MSK key points Flashcards
What classifcation system is used to grade open fractures?
Gustilo
What is an open fracture?
fracture with direct communication to the external environment
What are the features of a type I open fracture
simple fracture
wound <1cm
What are the features of a type II open fracture
simple fracture 1-10cm
What features automatically make an open fracture grade III
farmyard contamination neurovascular compromise periosteal stripping comminuted fracture >10cms
What are the features of a type IIIa open fracture
comminuted fracture
high energy mechanism
covered from existing tissue on repair
What are the features of a type IIIb open fracture
comminuted
needs plastic surgery
periosteal stripping
What are the features of a type IIIc open fracture
neurovascular compromise
comminuted
What is the immediate management of an open fracture
cannulate - bloods, analgesia, antiemetics, fluids assess neurovascular status!!! remove obvious contamination take photos cover with saline dressing realign and splint recheck neurovascular status!!! tetanus status x ray NBM call orthopaedic reg, anaesthetist and plastic surgeon drug chart - antibiotics, analgesia, fluids, antiemetics, thromboprophylaxis surgery within 24hrs
What are the indications for immediate surgery in an open fracture
neurovascular compromise
farmyard contamination
compartment syndrome
What does a higher grade of open fracture increase the risk of
infection
amputation
longer healing time
Why does periosteal stripping often result in non-union
the bone relies on the periosteum to provide a blood supply for healing
How can the risk of infection be decreased in an open fracture
antibiotics!
surgical debridement
What is septic arthritis?
acute infection of a joint capsule
What can cause septic arthritis
bacteraemia
direct inocculation
contiguous spread from adjacent osteomyelitis
What are the risk factors for septic arthritis
>80y diabetes HIV immunosupression recent joint surgery IVDU history of crystal arthropathies
Which joints are commonly affected by septic arthritis
knee hip shoulder elbow ankle
Which joint is commonly affected in IVDUs with septic arthritis
sternoclavicular
Which organisms are commonly present in septic arthritis
Staphylococcus aureus
Stahpylococcus epidermis
Neisseria gonorrheae
What are the signs and symptoms of septic arthritis
pain effusion erythema tenderness warmth inability to weight bear inability to complete full range of passive movements
Describe the pathophysiology of septic arthritis and what makes it an emergency
acute irreversible destruction of the cartilage at joints by proteolytic enzymes from inflammatory cells
can be within 8 hours
What are the differential diagnoses in septic arthritis
gout
pseudogout
cellulitis
What investigations need to be done in suspected septic arthritis
FBC, CRP, ESR
blood cultures
xray joint
joint aspiration
What are the findings on xray in septic arthritis
joint space widening
periarticular osteopenia
What are the tests you want to do on the joint aspirate in septic arthritis
cell count gram stain culture glucose leve; crystal analysis
What cell count is diagnostic for septic arthritis in joint aspiration?
WCC >50000
>1000 if there is a joint replacement
What is the management of septic arthritis
urgent surgical irrigation and debridement
IV abx for 3-4weeks
What is a fragility fracture?
fractures that result from mechanical forces that would not ordinarily result in fracture, known as low-level (or ‘low energy’) trauma
Define compartment syndrome
increased pressure within a myofascial compartment that exceeds capillary perfusion pressure, which exceeds the venous pressure and so impairs blood outflow. Lack of oxygenated blood and accumulation of waste products results in muscle ischaemia
What are the causes of compartment syndrome
trauma tight bandages/casts crush injuries extravasation of IV fluids post ischaemic swelling after revascularisation
What are the early symptoms of compartment syndrome
pain out of proportion
How do you test for pain on passive stretch of the calf?
moving the big toe upwards stretches flexor hallucis longus (FHL) in the deep flexor compartment of the calf;
moving the big toe downwards stretches extensor hallucis longus (EHL) in the anterior compartment
What are the signs of compartment syndome
pain on passive stretch of compartment
swollen and tense leg
What are the late signs and symptoms of compartment syndrome
pins and needles
paresthesia
loss of sensory function
absent pulses
When measuring the compartment pressure, what pressure counts as compartment syndrome
> 40mmHg
What is teh treatment for compartment syndrome
release any external compression
Fasciotomy
IV fluids - risk of myoglobinuria causing AKI
Describe the fasciotomy in the treatment of compartment syndrome
The muscle compartments are decompressed via long incisions along the limb, opening the skin, fat and fascia. If pressure is elevated, the muscle bulges out through the incisions.
The wounds are not closed at the initial operation. Instead, the swelling is allowed to settle and the patient is returned to theatre after 48–72 hours for a second look.
If the skin can be closed without tension this is done. If not, skin grafts may be required.
Which injuries most commonly cause compartment syndrome
supracondylar fractures of the humerus
tibial shaft injuries.
