MSK Flashcards
In what percentage of cases does mechanical back pain come on suddenly?
60%
What are the differential diagnoses for back pain?
Mechanical back pain Osteoarthritis of the spine Prolapsed intervertebral disc Spinal stenosis Spondylolisthesis Discitis Inflammatory causes Malignancy Fracture Referred from abomen/hip/pelvis/SI joints
What are the investigations for mechanical back pain?
No investigations unless suspecting a different differential diagnosis.
Which investigations would you carry out in patients with prolonged symptoms or red flag signs?
FBC with differential WCC ESR LFTs Bone profile Myeloma screen CRP
What is the management of mechanical back pain?
Promote patient education
Good early symptomatic control using simple analgesia
Early return to normal activities
Self referral to physiotherapists
What is the common aetiology of nerve root impingement?
Degenerative disc disease.
Intervertebral disc herniation.
What are the common levels for intervertebral dic herniation to occur at?
L4/5
L5/S1
Describe the process of disc herniation.
Nucleus pulpous prolapses out via a defect in the degenerative annulus fibrous. This compresses the adjacent nerve root or the exiting nerve root, depending on location of disc herniation.
What are the clinical features of nerve root impingement?
Radicular pain passes below the knee and follows the dermatome of the involved nerve root.
Leg pain often equal or worse in severity than the back pain.
Which clinical tests can be used to examine for nerve root impingement?
Straight leg raise
Lasegue sign
How is nerve root impingement diagnosed?
MRI
What are the indications for MRI in back pain?
Patients who present with radicular pain >6 weeks.
Patients who develop neurological deficit.
Bilateral lower limb deficit or peroneal symptoms.
What is the management for nerve root impingement?
Non-surgical: Physiotherapy Analgesics Muscle relaxants (short course initially) Alternative therapies (e.g. acupuncture)
What are the indications for surgical intervention in nerve root impingement?
Absolute:
Cauda equina syndrome
Progressive neurological deficit.
Relative indications:
Intractable radicular pain
Neurologic deficit that does not improve despite conservative measures
Recurrent sciatica following a successful trial of conservative measures.
What are the red flags of back pain?
Age <18 or >50 at onset of non-mechanical pain.
Bilateral radicular leg pain
Limb weakness
Alternation of bladder and/or bowel function
Peri-anal numbness
History of cancer
Constitutional symptoms or weight loss
Trauma
Thoracic pain
History of immuno-compromise or prolonged steroid use.
What are the clinical features of cauda equina syndrome?
Bilateral paresthesia
Bilateral muscle weakness
Saddle parasthesia
Bladder and bowel dysfunction
What are the red flags for cauda equina syndrome in a history?
Back pain with uni/bilateral sciatica Lower limb weakness Altered perianal sensation Faecal incontinence Acute urinary retention/incontinence.
What are the red flags for cauda equina syndrome on examination?
Limb weakness
Other neurological deficit/gait disturbance
Hyper-reflexia, clonus, up going plantars
Urine retention
DRE: saddle anaesthesia
DRE: loss of anal tone
What are the investigations for cauda equina syndrome?
PR exam recording sensation and anal tone
Bladder scan pre and post void to assess for bladder emptying
Urgent MRI
Refer to neurosurgeons if MRI not immediately available.
What is the management for cauda equina syndrome?
Emergency surgical decompression
What are the MRI findings in a patient with cauda equina syndrome?
Complete obliteration of the spinal canal space.
Compression of cauda equina.
What is discitis?
An infection of the disc space
What is vertebral osteomyelitis?
An infection of the vertebral body.
What are the risk factors for developing discitis or vertebral osteomyelitis?
IV drug use
Sepsis from another source
Post spinal surgery
Which organisms are most commonly associated with discitis and osteomyelitis?
Staphylococci and streptococci.
Streptococci and haemophilus in children.
Tuberculosis should also be considered.
What is the clinical presentation of discitis and vertebral osteomyelitis?
Fever
Generally unwell
Back pain (unrelenting)
Late cases may present with spinal deformity.
What are the investigations for suspected discitis and osteomyelitis?
WCC ESR CRP X-rays - deformity MRI - increased signal in the intervertebral disc or bone/ collection/associated epidural abscess.
What is the management of discitis and vertebral osteomyelitis?
CT guided biopsy
Appropriate IV antibiotics (minimum 6 weeks)
Surgical treatment occasionally required - stabilisation, draining a large abscess.
What is the clinical presentation of spinal tumours?
Pain
Neurological deficit
Ask about red flag symptoms
What is the investigation of suspected spinal tumours?
MRI whole spine
Bone scans
Serum calcium
Do isolated anterior column fractures tend to be stable or unstable?
Stable
Do both column (burst fractures) or associated ligament injuries tend to be stable or unstable?
Unstable
What might clinical examination reveal in spinal injuries?
Bony midline tenderness
Clinical deformity or palpable step
Boggy swelling or bruising
Neurological compromise.
What are two features of spinal shock?
Bradycardia
Hypotension
How are spinal injuries diagnosed?
Plain radiographs:
C-spine - AP/lateral view/peg view
Thoracic and lumbar spine - AP and lateral
CT - high energy injuries, more than one column involvement, inadequate plain films, spinal cord involvement or suspected ligamentous injury.
