MSK Flashcards
Describe fracture healing
Heamatoma formation - release of cytokines, growth factors, heamatoma forms, swelling, inflammation, macrophages/neutrophils remove necrotic tissue
Fibrocartilaginous callus formation (1-2 weeks) - granulation tissue forms, angiogenesis, osteoblasts begin forming spongy bone
Bony callus formation (2 months) - osteoblasts continue, fibrocartilaginous callus converted to bony (cancellous) callus, endochondral and intramembranous ossification
Bone remodelling (<7 years) - bone remodelled into compact bone, osteoclasts aid
*Wolff’s law - bone can remodel and adapt to the loads placed on it
Describe factors that affect bone healing
Patient factors - children (stem cells, thicker periosteum), smoking (nicotine/CO causes vasospasm and vasoconstriction), diabetes (defective collagen production), vitamin deficiency (vitamin D, C), corticosteroids, hyperparathyroidism (stimulates osteoclasts), hyperthyroidism (stimulates osteoclasts)
Fracture characteristics - excessive movement (disrupts repair), interposed tissues (blocking/delaying reunion), infection (osteomyelitis), large surrounding soft tissue injury (damage to blood supply, limited delivery of factors)
Describe management of hip fractures
Intracapsular displaced - THR (mobile, young, minimal comorbidities) or hemiarthroplasty
Trochanteric - sliding hip screw
Subtrochanteric - intramedullary nail
What is the Nottingham hip fracture score?
Determines risk of death/poor outcomes
Describe the Garden classification of hip fractures
Predicts Dec elopement of AVN
I - undisplaced, incomplete fracture
II - undisplaced, complete fracture
III - incompletely displaced, complete fracture
IV - completely displaced, complete fracture
Describe the Gustilo classification of open fractures
I - puncture from within to out, <1cm, minimal comminution
II - 1-10cm, moderate soft tissue damage/comminution
III - high energy trauma, farmyard/canal/sea contamination
A - adequate soft tissue damage of bone
B - extensive soft tissue loss, periosteal stripping, requires reconstructive surgery
C - vascular injury
Describe treatment of an open fracture
Initial management:
ATLS, analgesia, antiemetic, IV ABx within 3hrs, tetanus prophylaxis, control bleeding, assess soft tissue damage, neurovascular, debridememt/irrigation, photo, cover , stabilise/splint, reassess neurovascular
Surgical management:
Theatre within 24h unless vascular injury/gross contamination/compartment syndrome, aggressive debridement and irrigation, fracture stabilisation, coverage/closure
List scenarios where primary amputation is necessary
Uncontrollable haemorrhage Incomplete traumatic amputation 4-6 hours ischaemia Segmental muscle loss of two compartments Bone loss > 1/3 tibia
List signs and treatment of acute compartment syndrome
Pain (+ on passive stretch) Swollen tense compartment Paraesthesia Pressure >40mmHg --> dermatofasciotomy
What is the most common primary bone neoplasia?
Myeloma (40%)
Describe types of changes on X-ray in keeping with neoplasia
Lyric
Sclerotic
Mixed
What cancers cause lytic bone changes?
Renal Thyroid Adrenal Uterine GI
What cancers cause sclerotic bone changes?
Prostate
Breast
Renal (TCC)
What cancers cause mixed sclerotic/lytic bone changes?
Primary bone tumour (Ewing’s sarcoma/osteosarcoma/chondrosarcoma)
Which cancers metastasise to bone?
