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MSK Flashcards

1
Q

Stages of Fracture Healing

A
  • Haematoma
  • Inflammation –> Granulation tissue
  • Cartilage callus
  • Lamellar bone (primary
  • Remodelling –> secondary bone
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2
Q

Factors that affect fracture healing

A
  • Age
  • malnourished
  • local pathology
  • neurological condiitons
  • NSAIDs
  • smoking
  • DM
  • Hormones - Cortisol, GH, Oestrogen, T3 &4, PTH
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3
Q

Describing a fracture

A
  • Patient details
  • Pattern of fracture
  • anatomical location
  • Intra/extra - articular
  • Deformity (translation/ angulation)
  • Soft tissue involvement
  • Specific # classification
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4
Q

General priniciples of fractures management

A 
4R's
Resuscitation  - & assess NV status 
Reduction 
Restriction
Rehabilitation (PT, OT, home help)
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5
Q

Open fracture management

A

 Analgesia: M+M
 Assess: NV status, soft tissues, photograph
 Antisepsis: wound swab, copious irrigation, cover with
betadine-soaked dressing.
 Alignment: align # and splint
 Anti-tetanus: check status (booster lasts 10yrs)
 Abx - Fluclox 500mg IV/IM or Co-amox

Mx: debridement and fixation in theatre

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6
Q

Gustillo’s classification of open fractures

A
  1. Wound <1cm in length
  2. Wound ≥1cm c¯ minimal soft tissue damage
  3. Extensive soft tissue damage
    a) periosteal stripping
    b) requires free tissue flap
    3) NV damage
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7
Q

Major complication of open fractures

A

 Wound infections and gas gangrene (clostridium perfringes)
 ± shock and renal failure

Rx: debride, benpen + clindamycin

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8
Q

Methods of reduction in fractures

A

Manipulation / Closed reduction
 Under LA, RA, GA
 Traction to disimpact
 Manipulation to align

Traction
 Employed to overcome contraction of large
muscles: e.g. femoral #s
 Skeletal traction vs. skin traction

Open reduction (and internal fixation)
 Accurate reduction vs. risks of surgery
 Intra-articular #s
 Open #s
 2 #s in 1 limb
 Failed conservative Rx
 Bilat identical #s
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9
Q

General complications of fractures

A

Tissue Damage
 Haemorrhage and shock
 Infection
 Muscle damage → rhabdomyolysis

Anaesthesia
 Anaphylaxis
 Damage to teeth
 Aspiration

Prolonged Bed Rest
 Chest infection, UTI
 Pressure sores and muscle wasting
 DVT, PE
 ↓ BMD
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10
Q

Specific fracture complications

A 
Immediate
 Neurovascular damage
 Visceral damage
Early
 Compartment syn.
 Infection (worse if metal)
 Fat embolism → ARDS
Late
 Problems -  union
 AVN
 Growth disturbance
 Post-traumatic OA
 CRPS
 Myositis ossificans
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11
Q

Pathophysiology of compartment syndrome

A

Raised pressure within any enclosed facial space leading to localised tissue ischaemia
 Oedema following # → ↑ compartment pressure → ↓
venous drainage → ↑ compartment pressure
 If compartment pressure > capillary pressure →
ischaemia
 Muscle infarction →
- Rhabdomyolysis and ATN
- Fibrosis → Volkman’s ischaemic contracture

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12
Q

Presentation of compartment syndrome

A

 Pain > clinical findings (not relieved by analgesia)
 Pain on passive muscle stretching
 Warm, erythematous, swollen limb
 ↑ CRT and weak/absent peripheral pulses
 shiny skin
 tense compartment
 +/- paraesthesiae

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13
Q

Prevention of compartment syndrome

A

avoid repeated manipulation
use open plaster initially
elevate leg
mobilise early

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14
Q

Rx of compartment syndrome

A 
 Elevate limb
 Remove all bandages and split/remove cast
 Get senior help
 Prophylactic Abx and Analegesia
 Fasciotomy
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15
Q