MRI - investigation of choice when assessing for ligament or spinal cord injuries.
What is the treatment for spinal injuries?
Stable injuries:
Cervical - cervical collar, analgesia
Thoracic and lumbar - early mobilisation, bracing for symptomatic relief.
Unstable:
Cervical - HALO jacket, cervical collar, ORIF
Thoracic and lumbar - ORIF, bracing (extended application), bed rest in medically unfit patients.
What is scoliosis?
Lateral deviation or rotational deformity of the spine
What are the clinical features of scoliosis?
Noticed deformity such as: Rib hump Asymmetrical shoulder height Limb length inequality Chest expansion may be affected in severe deformities
What is the treatment for scoliosis?
Mild curves - conservative treatment, occassionally bracing if risk of progression of curve identified.
Moderate/severe curves - surgical correction more commonly needed to prevent curve progression, or correct deformity that is compromising cardio respiratory function.
Give a differential diagnosis for shoulder pain.
Subacromial impingement
Rotator cuff tears
Dislocation
Arthritis
What is subacromial imipingement?
Inflammation of the subacromial bursa due to abutment betwen greater tuberosity/RC and the acromioin/coraco-acromial liagement/acromioclavicular joint
Which conditions are associated with subacromial impingement?
Hook-shaped acromion
Greater tuberosity fracture malunion
Shoulder instability
What is the presentation of subacromial impingement?
Insidious onset shoulder pain
Exacerbated by overhead activities
+/- night pain
What are the physical exams for shoulder impingement?
Painful arc test
Neer impingement sign
Hawkins test
What might be seen on x-rays of somebody with shoulder impingement?
Type 3 hooked acromion
ACJ osteoarthritis
Sclerosis/cystic changes in greater tuberosity
What is the non-operative treatment for shoulder impingement?
Physiotherapy
NSAIDs
Subacromial corticosteroid injections
What is the operative treatment for shoulder impingement?
Arthroscopic subacromial decompression + acromiplasty
What are the risk factors for a rotator cuff tear?
Age
Smoking
Hypercholesterolemia
Thyroid disease
What are the mechanisms of a rotator cuff tear?
Chronic degenerative tear
Acute traumatic avulsion
What are the symptoms of a rotator cuff tear?
Pain - acute or insidious onset, in deltoid region, worse with overhead activities +/- night pain
Weakness: loss of active ROM
What is the special test to check for a supraspinatous tear?
Jobe’s test (empty can test)
What is the special test to check for an infraspinatous tear?
External rotation lag
What is the special test to check for a teres minor tear?
Hornblower sign
What is the special test to check for a subscapularis tear?
Lift-off test and belly press test.
What are the four muscles of the rotator cuff?
Supraspinatous
Infraspinatous
Teres minor
Subscapularis
Which forms of imaging can be used to look for a rotator cuff tear?
Ultrasound
MRI
What is the non-operative treatment for a rotator cuff tear?
Physiotherapy
NSAIDs
Subacromial corticosteroid injection
What is the operative treatment for a rotator cuff tear?
Rotator cuff repair (young, fit)
Rotator cuff debridement (elderly, irreparable tear)
Tendon transfer (young, fit, irreparable tear)
Reverse total shoulder arthroplasty (if massive tear with advanced arthritis)
What are the clinical features of a shoulder dislocation?
Severe shoulder pain
Inability to move the shoulder
Empty glenoid fossa: a palpable dent may be present at the point where the head of the humerus is supposed to lie.
The arm is typically in external rotation and slight abduction.
What are the complications associated with shoulder dislocation?
Damage to the axillary nerve - numbness over the lateral surface of the shoulder and loss of function of the deltoid muscle.
Injury to the brachial plexus, axillary artery/vein.
Avulsion fracture of greater or lesser tuberosities.
Recurrent shoulder instability
Rotator cuff injury
What is the treatment of a shoulder dislocation?
Emergent treatment:
Immobilisation of the joint with a sling
Analgesia
Conservative management: closed reduction
Surgical management: reduction of humeral head and repair of labrum.
What are the indications of surgical management of a shoulder dislocation?
Unsuccessful closed reduction
Displaced Bankart lesion
Recurrent shoulder dislocations
Young and active individuals may require early surgery to prevent recurrent dislocations in the future.
What is the definition of shoulder osteoarthritis?
Glenhumeral degenerative joint disease characterised by damage to the articular surfaces of the humeral head and/or glenoid.
What is the aetiology of shoulder osteoarthritis?
primary osteoarthritis Secondary arthritis: - post traumatic (fracture or dislocation) - inflammatory /crystalline arthritis - osteonecrosis - rotator cuff arthropathy
What are the symptoms of shoulder osteoarthritis?
Shoulder pain
Loss of range of motion - especially external rotation due to anterior capsule contraction
Pain at night
What will a physical exam of a patient with shoulder osteoarthritis show?
Decreased range of movement
Crepitus
Which x-ray views should be taken to look for shoulder osteoarthritis?
AP and lateral
What will x-ray of a patient with osteoarthritis show?
Joint space narrowing Subchondral sclerosis Subchondral cysts Osteophytes circumferentially at humeral head "goat's beard" Posterior glenoid wear
What is the non-operative treatment for shoulder osteoarthritis?