Thyroid Breast Lung Renal Prostate
List red flag symptoms of back pain
Age <16 or >50 new onset
Non mechanical
Thoracic
Malignancy history, unexplained weight loss
Long term steroid use
Fevers/rigors, recent significant infection
Difficulty passing urine (retention), urine/faecal incontinence, bilateral sciatica, saddle anaesthesia, decreased anal tone
List yellow flag symptoms of back pain
Attitudes Beliefs Compensation Diagnosis Emotions Family Work
Describe the conditions cauda equina syndrome, myelopathy, radiculopathy
Cauda equina - pressure on nerve roots at cauda equina of spinal cord due to prolapsed disc/infection/cancer/lumbar spinal stenosis
Myelopathy - injury to spinal cord due to severe compression
Radiculopathy - pinched nerve
Describe how you would undertake an examination of the spine
Look - posture, asymmetry, scoliosis, muscle wasting, soft tissue abnormalities, cafe au lait spots, cervical lordosis/thoracic kyphosis/lumbar lordosis
Feel - temperature, spinous processes, sacroiliac joints, paraspinal muscles
Move - lateral flexion, lumbar flexion and extension cervical spine flexion and extension/rotation/deviation, thoracic rotation
Special tests - modified shobers test, femoral nerve stretch test, straight leg raise
Describe the shoulder joints and how it is stabilised
Ball and socket joint
Joints - sternoclavicular, acromioclavicular, glenohumeral, scapulothoracic
Stabilised by - rotator cuff muscles, labrum, glenohumeral ligaments
List the functions and innervations of the rotator cuff muscles
Supraspinatus - abducts humerus, suprascapular nerve
Infraspinatus - external rotation, suprascapular nerve
Teres minor - external rotation, axillary nerve
Subscapularis - internal rotation, adducts humerus, subscapular nerve
List the common shoulder problems in different age groups
Young - instability, fractures, dislocations
Middle (40-60) - impingement, frozen shoulder, rotator cuff tears, tendinitis, bursitis
Older (60-80) - arthritis
Describe the difference between impingement syndrome and frozen shoulder
Impingement syndrome - tendons of the rotator cuff muscles become irritated and inflamed as they pass through a narrowed subacromial space
Frozen shoulder - benign, self limiting condition (freezing, frozen, thawing stages) where the connective tissue surrounding the glenohumeral joint becomes inflamed and stiff
Describe signs and symptoms of impingement syndrome
Pain, weakness, loss of movement
Pain worsened by overhead activities
Worse at night, particularly if lying on the affected shoulder
Pain during abduction from 60-120 (painful arc)
Positive empty cans, Hawkins-Kennedy test, scarf test
Describe signs and symptoms of frozen shoulder
Constant pain, worse at night and with cold weather
Severely restricted range of movement (active and passive)
Lack of external rotation on affected side
Positive scarf test
*Risk factors - diabetes, stroke, connective tissue disease, thyroid disease, heart disease
List short term complications of anterior shoulder dislocations
Bankhart lesion
Hill Sachs lesion
Axillary nerve damage
What is a Bankhart lesion?
Tear to anterio-inferior glenoid labrum +/- avulsion fracture
What is a Hill Sachs lesion?
Compression to postero-lateral humeral head
List long term complications of anterior shoulder dislocation
Recurrence
Glenohumeral arthritis
Deltoid muscle wasting
Describe how you would undertake an examination of the shoulder
Look (front, side, behind) - asymmetry, rotation (internal = posterior shoulder dislocation), bony prominences, scars, bruising, swelling, muscle wasting, large effusions
Feel - temperature, bony landmarks, muscle bulk, tendons
Move (active first, passive if necessary) - forward flexion, extension, abduction, adduction, external rotation, internal rotation
Special tests - muscle power (push against wall, empty cans, bubble, napoleon), Hawkins-Kennedy, apprehension test, scarf test
*Function - getting hands behind head and behind back
List red flag symptoms of hip pain
Severe night pain
Inability to weight bear
Malignancy history
Rapid deterioration
List common hip problems and how they may present
Arthritis - groin/buttock pain, stiffness, decreased ROM, loss of internal rotation
Trochanteric bursitis - lateral pain over greater trochanter
Fracture - pain, shortened leg, externally rotated
Describe how you would undertake an examination of the hip
Gait - walking phases, stride length, arm swing, trendelenburg, antalgic, high steppage, waddling, short leg
Tremdelenburg test
Look (standing) - straight stance, pelvic tilt, deformities, stoop, lumbar lordosis, scoliosis, gluteal atrophy, scars, true/apparent leg length
Feel - temperature, effusions, bony landmarks (greater trochanter, ASIS, pubic rami)
Move (active then passive) - flexion, internal/external rotation, abduction/adduction, extension
Special tests - Thomas test, trendelenburg
List red flag symptoms of knee pain
Inability to weight bear, worsening pain, acutely very stiff, fever, night pain, malignancy history
List common knee problems and how they may present