Problems with union

A

Delayed Union: union takes longer than expected

Non-union: # fails to unite
- Hypertrophic
 Bone end is rounded, dense and sclerotic
- Atrophic
 Bone looks osteopenic

Malunion: # healed in an imperfect position
 Poor appearance and/or function

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16
Q

Causes of non/delayed union

A

 Ischaemia: poor blood supply or AVN
 Infection
 ↑ interfragmentary strain
 Interposition of tissue between fragments
 Intercurrent disease: e.g. malignancy or malnutrition

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17
Q

Management of delayed/ non-union

A

 Optimise biology: infection, blood supply, bone
graft, BMPs
 Optimise mechanics: ORIF

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18
Q

Features of AVN

A

 Death of bone due to deficient blood supply.
 Sites: femoral head, scaphoid, talus
 Consequence: bone becomes soft and deformed
→ pain, stiffness and OA.
 X-ray: sclerosis and deformity.

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19
Q

Features of myositis ossificans

A

 Heterotopic ossification of muscle @ sites of
haematoma formation
 → restricted, painful movement
 Commonly affects the elbow and quadriceps
 Can be excised surgically

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20
Q

Definition of complex regional pain syndrome

A

 Complex disorder of pain, sensory abnormalities,
abnormal blood flow, sweating and trophic changes in
superficial or deep tissues.
 No evidence of nerve injury.
(type 2 - persistent pain following injury caused by nerve lesions)

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21
Q

Causes and presentation of CRPS

A

Causes
 Injury: #s, carpal tunnel release, ops for Dupuytren’s
 Zoster, MI, Idiopathic

Presentation
 Wks – months after injury
 NOT traumatised area that is affected: affects a
NEIGHBOURING area.
 Lancing pain, hyperalgesia or allodynia
 Vasomotor: hot and sweaty or cold and cyanosed
 Skin: swollen or atrophic and shiny.
 NM: weakness, hyper-reflexia, dystonia, contractures

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22
Q

Rx of CRPS

A

 Usually self-limiting
 Refer to pain team
 Amitryptilline, gabapentin
 Sympathetic nerve blocks can be tried.

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23
Q

Salter harris classification

A
  1. Straight across physis
  2. Above (metaphysis)
  3. Lower (epiphysis)
  4. Through (all 3)
  5. CRUSH

TYPE 2 most common

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24
Q

Risk factors for osteoporosis

A 
SHATTERERED 
 Steroids
 Hyper- para/thyroidism
 Alcohol and Cigarettes
 Thin (BMI<22)
 Testosterone low
 Early Menopause
 Renal / liver failure
 Erosive / inflame bone disease (e.g. RA, myeloma)
 Dietary Ca low / malabsorption, DM

Age

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25
Q

Presentation of a hip fracture

A

Shortened and externally rotated

Pain

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26
Q

Initial management of a hip fracture

A
  • Resuscitate: dehydration, hypothermia
  • Analgesia
  • Assess NV status of limb
  • Imaging: AP and lateral films
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27
Q

Garden classification of intracapsular fractures

A
  1. Incomplete #, undisplaced
  2. Complete #, undisplaced
  3. Complete #, partially displaced
  4. Complete #, completely displaced
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28
Q

Classification of hip fractures

A

 Intracapsular: subcapital, transcervical, basicervical

 Extracapsular: Intertrochanteric, subtrochanteric

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29
Q

Blood supply to the femoral head

A
  1. Intramedullary vessels in femoral neck - Interrupted by #
  2. Ascending branches of medial (Major contributor) and lateral circumflex femoral arteries, which travel in the capsular retinaculum. - Can be torn if # is displaced
  3. Vessels of the ligamentum teres - Insufficient in adults.
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30
Q

Specific complications of hip fractures

A 
 AVN of fem head in displaced #s (30%)
 Non / mal-union (10-30%)
 Infection
 OA
 Intracapsular haematoma (garden 3&amp;4)
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31
Q