NSAIDs
Physiotherapy
Corticosteroid injections
What is the operative treatment for shoulder osteoarthritis?
Shoulder replacement
What is the differential diagnosis of shoulder pain?
Osteoarthritis Rheumatoid arthritis Tennis elbow Golfer's elbow Olecranon bursitis
What are the symptoms of elbow osteoarthritis?
Progressive painful movement.
Loss of terminal extension.
Painful locking or catching of elbow.
What can be found on examination in elbow osteoarthritis?
Reduce range of movement.
What can be seen on x-ray in elbow osteoarthritis?
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
What are the two types of elbow osteoarthritis?
Primary
Post-traumatic
What is the non-operative treatment for elbow osteoarthritis?
NSAIDs
Cortisone injections
What is the operative treatment for elbow osteoarthritis?
Debridement: removal of osteophytes and capsular release
Arthroplasty
What can be found on physical examination in elbow rheumatoid arthritis?
Fixed flexion deformity and ligamentous incompetence
What can be seen on x-rays in rheumatoid arthritis of the elbow?
Periarticular erosions
Cystic changes
What is tennis elbow?
Overuse injury at origin of common extensor tendon leading to tendinosis and inflammation.
What are the symptoms of tennis elbow?
Pain with gripping
Resisted wrist extension
What can be found on examination in tennis elbow?
Point tenderness at ECRB origin (lateral epicondyle).
Resisted extension of long finger exacerbates pain.
What do x-rays show in tennis elbow?
Usually normal.
May be calcifications at extensor origin.
What is the non-operative treatment for tennis elbow?
NSAIDs
Physiotherapy
Corticosteroid injections
What is the operative treatment of tennis elbow?
Release and debridement of ECRB origin.
What is golfer’s elbow?
Overuse of flexor-pronator origin (medial epicondylitis).
What are the symptoms of golfer’s elbow?
Pain with gripping
Resisted wrist flexion.
What can be found on examination in golfer’s elbow?
Point tenderness just distal to medial epicondyle.
Test: pain with resisted forearm pronation and wrist flexion.
What can be seen on x-rays in a patient with golfer’s elbow?
Usually normal
May be calcifications at flexor origin.
Which other imaging (in addition to x-ray) may be used in a patient with golfer’s elbow?
MRI - to rule out ulnar collateral ligament injury in overhead throwers.
What is the non-operative treatment of golfer’s elbow?
NSAIDs
Physiotherapy
Bracing
Corticosteroid injections
What is the operative treatment in golfer’s elbow?
Debridement and reattachement of flexor-pronator origin
What causes olecranon bursitis?
Trauma Prolonged pressure Infection Rheumatoid arthritis Gout
What is the presentation of olecranon bursitis?
Swelling Pain Redness Warmth Fever and malaise if infective.
What are the investigations of olecranon bursitis?
FBC
Uric acid level
CRP
X-rays - radio-opaque foreign bodies, olecranon spur
Aseptic needle aspiration of bursa (gold standard for diagnosis of infection) - urgent gram stain, culture and sensitivity. Pathology for crystals.
What is the treatment for olecranon bursitis?
Non-infective: Ice, elevation, NSAIDs, treat the cause.
Infective: After aspiration start broad-spectrum antibiotics (covering S.aureus), oral or IV depending on severity of infection.
What is the treatment for recurrent bursitis?
Once the infection has settled and interval bursectomy can be considered.
What is the differential diagnosis of tingling fingers?
Peripheral nerve entrapment (carpal tunnel syndrome and cubital tunnel syndrome)
Central nerve entrapment
Peripheral neuropathy
What are the key features of peripheral nerve entrapment?
Pain/parasthesia in the distribution of the nerve.
Altered sensation in the distribution of the nerve.
Reduce muscle function supplied by the nerve.
What are the structures that pass through the carpal tunnel?
Median nerve
4 x flexor digitorum superficialis
4 x flexor digitorum profundus
flexor pollicis longus
Which conditions are associated with carpal tunnel syndrome?
Diabetes mellitus Hypothyroidism Rheumatoid arthritis Acromegaly Wrist fractures Pregnancy Use of heavy vibrating mechinery
What is the presentation of carpal tunnel syndrome?
Nocturnal waking with tingling (relieved by shaking hands/running under water/keeping dependant)
Altered/reduced sensation in median nerve distribution
Difficulty manipulating small objects
Clumsiness (dropping cups/mugs/loose change)
What are the clinical signs of carpal tunnel syndrome?
Altered sensation in median nerve distribution Ring finger splitting Reduced power of thumb abduction. Thenar muscle wasting Positive tinel's sign Positive phalen's test
What is the management of carpal tunnel syndrome?
Wrist splints Steroid injection Carpal tunnel decompression surgery - local anaesthetic with tourniquet - divide flexor retinaculum longitudinally.
Where is the cubital tunnel?
Behind medial epicondyle of the elbow.
What is the cubital tunnel formed by?
Cubital tunnel retinaculum.
Where does the ulna nerve travel between?
Between two heads of flexor carpi ulnaris under the cubital tunnel retinaculum.
What is the presentation of cubital tunnel syndrome?
Nocturanl waking with tingling (in ulnar nerve distribution).
Altered/reduced sensation in ulnar nerve distribution.
What are the clinical signs of cubital tunnel syndrome?