ACL tear - sport injury, high twisting force applied to a bent knee, loud crack, pain, rapid joint swelling (haemoarthrosis), poor healing, increased laxity on anterior drawer test
PCL tear - high energy trauma/hyperextension injury, tibia lies back on femur, increased laxity on posterior drawer test
Meniscal tears - sport injury, rotational, delayed knee swelling, joint locking/gives way, recurrent pain and effusions, tender over joint line, +ve McMurray’s test
Collateral ligament tears - effusion, tenderness over ligaments, varus laxity (LCL)/valgus laxity (MCL)
OA - pain, stiffness, decreased ROM, crepitus
Prepatellar bursitis - localised swelling over patella, precipitated by period of kneeling, tender over patella, normal ROM
Osteochondritis dissecans - swelling, occasional locking
Describe how you would undertake an examination of the knee
Gait - phases (looking at knee), limp, movement restriction
Look (standing) - alignment, varus/valgus deformity, fixed flexion deformity, hyperextension, baker’s cyst
Look (lying) - scars, bruising, swelling, effusions, RA nodules, psoriasis, alignment, position, knobbly knees, quadriceps bulk
Feel - temperature, tibial lag, joint line, synovial thickening, effusions (sweep test, patella tap test)
Move (active then passive) - flexion, extension, hyperextension
Special tests - collateral tests, drawer test, lachman’s, McMurray’s, patellofemoral apprehension test
Function - squat test
List common orthopaedic paediatric conditions including presentation and management
Clubfoot - feet rotated inwards and downwards –> ponseti method (manipulation and casting)
Septic arthritis - unable to weight bear, fever >38.5, raised WCC/CRP
Development dysplasia of the hip (DDH) - limping toddler (1-3 years), neonate checks (Barlow/Ortolani) –> pavlik harness
*Risk factors - breech birth, family history, female, oligohydramnios
Perthes - limping child (4-9 years), AVN of femoral head/epiphysis, can lead to OA, premature fusion of growth plates, *Catterall staging 1-4 –> cast/braces/observation/surgery
Transient sinovitis - limping child (2-10), associated with viral infection
Slipped upper femoral epiphysis (SUFE) - limping child (10-15), obese, M>F, knee/distal thigh pain, displacement of femoral head epiphysis posters-inferiorly, loss of internal rotation *xray = melting ice cream –> bed rest, no weight bearing/percutaneous pinning
Juvenile idiopathic arthritis (JIA) - arthritis in <16 year old for >3 months, pauciarticular = <4 joint affected - pain, swelling, limp, ANA +ve, anterior uveitis
Describe the Salter Harris classification of fractures
Involves growth plate I - straight across physis II - above physics III - lower than physis IV - through metaphysics, physis and epiphysis V - rammed, crushed physis 50% are salter Harris II
Describe when paediatric elbow ossification occurs
CRITOL Capitellum - 1 Radial head - 3 Internal epicondyle - 5 Trochlea - 7 Olecranon - 9 Lateral epicondyle - 11
Describe physiological genu varus/valgus
Infant - varus
18 months - normal
3.5 years - valgus
7 years - normal
List causes of intoeing
Femoral neck anteversion
Tibial torsion
Metatarsal adductus
Describe how to interpret a radiograph
- Describe the film - type of radiography, views, patient demographics
- The abnormality (fracture):
Type - complete (transverse/oblique/spiral/comminuted), incomplete (buckle/greenstick)
Location - epiphysis/metaphysics/diaphysis/apophysis, specific part of bone (e.g. neck of femur) - Complications/other - evidence of compound fracture/fracture enters joint/another fracture
Describe X-ray changes of osteoarthritis
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
Describe X-ray changes of rheumatoid arthritis
Loss of joint space Erosions Osteopenia Soft tissue swelling Ulnar deviation of hands
What is Shenton’s line?
Imaginary curved line along superior border of obturator foramen and inferior border of femoral neck
Disruption = fracture/dislocation of neck of femur
Name the likely organism in an animal bite injury
Pasteurella multocida
Describe different wrist fractures
Colles - distal radial fracture with dorsal displacement
Smith - distal radial fracture with volar displacement
Barton - fracture dislocation of the radiocarpal joint
Monteggia - ulnar shaft fracture with radial heal dislocation
Galaezzi - distal radius fracture with distal radio-ulnar joint dislocation
Describe Weber’s classification of ankle fractures and their management
Weber A - fracture of lateral malleolus distal to syndesmosis (usually stable)
Weber B - fracture at level of syndesmosis (may require ORIF)
Weber C - fracture above level of syndesmosis (requires ORIF)
Describe the presentation, investigations, management and complications of a scaphoid fracture
FOOSH in an adolescent/young adult
CFs - pain/tenderness in anatomical snuffbox
Ix - X-ray (repeat in 7-10 days if no fracture seen), CT/MRI
Rx - cast immobilisation, internal fixation if unstable
Complications - malunion, secondary OA, avascular necrosis (of proximal part)
Describe the treatment options for a Boxer’s fracture
Conservative
K-wire fusion
Closed reduction