Surgical management of hip fractures

A 
Intracapsular
 1,2: ORIF (cancellous/transcervical screws) 
- hemi if unfit
 3,4:
 <55: ORIF c¯ screws.
- arthroplasty if AVN
55-75: total hip replacement
>75: hemiarthroplasty

Extracapsular
 ORIF - dynamic hip screw

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32
Q

What score is used to predict the outcomes of hip fractures

A

Nottingham hip fracture score

  • Age
  • SEx
  • Hb
  • Residence
  • Co-morbidities
  • Malignancy
  • additionally high venous lactate is a predictor of early death
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33
Q

Features of a colles fracture

A

 Fall onto an outstretched hand
 Most common in elderly females c¯ osteoporosis
 Dinner fork deformity

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34
Q

Radiographic features of a colles fracture

A

 Extra-articular transverse # of dist. radius (w/i 1.5” of radio-carpal joint)
 Dorsal displacement and angulation of distal fragment
- Normally 11° volar tilt
- ↓ radial height (<11mm)
- ↓ radial inclination (<22°)
 ± avulsion of ulna styloid
 ± impaction

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35
Q

Management of colles fracture

A
  • Examine for NV injury (median N and radial A)
  • displacement → reduction
     RA/ GA.
     Disimpact and correct angulation.
     Position: ulnar deviation + some wrist flexion
     Apply dorsal backslab: provide 3-point pressure
  • Re X-Ray – satisfactory position?
     No: ortho review and consider MUA ± K wires
     Yes: home c¯ # clinic f/up w/i 48hrs for completion
    of POP
  • 6 wks in POP + physio
  • If comminuted, intra-articular or re-displaces:
     Surgical fixation c¯ ex-fix, Kirschner-wires or
    ORIF and plates.
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36
Q

Specific complications of colles fracture

A 
 Median N. injury
 Frozen shoulder / adhesive capsulitis
 Tendon rupture: esp. EPL
 Carpal tunnel syn.
 Mal- /non-union
 Sudek’s atrophy / CRPS
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37
Q

What is a Barton’s fracture

A

Oblique intra-articular # involving the dorsal aspect of

distal radius and dislocation of radio-carpal joint

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38
Q

Management of a Buckle and greenstick fracture

A

Buckle - 2 weeks plaster, 2 weeks reduced activity

Greenstick - closed reduction and arm immobilisation f r6 weeks

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39
Q

Clinical features of a scaphoid fracture

A

 FOOSH
 Pain in anatomical snuffbox
 Pain on telescoping the thumb

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40
Q

Management of a scaphoid fracture

A

 Sscaphoid x-ray view
 initially treat even if hx suggestive
- If initial x-ray is negative, pt. returns to # clinic after 10
days for re-xray (as localised decalcification)
 Place wrist in scaphoid plaster (beer glass position)
 # visible → plaster for 6 wks
 No visible # but clinically tender → plaster for 2
wks
 # not visible and not clinically tender → no plaster

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41
Q

Specific complications of a scaphoid fracture

A

AVN of the scaphoid as blood supply runs
distal to proximal.
 → stiffness and pain at the wrist

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42
Q

Classification of ulna shaft fractures

A

Monteggia
 # of proximal 3rd of ulna shaft
 Anterior dislocation of radial head at capitellum
 May → palsy of deep branch of radial nerve →
weak finger extension but no sensory loss

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43
Q

Classification of radial shaft fractures

A

Galleazzi
 # of radial shaft between mid and distal 3rds
 Dislocation of distal radio-ulna joint

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44
Q

Management of ulnar and radial shaft fractures

A

Unstable fractures
 Adults: ORIF
 Children: MUA + above elbow plaster

Fractures of forearm should be plastered in most stable
position:
 Proximal #: supination
 Distal #: pronation
 Mid-shaft #: neutral
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45
Q

Most common form of shoulder dislocation

A

Humeral head dislocates antero-inferiorly

- direct trauma/ falling on hand

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46
Q

Lesions associated with shoulder dislocation

A

Bankart Lesion
 Damage to anteroinferior glenoid labrum.