Relative loss of sensation between hands or nerve territories. Ring finger splitting Reduce power of finger abduction Claw posture (if severe) Hypothenar muscle wasting Interosseus muscle wasting Positive Tinel's sign at elbow.
What is the management of cubital tunnel syndrome?
Soft elbow splints
Cubital tunnel decompression surgery
What is the differential diagnosis of sticking fingers?
Trigger finger
Extensor tendon subluxation
What happens is the pathophysiology of trigger finger?
Constriction and thickening of A1 pulley.
Nodule on tendon.
What is the clinical presentation of trigger finger?
Finger sticks in flexion then clicks painfully as finger is extended.
Symptoms generally worse in morning.
Who is at increased risk of trigger finger?
People with diabetes.
What is the management of trigger finger?
Non-operative:
Splintage
Steroid injection
Operative:
Surgical release/widening of A1 pulley
What is the pathophysiology of extensor tendon subluxation?
Weakness of saggital bands that hold extensor tendon centrally over MCPJ.
Who is extensor tendon subluxation more common in?
People with rheumatoid arthritis.
What is the clinical presentation of extensor tendon subluxation?
Tendon subluxes on flexion into the ulna gutter.
Flicks back in extension or finger has to be straightened manually.
What is the management of extensor tendon subluxation?
Acute: splint with metacarpo-phalangeal joints extended for 6 weeks.
Failed conservative or chronic presentation: surgical repair/reconstruction.
What is the differential diganosis of stuck fingers?
Dupuytren’s disease
Radial nerve or posterior interosseus nerve palsy
Locked trigger finger
Subluxed MCPs
What is the genetic inheritence of dupuytren’s disease?
Autosomal dominant with variable penetrance.
What is the pathophysiology of dupuytren’s disease?
Proliferation of myofibroblasts in the palmar fascia producing pathological nodules and cords.
What are the ectopic manifestations of dupuytren’s disease?
Plantar fascia of feet
Knuckls pads on dorsal aspect of PIPJs
Dartos fascia of penis
Which conditions are associtaed with dupuytren’s disease?
Diabetes
Epilepsy and anti-convulsants
What is the clinical presentation of dupuytren’s disease?
Fixed flexion deformities of MCP and PIP joints.
Difficulty with ADLs (can’t put hand in pocket, poke themselves in eye when washing face)
What is the management of dupuytren’s disease?
Needle aponeurectomy
Collagenase injections
Fasciectomy
Dermofasciectomy
What causes raidal/posterior interosseus nerve palsy?
Trauma - laceration of nerve
RA of elbow - synovitis causes swelling and pressure on nerve
Compression neuropathy
What is the presentation of radial/posterior interosseus nerve palsy?
Weakness of active extension of wrist/fingers and thumb.
Wrist drop.
Normal passive movement.
What is the treatment for radial/posterior interosseus nerve palsy?
Laceration - repair nerve
Synovitis - treat inflammation
Compression neuropathy - surgical decompression
What are the causes of subluxed MCPs?
Rheumatoid arthritis
What is the clinical presentation of subluxed MCPs?
Swollen painful MCPs
Inability to extend with obvious deformity.
What is the treatment of subluxed MCPs?
Joint replacement if painful.
What is the differential diagnosis of radial sided wrist pain?
De Quervain's stenosinsg tenovaginitis Scaphoid fracture Radial styloid fracture Thumb CMC joint osteoarthritis Scaphotrapeziotrapezoid osteoarthritis
What is the pathophysiology of de uervain’s stenosing teno-vaginitis?
Stenosing process at 1st dorsal extensor compartment.
APL and EPB tendons pass through compartment
What is the clinical presentation of de quervain’s stenosing teno-vaginitis?
Pain on wringing or removing stiff lids.
Pain on resisted abduction
Positive Eichoff’s test
Pain over De Quervain’s tendons on ulna deviatin with thumb in fist.
What is the treatment for de quervain’s stenosing teno-vaginitis?
Non operative: splintage, steroid injection
Operative: surgical release of 1st dorsal compartment
What is the clinical presentation of thumb carpo-metacarpal osteoarthritis?
Pain and stiffness
Pain on wringing or removing stiff lids
Positive grind test
Often comes to light after a fall
What is the investigation for carpo-metacarpal osteoarthritis?
X-ray - ask for writs and thumb views. Look for x-ray features of OA. Look for scapho-trapezio-trapezoid OA as well
What are the treatment options for thumb carpo-metacarpal osteoarthritis?
Non-operative:
Analgesia
Splintage
Steroid injection
Operative:
Excise (trapeziectomy)
Fuse
Replace
What are the differential diagnosis of lumps and bumps in the hands?
Ganglion Giant cell tumour Heberden's and bouchard's nodes Skin lesions Gouty tophi Rheumatoid nodules lnclusion cysts Osteochondroma Enchondroma
What are the common sites for ganglions?
Dorsal wrist
Volar wrist
Finger flexor sheath
DIP joint
What are the treatments for ganglions?
Leave alone (many will spontaneously regress)
Aspirate
Excise
Are giant cell tumours of the tendon sheath benign or malignant?
Benign
What is the treatment for giant cell tumours of the tendon sheath?
Excision
What is the treatment for gouty tophi?
Control gout
Excision
What is an enchondroma?