What can happen if compartment syndrome is missed
muscles undergo necrosis
leads to irreversible scarring and contraction of muscles
= Volkmann’s ischaemic contracture
What is the pathophysiology of developmental dysplasia of the hip
shallow and underdeveloped acetabulum
leads to subluxation and dislocation of the hip
How are babies examined for DDH
barlow
ortalani
galezzi
How is the barlow test done
adduct and depress flexed femur
+ve = dislocates posteriorly
How is the ortalani test done
abduction and elevation flexed femur
+ve = reduction
What is the galezzi sign?
patient supine
knees and hips flexed, feet on table
look at knee heights
if one knee lower = dislocation of that hip causing leg shortening
What is the treatment for DDH
pavlick harness
What is the proper name for club foot
Talipes equinovarus
How is teh foot positioned in talipes equinovarus
inverted
plantarflexed
How is club foot treated
Ponseti method = manipulation and progressive casting
Describe the mechanism of action of bisphosphonates
inhibit bone reabsorption by osteoclasts
Name a bisphosphonate
alendronic acid
When are bisphosphonates prescribed
osteoporosis
prevention of steroid induced osteoporosis
How should alendronic acid be taken
30 minutes before any other food and drink
with large glass of plain water
standing/sitting
remain upright for 30 mins afterwards
When might alendronic acid be contraindicated
Abnormalities of oesophagus;
hypocalcaemia;
other factors which delay emptying (e.g. stricture or achalasia)
What are the common side effects of alendronic acid
indigestion, abdominal pain, bloating, wind (flatulence), acid regurgitation, feeling sick (nausea) Diarrhoea Constipation Headache, muscle or joint pain Feeling dizzy, itching
What are some serious side effects of alendronic acid
gastric ulcers
osteonecrosis of the jaw or ear
increased risk of atypical stress fractures of the proximal femoral shaft
Severe oesophageal reactions (oesophagitis, oesophageal ulcers, oesophageal stricture and oesophageal erosions)
What advice should be given to patients who are taking alendronic acid
report any thigh, hip, or groin pain to a doctor
maintain good oral hygiene, receive routine dental check-ups, and report any oral symptoms - osteonecrosis of jaw
report ear pain, discharge from ear or an ear infection
to stop taking alendronic acid and to seek medical attention if they develop symptoms of oesophageal irritation such as dysphagia, new or worsening heartburn, pain on swallowing or retrosternal pain.
When are NSAIDs contraindicated
Active gastro-intestinal bleeding;
active gastro-intestinal ulceration;
history of gastro-intestinal bleeding related to previous NSAID therapy;
history of gastro-intestinal perforation related to previous NSAID therapy;
history of recurrent gastro-intestinal haemorrhage (two or more distinct episodes);
history of recurrent gastro-intestinal ulceration (two or more distinct episodes);
severe heart failure - due to impairment of renal function
Describe the mechanism of action of NSAIDs
inhibition of COX2 enxyme
decreased prostaglandin synthesis
decreased pain and inflammation
What affect does NSAID use have on the CVS
increased risk of thrombotic events eg MI, stroke
How are NSAIDs most safely prescribed
The lowest effective dose
for the shortest period of time to control symptoms
the need for long-term treatment should be reviewed periodically.
What are the different mechanisms of fracture healing
primary
secondary
describe primary fracture healing
can only occur if there is absolute stability
intramembranous ossification occurs with internal Haversian remodelling
describe secondary fracture healing
occurs with relative stability and fixation
callus formation, endochondral healing
Describe the stages of endochondral fracture healing
haematoma - inflammatory cascade and granulation tissue
soft callus - fibroblasts and chondroblasts lay down fibrous tissue and cartilage. intramembranous ossification to close gap
hard callus - endochondral ossification of callus to form woven bone
remodelling - woven to lamellar, sufrace erosion and osteonal remodelling
How long does is take for each of the stages of endochondral fracture healing to occur
haematoma - 1-7d
soft callus - 2-3weeks
bony callus - 3-4m
remodelling -
What can delay fracture healing
poor blood supply diabetes smoking - nicotine steroids NSAIDs Ischaemia: poor blood supply or AVN infection interfragmentary strain Interposition of tissue between fragments Intercurrent disease: e.g. malignancy or malnutrition
What can be used to stimualte fracture healing
bone morphogenetic protein - member of TNF beta superfamily
When is open reduction and internal fixation of a fracture required?
intra-articular #s Open #s 2 #s in 1 limb Failed conservative Rx Bilat identical #s
Why do we fixate fractures
fixation increases strain leading to bone formation
Fixation also decreases pain, and increases stability and ability to function
What are the principles of rehabilitation after a fracture
Immobility decreases muscle and bone mass and leads to joint stiffness
Need to maximise mobility of uninjured limbs
Quick return to function reduces later morbidity
What neurological complication does a humeral shaft fracture lead to
radial nerve palsy
unopposed flexion of wrist = wrist drop
loss of sensation over posterior forearm and hand
Describe Erb’s palsy
waiter’s tip
arm adducted and internally rotated, wrist flexed
due to damage to C5/C6 over stretch of neck
What antibiotics be given after an open fracture
co-amoxiclav 1.2g within 3 hours
What is the relevance of the mangled extremity score?