Hill-Sachs Lesion
 Cortical depression in the posterolateral part of the
humeral head following impaction against the glenoid
rim during ant dislocation.

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47
Q

Presentation of shoulder dislocation

A

 Shoulder contour lost: appears square
 Bulge in infraclavicular fossa: humeral head
 Arm supported in opposite hand
 Severe pain

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48
Q

Management of shoulder dislocation

A

 Assess for neurovascular deficit: esp. axillary N.
- Sensation over regimental badge before and after reduction
 X-ray: AP and transcapular view
 Reduction under sedation
 Rest arm in a sling for 3-4wks
 Physio

49
Q

Complications of shoulder dislocation

A

 Recurrent dislocation
- 90% of pts. <20yrs with traumatic dislocation
 Axillary N. injury

50
Q

Pathology of painful arc syndrome

A

Entrapment of supraspinatus tendon and subacromial
bursa between acromion and grater tuberosity of
humerus → subacromial bursitis and/or supraspinatous
tendonitis

51
Q

Presentation of painful arc syndrome

A

 Painful arc: 60-120O

 Weakness and ↓ ROM

52
Q

Ix and Rx of painful arc syndrome

A

 Plain radiographs: may see bony spurs
 US
 MRI arthrogram

Rx
 Rest
 Physiotherapy
 NSAIDs
\+/-  Subacromial bursa steroid ± LA injection

Surgery - Arthroscopic acromioplasty

53
Q

Differentials of painful arc

A

 Impingement
 Supraspinatous tear or partial tear
 Adhesive capsulitis - joint OA

54
Q

Presentation of frozen shoulder

A 
Progressive ↓ active and passive ROM
 ↓ ext. rotation <30O
 ↓ abduction <90O
Shoulder pain, esp. @ night (can’t lie on affected side)
- assoc DM
55
Q

Rx of painful arc

A

Conservative: rest, physio
Medical
 NSAIDs
 Subacromial bursa steroid ± LA injection

56
Q

Features of rotator cuff tears

A

Partial tears → painful arc

 Shoulder tip pain
 Full range of passive movement
 Inability to abduct the arm
 Active abduction possible following passive
abduction to 90°

Supraspinatous –> Lowering the arm beneath 30° → sudden drop
Subscapularis - weak int rotation
Infraspinatous - pain on resisted ext rotation

Rx - open/ arthroscopic repair

57
Q

Supracondylar # of humerus presentation

A

 Common in children after FOOSH
 Elbow very swollen and held semi-flexed.
 Sharp edge of proximal humerus may injure brachial
artery which lies anterior to it.

58
Q

Supracondylar # of humerus classification

A

Extension (Commonest type)
 Distal fragment displaces posteriorly

Gartland further classified extension type:
 Type 1: non-displaced
 Type 2: angulated - intact posterior cortex
 Type 3: displaced - no cortical contact

Flexion
 Distal fragment displaces anteriorly

59
Q

Supracondylar # of humerus management

A

Ensure there is no NV damage
 If radial pulse absent or damage to brachial
artery suspected, take urgently to theatre for
reduction ± on-table angiogram.
 Median nerve is also vulnerable

 Restore the anatomy
- No displacement → flex the arm as fully as
possible and apply a collar and cuff for 3wks –
triceps acts as sling to stabilise fragments.
- Displacement → MUA + fixation with K-wires +
collar and cuff with arm flexed for 3wks.

60
Q

Specific complications of Supracondylar # of humerus

A

NV injury
 Brachial A;  Radial and median N (esp. ant interosseous branch of med- Supplies deep forearm flexors (FPL, lateral half
of FDP and PQ))

Compartment syndrome
 Monitor closely first 24h
 Pain on passive extension of the fingers early sign.
 Mx: try extension of the elbow, surgical Rx may be
needed.
 Volkmann’s ischaemic contracture can result → fibrosis of flexors → claw hand.