Commonest bony tumour of hand.
How do enchondroma’s often present?
Pathological fracture
What is the treatment for enchondromas?
Observation only
Curretage and bone graft.
What are the symptoms of OA of the hip?
Pain in buttock, groin and thigh or knee.
Pain during activities or at night.
What are the examination findings of a patient with osteoarthritis of the hip?
Antalgic or trendelenberg gait.
Deformity, asymmetry, swelling, muscle wasting.
Walking stick.
Tenderness on deep palpation over groin or around greater trochanter.
Reduced range of motion, especially internal rotation.
What is the non-operative management of OA of the hip?
Weight loss advice
Use of walking stick in opposite side to pain.
Analgesia
Physiotherapy
What is the operative treatment of OA of the hip?
Total hip arthroplasty.
What is the non-operative management of OA of the knee?
Weight loss advice Walking stick in opposite hand to pain. Analgesia Physiotherapy Lifestyle modification
What are the operative management options for OA of the knee?
Tibial osteotomy (wedge of bone removed from lateral side of tibia) Unicompartmental joint replacement Total knee replacement
What are the risk factors for traumatic avascular necrosis?
Femoral head/neck fracture
Hip dislocation
SUFE
What are the risk factors for non-traumatic avascular necrosis?
Alcohol abuse Corticosteroids Irradiation Haematological disease Dysbaric disorders Hypercoagulable states Connective tissue disorders Viral e.g. hepatitis, HIV Idiopathic
What are the clinical features of avascular necrosis of the hip?
Insidious onset of buttock, groin/anterior hip, or thigh pain. A sudden increase in pain may indicate femoral head collapse.
Can be asymptomatic until late stage disease.
Hip joint will be stiff
Patient may walk with limp.
What are the investigations for avascular necrosis of hip?
X-ray - will detect advanced disease
MRI - will detect much earlier change in the bone
What is the management of avascular necrosis?
Non-operative - observe with symptom control, bisphosphonates may be beneficial in early stage disease.
Operative:
- Core decompression with or without bone grafting
- Rotational osteotomy
- Total hip resurfacing
- Total hip replacement
What is slipped upper femoral epiphysis?
A fracture through the femoral physis, causing the epiphysis to ‘slip’ posteriorly and inferiorly
What are the risk factors for slipped upper femoral epiphysis?
Adolescents
Male
Obesity
What are the clinical features of slipped upper femoral epiphysis?
Limp
Groin pain
Externally rotated and shortened leg
Pain on attempts to rotate hip
Decreased range of motion, esp. internal rotation
Presentation can be acute, after injury, subacute or chronic.
What will a slilpped upper femoral epiphysis look like on x-ray?
Disruption to Shenton’s line
Additional shadow behind superior femoral neck.
Widening of physis and reciprocal decreases in height of epiphysis.
Prominent lesser trochanter due to external rotation.
Line drawn along superior edge of femoral head (Klein’s line) fails to intersect the lateral part of the superior femoral epiphysis.
What are the risk factors for developmental dysplasia of the hip?
Female First born Breech position in utero or delivery Family history Other MSK disorders
What is the main clinical feature of a quadriceps tendon rupture?
Unable to extend knee against resistance.
May be unable to straight leg raise.
What are the main clinical features of a patella tendon rupture?
Unable to straight leg raise or maintain extension of knee.
Reduced range of motion at knee joint with difficulty weight bearing.
What is the management of quadriceps tendon rupture?
Open repair followed by protection in extension cast or splint.
What is the management of patella tendon rupture?
Non-operative - immobilisation in full extension with progressive exercise programme.
Operative - open repair of tendon.
What are the risk factors for quadricep and patella tendon rupture?
Previous tendon injury Existing tendinopathy Previous corticosteroid injection Steroid use Co-morbidities e.g. SLE, RA Increasing age (for quadriceps rupture).
What is the typical mechniam of injury for meniscal tears?
Twisting the knee while weight bearing.
What are the investigations used to diagnose meniscal tears?
MRI
Diagnostic arthroscopy
Which T score is diagnostic of osteoporosis?
T< -2.5
What are common places for fragility fractures?
Hip fractures
Vertebral fractures
Distal radius fractures
Humeral neck fractures
What are causes for fragility fractures?
Osteoporosis Metastatic disease Myeloma Osteomalacia Paget's disease
What is the treatment for osteoporosis?
Weight bearing activity Reduce fizzy drinks HRT for menopause <40 Vitamin D Calcium Bisphosphonates e.g. alendronate
What are osteomalacia and rickets most commonly due to a deficiency of?
Vitamin D
Which age group gets rickets?
Children
What is the pathophysiology of rickets?
Poor calcification of cartilage matrix of growing long bones.
Occurs at zone of provisional calficiation - fraying and widening of metaphysis called cupping.
Leads to increased physeal width and cortical thinning and bowing.
Most prominent at large physes (knee, wrist).
What effect does rickets have on long bones?
Bowing of long bones.
What are the clinical features of rickets?
Rachitic rosary - widening of anterior ribs at costal cartilages leading to line of prominences (like beads)
Flattening of skull
Pain may be associated with deformities
What is the treatment for rickets?
Replacement of missing components: Vitamin D Calcium Calcitriol Phosphate
What are the clinical features of osteomalacia?
