and lifting objects away from body
- night pain
- painful arc of abduction between 60-120 degrees
- tenderness over anterior acromion
- X-ray may show calcification of supraspinatus tendon
management
- physiotherapy
- NSAIDs
- subacromial injections
- surgery
describe spondylolysis and spondylolisthesis
spondylolysis
- congenital or acquired deficiency of the pars interarticularis of the neural arch of a particular vertebral body, usually affects L4/5
- commonest cause of spondylolisthesis in children
spondylolisthesis
- one vertebra is displaced relative to its immediate inferior vertebral body
- may occur as a result of stress fracture or spondylolysis
- treatment
> active monitoring
> individuals with radicular symptoms or signs will require spinal decompression and stabilisation
describe metatarsal fractures
the 5th metatarsal is the most commonly fractured metatarsal and is the most common site of midfoot
> proximal avulsion fractures (pseudo-Jones fractures): most common type
> associated with lateral ankle sprain and often follows inversion injuries of the ankle
> jones fractures
> transverse fracture at the metaphyseal-diaphyseal junction
metatarsal stress fractures
- occurs in otherwise healthy athletes
- most common site is 2nd metatarsal shaft
> features: pain and bony tenderness, swelling, antalgic gait
investigations: stress fractures may appear normal on X-ray but sometimes there is a periosteal reaction 2-3 weeks later
> isotope scan or MRI if inconclusive
describe Sweet’s syndrome
aka acute febrile neutrophilic dermatosis
features
- fever
- painful inflamed or blistered skin rash
- mucosal lesions
- joint pain
- headache
associations: HLA B54
- IBD
- RA / lupus
- URTI
- immunodeficiency
treatment
- systemic steroids
describe acetabular labral tear and femoroacetabular impingement (FAI)
labral tears may occur as a result of trauma or degenerative change
features
- acute history / contact sport
- hip/groin pain
- snapping sensation
- patient able to weight bear with pain on external rotation
- locking sensation
FAI
- chronic condition predisposing to acetabular tear
describe de Quervain’s tenosynovitis
common condition in which sheath containing extensor pollicis brevis and abductor pollicis longus tendons is inflamed
typically affects females 30-50 years old
features
- pain on radial side of wrist
- tenderness over radial styloid process
- abduction of thumb against resistance is painful
- Finkelstein’s test: examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction
> if positive will cause pain over radial styloid process and along tendons
management
- analgesia
- steroid injection
- immobilisation with a thumb splint (spica)
- surgery
describe plantar fasciitis
inflammation of plantar fascia
most common cause of heel pain in adults
clinical features
- gradual onset heel pain
- pain is worse around medial calcaneal tuberosity
- exacerbated by walking on tip toes
management
- rest, ice, analgesia
- wear shoes with good arch support and cushioned heels
- insoles / heel pads
- physio
- steroid injections