Gunstock Deformity
 Valgus, varus and rotational deformities in the coronal plane do not remodel and → cubitus varus

61
Q

Management of femoral and tibial fractures

A

 Resus and Mx life-threatening injuries first.
- X-Match
 Tibial #: 2 units
 Femoral #: 4 units

  • Assess NV status: esp. distal pulses
     If open
  • Abx and ATT then Take to theatre urgently for debridement, washout and stabilisation
Fixation methods
 Intramedullary nail
 Ex-fix
 Plates and screws
 MUA c¯ fixed traction for 3-4mo
62
Q

Specific complications of femoral and tibial fractures

A 
 Hypovolaemic shock
 Neurovascular
- SFA: swelling and check pulses
-  Sciatic nerve
 Compartment syndrome
 Respiratory complications
-  Fat embolism
-  ARDS
-  Pneumonia
63
Q

Ankle fracture rules and classification

A

Ottowa Ankle Rules
 X-ray ankle if pain in malleolar zone + in any of:
 Tenderness along distal 6cm of posterior tib / fib
including posterior tip of the malleoli.
 Inability to bear weight both immediately and in
ED

Weber Classification
 Relation of fibula # to joint line
 A: below joint line
 B: at joint line
 C: above joint line
64
Q

Mx of ankle fracture

A

Weber A
 Boot or below-knee POP 6 wk

Non-displaced Weber B/C
 Below-knee POP 6-8 wk

Displaced Weber B/C
 Closed reduction and POP if anatomical
reduction achieved
 ORIF if closed reduction fails (and crutch 6-12 wk)

65
Q

Achilles rupture signs on examination

A

Simmonds triad

  • abnormal angle of declination
  • feel for gap
  • calf squeeze
66
Q

Common ankle ligament strain

A

Typically twisting inversion injury - Strains anterior talofibular part of lateral collateral ligament

67
Q

What is trochanteric bursitis

A

Pain and tenderness in lateral thigh due to repeated movements of IT band

68
Q

what is meralgia paraesthesiae

A

 Entrapment of lat. cutaneous nerve of thigh between ASIS and inguinal ligament
 Pain ± paraesthesia on the antero lateral thigh
 No motor deficit
 ↑ risk c¯ obesity: compression by belts, underwear
 Relieved by sitting down
 Can occasionally be damaged in lap hernia repair

69
Q

Unhappy triad for knee injuries

A

 ACL
 MCL
 Medial Meniscus

70
Q

What is the likely diagnosis if there is swelling after a knee injury

A

 Immediate = haemarthrosis = # or torn cruciates

 Overnight = effusion = meniscus or other lgt

71
Q

What is the likely diagnosis if there is pain/tenderness after a knee injury

A

 Joint line = meniscal

 Med/lateral margins = collateral lgts.

72
Q

What is the likely diagnosis if there is locking after a knee injury

A

meniscal tear → mechanical obstruction

73
Q

Causes of knee haemarthrosis (rapid joint swelling)

A 
1°: spontaneous bleeding
 Coagulopathy: warfarin, haemophilia
2°: trauma
 ACL injury: 80%
 Patella dislocation: 10%
 Meniscal injury: 10%
 Outer third where its vascularised
 Osteophyte #
74
Q

Mx of an acutely injured knee

A

 Full examination of acutely swollen knee after injury is
difficult.
 Take x-ray to ensure no #s
- Fluid level indicates a lipohaemarthrosis and
indicates either a # or torn cruciate.
 If no # → RICE + later re-examination for pathology
 If meniscal or cruciate injury suspected → MRI

75
Q

Mc of ruptured ACL

A

Conservative
 Rest
 Physio to strengthen quads and hamstrings
 Not enough stability for many sports

Surgical
 Gold-standard is autograft repair - Usually semitendinosus ± gracilis
 Tendon threaded through heads of tibia and femur and
held using screws.