Pain in bones and muscles
Proximal muscle weakness - waddling gait
Fractures
What is Paget’s disease?
Disorder of bone remodelling.
Increased osteoclast activity.
What are the 3 stages of paget’s disease?
Lytic
Mixed
Sclerotic
What are the common sites for paget’s disease?
Femur Tibia Pelvis Skull Spine
What are the biochemistry results in paget’s disease?
Calcium and phosphate normal
Alkaline phosphate raised
Urinary hydroxyproline raised
What are the clinical features of paget’s disease?
Localised pain and tenderness Increased focal temperature due to hyperaemia Increased bone size Bowing deformities Kyphosis of the spine Decreased range of motion
What are the complications of Paget’s disease?
Osseious weakening resulting in deformity and pathological fractures Increased risk of osteoarthritis Hearing loss Neural compression Malignant transformation Hyperparathyroidism Extramedullary haematopoeisis
What is the treatment of paget’s disease?
Expectant if symptoms minimal.
Bisphosphonates
Calcitonin
What is the definition of major trauma?
Any injury that has the potential to cause prolonged disability or death.
An injury severity score >15.
What is polytrauma?
A syndrome of multiple injuries exceeding a defined severity with sequential system reactions that may lead to dysfunction or failure of remote organs and vital systems which have themselves been directly injured.
What is golden hour?
Period of time following an injury with the highest likelihood that prompt medical and surgical treatment will prevent death.
What are the sources of major haemorrhage?
Chest Abdomen Pelvis Long bones Obvious wounds
What is the definition of shock?
A life-threatening condition of circulatory failure resulting in cellular injury and inadequate tissue function.
What are the complications of major trauma?
Fat embolism syndrome
Compartment syndrome
What are the symptoms of fat embolism syndrome?
Respiratory
Neurological
Dermatological
Haematological
What are the treatments for finger tip injuries?
Dressings only
Trimming of bone and dressings
Terminalisation and primary closure
Local advancement or transposition flap
Which tendon and nerve are most at risk from cutting wrists due to self harm?
Palmaris longus tendon
Median nerve
How should tendon and nerve injuries be assessed?
Vascular assessment
Neurological assessment
Tendon assessment
What is the treatment for tendon and nerve injuries?
Local anaesthetic and irrigation - not instil local anaesthetic until neurological assessment has been made.
Tetanus
IV antibiotics
Dressing and back slab
Low threshold for surgical exploration - any suspicion of tendon or nerve injury refer to orthopaedics/plastics.
How should animal or human bites be treated?
X-ray for tooth
Consider surgical debridement
Low threshold for surgical irrigation
What are the common pathogens causing post-operative infection in hip-arthroplasty?
Coagulase negative staphylococcus
Staphylococcus aureus
What are the risk factors for post-operative AKI?
Age Pre-existing CKD Diabetes Liver disease Hypertension Use of ACE inhibitors
What are the risk factors for compartment syndrome?
Trauma with crushing injuries to tissues Trauma with long lie Long bone fractures Patients with vascular injury to limb Ischaemia of tissues Patients with coagulopathy
What are the clinical features of compartment syndrome?
Paraesthesia Pallor Pulselessness Paralysis Perishing cold
What is the management of compartment syndrome?
Immediately splint all dressings to skin along length of limb.
Reassess if this has helped pain. If not, call for senior orthopaedic help.
Patient is likely to require emergency fasciotomy.
What are the three features of Virchow’s triad?
Blood stasis
Endothelial injury
Hypercoagulability
What are the risk factors for thromboembolic disease post-operatively?
Age Obesity Varicose veins Family history of VTE Thrombophilia Combined OCP/HRT Immobility Immobility due to travel Lower limb fracture Spinal cord injury Lower limb surgery
Gives examples of mechanical VTE prophylaxis?
Early mobilisation
Graduated compression stockings
Intermittent pneumatic compression devices
Gives examples of pharmacological VTE prophylaxis.
Aspirin
Vitamin K antagonists
Unfractionated heparin
DOACs
How many weeks after hip fracture can hypercoagulability persist?
6 weeks
What are the benign osteogenic tumours?
Osteoid osteoma
Osteoblastoma
What are the benign chondrogenic tumours?
Enchondroma
Osteochondroma
Chondroblastoma
Chondromyoid fibroma
What are the benign bone tumours of unknown origin?
Giant cell tumour
Histiocytoma
Name a benign fibrogenic tumour.
Nonossifying fibroma
Name a benign vascular tumour.
Hemangioma
Name a benign lipogenic tumour.
Lipoma
What are the malignant osteogenic tumours?
Parosteal osteosarcoma
Periosteal osteosarcoma
Intramedullary osteosarcoma
What are the malignant chondrogenic tumours?
Chondrosarcoma
What are the malignant bone tumours of unknown origin?
Adamantinoma
Ewing’s tumour
What are the malignant fibrogenic tumours?
Desmoplastic fibroma
Fibrosarcoma
what are the malignant haematopoeitic tumours?
Multiple myeloma
Lymphoma
Leukaemia
Name a malignant vascular tumour?
Hemangioendothelioma
Name a malignant notochordal tumour.
Chordoma
What are the signs and symptoms of bone tumours?