76
Q

Pathology of Osteochondritis

A

 Idiopathic condition in which bony centres of
children/adolescents become temporarily softened due
to osteonecrosis.
 Pressure → deformation
 Bone hardens in new, deformed position

77
Q

features of osteochondritis on Xray

A

Initially: ↑ density / sclerosis

 Then: patchy appearance

78
Q

Main types of traction apophysitis

A

Osgood-Shlatter’s
 Tibial tuberosity apophysitis + patellar tendonitis
 Children 10-14yrs, M>F=3:1
 Assoc. c¯ physical activity
 Symptoms: pain below knee, esp c¯ quads contraction
 X-ray: tuberosity enlargement ± fragmentation
 Rx: rest, consider POP

Sever’s Disease
 Calcaneal apophysitis
 8-13yrs
 Symptoms: pain behind heal + limping
 Rx: physio and temporary cushioned heel support
79
Q

Pathology and mx of Osteochondritis Dissecans

A

 Piece of bone and overlying cartilage dissects off into joint space (AVN of subchondral bone)
 Commonly knee (med. fem. condyle), also elbow, hip and ankle.
 Young adult / adolescent
 Symptoms: pain, swelling, locking, ↓ ROM, crepitus
 X-ray: loose bodies, lucent crater
 Mx: arthroscopic removal of loose body

80
Q

Causes of avascular necrosis

A 
 # or dislocation
 SCD, thalassaemia
 SLE
 Gaucher’s
 Drugs: steroids, NSAIDs
81
Q

Differentials for a limbing child

A 
 Developmental dysplasia of the hip
 Transient synovitis
 Septic arthritis
 Perthes’
 Slipped Capital Femoral Epiphyses
 JIA / Still’s Disease
82
Q

Predisposing factors for Developmental dysplasia of the hip

A

 FH
 Breach presentation
 Oligohydramnios

83
Q

Presentation of Developmental dysplasia of the hip

A

Congenital hip joint deformity in which the femoral head is or can be completely / partially displaced.
 Screening
 Asymmetric skin folds
 Limp / abnormal gait

84
Q

Ix, Mx and complications if Developmental dysplasia of the hip isnt treated

A 
Ix - US
-+ve Barlow and Ortolani's
Mx: maintain abduction
 Pavlik harness (birth)
 Plaster hip spica (>2m)
 Open reduction: derotation varus osteotomy (>6m)
85
Q

Presentation of transient hip synovisitis

A

 2-12yrs
 Sudden onset hip pain / limp
 Often following or with viral infection
 Not systemically unwell

86
Q

Ix and Mx of transient hip synovitis

A

Ix
 PMN and ESR/CRP are normal
 -ve blood cultures
 May need joint aspiration and culture

Mx
 Rest and analgesia
 Settles over 2-3d

87
Q

Pathology and presentation of Perthes Disease

A

 Osteochondritis of the femoral head 2O to AVN.
 4-10yrs  M>F=5:1

Presentation
 Insidious onset
 Hip pain initially, then painless
10-20% bilateral

88
Q

Ix and Mx of Perthes disease

A 
Ix
 X-rays normal initially
 ↑ density of femoral head
- Becomes fragmented and irregular
-  Flattening and sclerosis
 Bone scan is useful
Mx
 Detected early and < half femoral head affected
-  Bed rest and traction
 More severe
- Maintain hip in abduction c¯ plaster
-  Femoral or pelvic osteotomy
89
Q

Pathology and presentation of SUFE

A 
 Postero-inferior displacement of femoral head epiphysis
 10-15yrs
 Two main groups
- Fat and sexually underdeveloped
-  Tall and thin
Presentation
 Slip may be acute, chronic or acute-on-chronic
Acute
 Groin pain
 Shortened, externally rotated leg
 All movements painful and limited abduction 
 20% bilateral 
Confirm on X-Ray
90
Q