Pain Swelling Joint swelling and stiffness Limping Fever Generally unwell Weight loss Anaemia
What are the early investigations of suspicious bone/soft tissue lesions?
X-ray Blood tests - alkaline phosphatase CT scan MRI Biopsy
What is osteoid osteoma?
A benign bone tumour that arises from osteoblasts.
What is osteochondroma?
Most common benign tumours of bones. Take the form of cartilage-capped bony projections.
What is an enchondroma?
A noncancerous bone tumour that begins in cartilage.
How can unicameral bone cysts be classified?
Active or latent
What is fibrous dysplasia?
A bone disorder in which fibrous tissue develops in place of normal bone.
What is a lipoma?
A benign tumour made of fat tissue.
What is osteosarcoma?
Most common bone sarcoma. Peaks in adolescents during growth spurts. Classically arise from the metaphysis of the distal femur, proximal tibia or proximal humerus.
What is chondrosarcoma?
Malignant tumour of cartilaginous origin. Arises from diaphyseal-metaphyseal region of long bones.
Common in males aged 30-50.
What is Ewing’s sarcoma?
Highly malignant tumour occuring in children.
Arises from mesenchymal cells of medullary cavity.
Arises at diaphysis of long bones and flat bones like pelvis.
Which cancers commonly causes bony metastases?
Breast Prostate Thyroid Renal Lung
In a hip fracture in which the blood supply to the femoral head is preserved how could it be fixed?
Fix with screws and plate
What are the complications of a hip fracture and treatment?
Fixation can fail if poorly done.
Hemiarthroplasty may dislocate if a patient falls or if the capsule and surrounding tissue give way.
Important to mobilise patients as soon as possible to prevent DVT, chest infections and pressure sores.
What is the post-op management of a patient with a hip fracture?
Physiotherapists - mobilise patient with appropriate walking aids.
Occupational therapists -assess safety of patient to function at home.
Care of elderly medicine team - assess general health and any underlying cause for fall.
Home care - may be required after discharge.
Patient may not be able to return home.
Which bones are scanned in a DEXA scan?
Lumbar spine
Hip
Which structures are at risk of damage in a pelvic fracture?
Bowel Bladder Female genital organs Male prostate/urethra Nerves
What is the management of pelvic fractures?
Immediate management: pelvic binder
Definitive management: plates and bolts
Which fracture are hip dislocations often associated with?
Acetabular fracture
What are the risks associated with hip dislocations?
Damage to local nerves - sciatic if posterior.
Avascular necrosis of native femoral head.
Post-traumatic arthritis in native hip.
Which artery is at risk of damage in knee dislocations?
Popliteal artery
What is the management of knee dislocations?
Reduce and splint
Angiogram
Multiple ligament reconstruction
Name a risk associated with fracture of the femur.
Hypovolaemic shock
What is emergency management of the fracture of the femur?
Reduce and splint
Thomas-type splint - fixed traction.
What is the surgical management of fracture of the femur?
Intramedullary nail
Plates may be used
How long does a femoral shaft fracture generally take to heal?
4 months
How are fractures of the proximal tibia investigated?
CT scan
What is the management of a fracture of the tibial shaft?
May be treated in cast if undisplaced.
May require fixation for early mobilisation.
What risk is associated with fracture of the tibial shaft?
Compartment syndrome.
What is the clinical examination for compartment syndrome?
Pain on passive movement of distal extremity.
What would a compartment pressure monitor show in compartment syndrome?
Difference in <30mmHg between compartment pressure and diastolic blood pressure
What is the management of compartment syndrome?
Fasciotomies - all 4 compartments in leg.
Secondary closure - +/- skin grafting.
Which part of the bone do fractures of the distal tibia affect?
Metaphyseal bone
How should distal tibia fractures be assessed?
CT scan
How are distal tibia fractures managed?
Reconstruct joint to reduce risk of osteoarthritis.
What is the name of the structure between the distal tibia and fibula?
Syndesmosis
How do you know if an ankle fracture is stable or unstable?
Damage to one side or both sides of joint.
Disruption to ankle joint mortice.
How are ankle joint fractures stabilised?
Internal fixation
What are the main dangers of an unreduced ankle joint?
Pressure on skin and soft tissues - may make surgery difficult if skin breaks down or swells/blisters.
Pressure damage to articular cartilage of ankle joint surface - arthritis of ankle.
What are the areas of the foot?
Hindfoot - calcis/talus
Midfoot - navicular/cuboid/cuneiforms
Forefoot - metatarsals/phalanges
What is the risk with a fracture of the talus?
Blood supply passes along neck of talus. Risk of avascular necrosis if fracture displaced.
May require fixation if displaced.
What is a lisfranc fracture?
Dislocation of midfoot between tarsal bones and base of metatarsals.
Requires reduction and fixation.
Which nerves provide sensation to ankle and foot?
L3-S2
check diagram for regions
What are the compartments of the leg?
Anterior
Lateral
Superficial Posterior
Deep posterior
Which nerve is in the anterior compartment of the leg?
Deep peroneal nerve
Which nerve is the lateral compartment of the leg?
Superficial peroneal nerve
Which nerve is in the superficial posterior compartment of the leg?
Tibial nerve
Which nerve is in the deep posterior compartment of the leg?
Tibial nerve
What is a high foot arch called?
Cavus
What is a flat foot called?