Mx of SUFE

A

 Acute: reduce and pin epiphysis
 Chronic: in situ pinning
- Epiphyseal reduction risks AVN

91
Q

Complications of SUFE

A

 Chondrolysis: breakdown of articular cartilage
 AVN
 OA
 Subtrochanteric # (pinned too low)

92
Q

Complications of Perthes

A
  • OA

- premature fusion of growth plates

93
Q

Common organism of acute osteomyelitis

A 
 Staph. aureus 
 Strep
 E. coli
 Pseudomonas
 Salmonella (in SCD)
94
Q

Risk factors for developing acute osteomyelitis

A 
 Vascular disease
 Trauma
 SCD
 Immunosuppression (e.g. DM)
 Children
-  Rich blood supply to growth plate
95
Q

Presentation of acute oseomyelitis

A

 Pain, tenderness, erythema, warmth, ↓ROM
 Effusion in neighbouring joints
 Signs of systemic infection

96
Q

Ix for acute osteomyelitis

A

 ↑ESR/CRP, ↑WCC
 +ve blood cultures in 60%

 X-ray:
 Changes take 10-14d
 Haziness + ↓ bone density
 Sub-periosteal reaction
 Sequestrum and involucrum
 MRI is sensitive and specific
97
Q

Mx of acute osteomyelitis

A

 IV Abx: Flucloxacylin until MCS known
 Drain abscess and remove sequestra
 Analgesia
 Elevate Limb

98
Q

Complication of acute osteomyelitis

A
  • Brodies abscess - infection can partly be overcome by natural defences - confined in abscess lined by cortical bone
  • Chronic osteomyelitis (adults) - pus spreads under periosteum and dies. Perisoteum forms new bone around abscess. Need to eradicate dead bone and give abx
99
Q

Commonest benign bone tumours

A
  • osteochondroma (often knee) - cartilage capped by bony outgrowth
  • chondroma
  • osteoid osteoma (lytic lesions and central nidus with sclerotic limb)
  • osteoblastoma
  • osteoclastoma (soap bubble appearance
100
Q

Types of malignant bone tumours

A
  • Chrondrosarcoma (lytic lesion, fluffy calcification)
  • Osteosarcoma (commonest) - periosteal elevation (sunburst appearance)
  • Ewings (lytic tumour, onion-skin)
101
Q

Commonest cancers to metastasise to bone

A
  • thyroid
  • breast
  • lung
  • kidney
  • prostate
102
Q

Causes of pathological #

A
  • oestomyelitis
  • osteoporosis
  • osteogenesis imperfecta
  • Paget’s
  • Malignancy
103
Q

Features of Erb’s palsy and Klumpke’s paralysis

A

High (C5/6): Erb’s Palsy
 Abductors and external rotators paralysed
 Waiter’s tip position
 Loss of sensation in C5/6 dermatomes

Low (C8/T1): Klumpke’s
 Paralysis of small hand muscles
 Claw hand
 Loss of sensation in C8/T1 dermatomes

104
Q

Presentation of radial nerve injuries

A

Low Lesions: posterior interosseous nerve
 Site: # around elbow or forearm
 E.g. # head of radius
 Loss of extension of CMC joints (finger drop)
 No sensory loss

High Lesions
 Site: # shaft of humerus where N. is in radial groove.
 Wrist drop
 Loss of sensation to dorsum of thumb root (snuff box)
 Triceps functions normally

Very High Lesions
 Site: axilla – e.g. crutches or Sat night palsy
 Paralysis of triceps and wrist drop

105
Q

Presentation of ulnar nerve injuries

A

 Elbow: cubital tunnel
 Wrist: in Guyon’s Canal
Effects

 Intrinsic hand muscle paralysis → claw hand
 Ulnar paradox: lesion at elbow has less clawing as
FDP is paralysed, decreasing flexion of 4th/5th digits.
 Weakness of finger ad/abduction (interossei)
 Sensory loss over little finger

Tests
 Can’t cross fingers for luck
 flexion of thumb IPJ when trying to hold paper held between thumb & finger.
 Indicates weak adductor policis.

106
Q

Presentation of medial nerve injuries

A

Injury Above the Antecubital Fossa
 Can’t flex index finger IPJs (e.g. on clasping hands)
 Can’t flex terminal thumb phalanx (FPL)
 Loss of sensation in median distribution

Injury at the Wrist
 Typically affects abductor pollicis brevis

CTS

107
Q

Anatomy of carpal tunnel

A 
 Carpal tunnel formed by flexor retinaculum and carpal
bones.
 Contains
 4 tendons of FDS
 4 tendons of FDP
 1 tendon of FPL
 Median N.

Median N. supplies LLOAF (aBductor pollicis brevis)
 Palmer cutaneous branch travels superficial to flexor
retinaculum → spares sensation over thenar area.

108
Q

Features of Dupuytren’s Contracture

A

Progressive, painless fibrotic thickening of palmar fascia.

 M>F
 Middle age / elderly
 Skin puckering and tethering
 Fixed flexion contracture of ring and little fingers
 Often bilateral and symmetrical
 MCP and IP joint flexion
109
Q

Associations of Dupuytren’s Contracture

A 
Associations: BAD FIBERS
 Bent penis: Peyronies (3%)
 AIDS
 DM
 FH: AD
 Idiopathic: commonest
 Booze: ALD
 Epilepsy and epilepsy meds (phenytoin)
 Reidel’s thyroiditis and other fibromatoses
 Ledderhose disease
 Smoking
110
Q

Mx and differentials of Dupuytren’s contractures

A 
Mx
 Conservative: e.g. physio / exercises
 Fasciectomy - when hand can’t be placed flat on table.
- Z-shaped scars: prevent contracture
- Can damage ulnar nerve
- Usually recurs

Differential
 Skin contracture: old laceration or burn
 Tendon fibrosis, trigger finger
 Ulnar N. palsy

111
Q

Pathology of trigger finger

A

 Tendon nodule which catches on proximal side of
tendon sheath → triggering on forced extension → Fixed flexion deformity
 Usually ring and middle fingers
 Assoc. c¯ RA

Rx: steroid injection (high recurrence) or surgery

112
Q

Pathology of DeQuervain’s tenosynovitis

A
  • Sheath containing EPB and APL inflammed
  • pain on radial side of wrist and tenderness over radial styloid process
  • abd thumb agaisnt resistance painful

Mx - analgesia, steroif injection, splint, surgery

113
Q

Pathology of flexor tenosynovitis

A 
infection of tendon sheath (s.aurues)
kanavel's sings 
- tenderness along tendon sheath
- finger held in flexion
- fusiform swelling
- pain with passive extension

Mx - incisional drainage/ Abx

114
Q

Pathology of chondromalacia patellae

A

Softening of cartilage of patella

  • young women
  • patellar aching after prolonged sitting/climbing stairs
  • pain on patellofemoral compression. Clarke’s test

No abnormality on X-Ray
Rx - vastus medialis strengthening

115
Q

Pathology of Baker’s cyst

A

 Popliteal swelling arising between the medial head of
gastrocnemius and semimembranosus muscle
 Herniation from joint synovium
 Usually 2O to OA

Rupture: acute calf pain and swelling
 DVT differential

116
Q

Common organisms causing infection after bite

A
  • Human - s.aureus/ streptococcus

- dog/cat - pasteurella multocida

117
Q

Mx of bites

A
  • remove any foreign bodies
  • encourage to bleed
  • irrigate
  • swab
  • splint
  • elevate
  • abx- 7d co-amox
  • tetanus prophylaxis
  • close is <6h and no signs of infection
118
Q

Complications of bites

A
  • abscess
  • cellulitis
  • joint infection
  • septicaemia
  • tenosynovitis

IPE (9 decks)

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