Planus
what are the movements of the ankle joint?
Dorsiflexion
Plantar flexion
What are the movements of the subtalar joint?
Inversion
Eversion
Name two deformities of the big toe.
Hallux valgus
Hallux rigidus
Name three deformities of the lesser toes.
Mallet toe
Hammer toe
Claw toe
What is the differential diagnosis for pain under the forefoot?
Overload from tight calf Fracture Morton's neuroma Freiberg's infarction Secondary to first ray pathology
What is the differential diagnosis for lateral ankle pain?
Peroneal tendon pathology
Lateral ligament
Subtalar joint arthritis
What is the differential for medial ankle pain?
Deltoid ligament injury
Tibialis posterior tendinopathy
Osteoarthritis
What is the differential for anterior ankle pain?
Osteophytes impingement
Osteoarthritis
Loose bodies
What is the differential diagnosis for posterior ankle pain?
Achilles tendon problems - ruptures, tendinopathy.
Os trigonum
Sub talar osteoarthritis
What is the treatment for hallux valgus?
Non-operative:
- accommodative shoes
- orthotics
Operative - osteotomy
What are the indications for an osteotomy to treat hallux valgus?
Failed non-operative
Pain
Skin compromise
Not for cosmesis.
What is hallux rigidus?
1st MTPJ osteoarthritis
Pain, stiffness, prominent bump.
What is the non-operative treatment for hallux rigidus?
Accommodative footwear
Rocker sole
Orthotics
What is the operative treatment for hallux rigidus?
Cheilectomy - for mild cases, treats the bump
Fusion - gold standard. Eliminates the joint and related pain.
What are the non-operative treatments for ankle arthritis?
Analgesia
Activity modification
Splints/supports
Injection
What are the operative treatments for ankle arthritis?
Fusion - eliminates movement
Replacement - maintains movement - can wear/loosen
What is subluxation?
Partial displacement - some continuity maintained
What is the name of the classification system for open fractures?
Gustillo-Anderson
What is a type I Gustillo-Anderson fracture?
<1cm skin wound
What is a type II Gustillo-Anderson fracture?
1-10cm skin wound
What is a type III Gustillo-Anderson fracture?
> 10cm wound or high energy fracture
What do types A, B and C means in a type III Gustillo-Anderson fracture?
A - adequate tissue for coverage.
B - extensive periosteal stripping and requires flap
C - vascular injury requiring vascular repair
What are the complications of open fractures?
Soft tissue infection Osteomyelitis Tetanus Crush syndrome Skin loss Non-union Amputation
What is the emergency department management of open fractures?
Control the bleeding Cover with sterile dressing Splint IV antibiotics Tetanus prophylaxis Assume any wound over or near a joint extends to the joint until proven otherwise.
Which pathogens usually cause septic arthritis?
Staph. aureus
Beta haemolytic streptococci
Streptococcus pneumoniae
What is the aetiology of septic arthritis?
Direct inoculation Trauma Iatrogenic Hematogenously Adjacent osteomyelitis Soft tissue infection
What are the clinical features of septic arthritis?
Rapid onset Joint pain Joint swelling Joint warmth Joint erythema Fever Decreased range of motion Pain with active and passive ROM
What is the management of septic arthritis?
Aspiration of joint - evidence that serial aspiration is as effective as surgical lavage.
IV antibiotics - tailored to infecting organism sensitivies. May require several months of treatment.
Washout of joint - arthroscopic or open
What are the complications of septic arthritis?
Rapid destruction of joint with delayed treatment (>24 hours) Degenerative joint disease Soft tissue injury Osteomyelitis Joint fibrosis Sepsis Death
What is the management of periprosthetic septic arthritis?
Aspiration in theatre
Debridement and implant retention can be effective
May require single or two stage revision.
What is compartment syndrome?
A condition where the intra-compartmental pressure in a fascial compartment becomes elevated beyond the capillary perfusion pressure.
What are the clinical features of compartment syndrome?
Pain Paresthesia Pallor Paralysis Pulselessness Pressure
What is necrotising fasciitis?
Life threatening bacterial infection of subcutaneous fascia.
What is the common infecting organism in necrotising fasciitis?
Group A strep.
What is the management of necrotising fasciitis?
Urgent surgical debridement of affected tissue.
High dose broad spectrum antibiotics.
What is cauda equina syndrome?
A syndrome where a space occupying lesion (usually a disc prolapse) within the lumbosacral canal puts pressure on the nerves of the cauda equina.
What are the symptoms of cauda equina syndrome?
Bowel/bladder dysfunction
Saddle aneasthesia
Lower sensorimotor changes.
What can be found on examination of a patient with cauda equina syndrome?
Reduced or absent sensation to pin prick in S2-S4.
Decreased/absent anal tone
What are the investigations of cauda equina syndrome?
Pre and post voiding bladder scan looking for retention and incomplete bladder emptying.
Emergent MRI scan.
What is the treatment for cauda equina syndrome?
Urgent surgical decompression within 24 hours of symptom onset.
If cord compression due to malignancy discuss with oncology as may be treated with radiotherapy.
What are the complications of cauda equina syndrome due to delayed presentation or decompression?
Urinary dysfunction, requiring catheterisation.
Sexual dysfunction
Chronic pain
Persistent leg weakness/altered sensation.