used to distinguish between salvageable and doomed limbs in lower extremity fracture
How do you test the function of the median nerve in the hand
abduction of thumb (up to sky)
dorsal surface middle finger
How do you test the function of the radial nerve in the hand
extension of thumb at interphalangeal joint
interdigital webbed space between thumb and index
How do you test the function of the ulnar nerve in the hand
abduction of index finger
dorsal surface of little finger
How do you test the function of the FDS tendon
hold other fingers flat in extension, palm up
ask pt to bend fingers
+ve = flexion at PIP
How do you test the function of the FDP tendon
hold middle phalanx of finger
ask pt to bend finger
flexion at DIP
How do you test the function of the Flexor carpi ulnaris tendon
ulnar deviation at wrist against resistance
How do you test the function of the Flexor carpi radialis tendon
radial deviation at wrist
How do you test the function of the flexor pollicis longus tendon
flexion at IPJ of thumb
How do you test the function of the extensor digitorum tendon
extension at MCP
How do you test the function of the extensor indicis tendon
palm flat on table
lift index finger
How do you test the function of the extensor digiti minimi tendon
palm flat on table
lift little finger
How do you test the function of the extensor pollicis longus tendon
extension of thumb at IPJ
What deformity does cutting the ulnar nerve at the wrist cause
ulnar claw
in medial 2 digits
hyperextension at MCP, flexion at IPJ
What muscles groups cause the problems in ulnar claw
loss of innervation to ulnar lumbricals
would normally flex at MCP and extend at IPJs
loss of innervation leads to unopposed extension at MCP by extensor digitorum and flexion at IPJs by FDS and FDP
If the ulnar nerve is cut higher up the arm, why is the ulnar claw less pronounced
loss of innervation to the FDP
loss of flexion at DIPJ
less pronounced flexion!
What does the nottingham n=hip fracture score used for
used to calculate risk of death following #NOF using pre-op patient characteristics
What parameters does the nottingham hip fracture score use
age sex AMTS Hb on admission residence - ?living in an institution comorbidities - >2 active malignancy in last 20y
why is lactate measured in #NOF
prognostic indicator
>3mmol/l on admission is a sign of high risk of death
What do you need to find out on clerking a #NOF
neurovascualr status of limb drug history past medical history - cardiac/lung probs prev cancer MSE
What investigations should be done in #NOF
ECG
FBC, U+E, glucose, G+S, cross match, bone profile
AP and lateral pelvis. full length femur if ?cancer
CXR pre-op
whihch vessel is at risk of being damaged in an intracapsular #NOF
medial femoral circumflex
What is the immediate management of a #NOF
analgesia + antiemetic IV FLUIDS mechanical prophylaixis LMWH (unfractionated if renal probs) - stop 12hrs pre-op surgery within 48hrs
What is the management of an undisplaced intracapsular #NOF
internal fixation - dynamic hip screw
What is the management of an displaced intracapsular #NOF
if uoung and fit - fynamic hip screw
if mobilise with no more than stick, no cognitive impairment, medically fit for op = THR
if mobilise with more than stick, frail, chronic health probs = hemiarthroplasty
What is the management of an extracapsular #NOF
sliding hip screw
What is the 30 day hospital mortality of #NOF
10%
What is the 12 month mortality of #NOF
30%
What is the normal volar tilt at the wrist
how is this measured?
11 degrees
lateral xray, from perpendicular line through long axis of radius
to tangent along radial articular surface
What is the normal radial inclination at the wrist
how is this measured?
22 degrees
AP xray from perpendicular line through long axis of radius
to line from most distal point of radial styloid to distal most point of ulnar articular surface
What is the normal relationship between the distal radius and ulnar
11mm between line perpendicular to tip of radial styloid
and line perpendicular to distal articular surface of ulnar head
= radial length
What does deformity of the wrist joint after a fracture lead to in the long term
shortening leads to instability
loss of radial inclination lead to pain
loss of volar tilt leads to reduced mobility
What is a Galezzi fracture?
Isolated fracture of the distal radius shaft with disruption of the distal‐radio‐ulnar joint
What is a Monteggia facture
isolated proximal third ulnar fracture with dislocation of the radial head
The radial head should be aligned with the capitellum, and on an elbow X‐ray (AP or lateral) a line drawn up the shaft of the radius should transect the middle of the capitellum (known as the radiocapitellar line).
What is a Colles fracture
simple extra‐articular transverse fracture of the distal radius one inch (2.5cm) from the joint line with dorsal displacement and a ‘dinner‐fork deformity’
What is a smith’s fracture
extra‐articular fracture of the distal radius with palmar displacement
What is a Barton’s fracture
a partial intra‐articular fracture in which either the dorsal or palmar rim of the radius is left intact
How are distal radius fractures managed
Undisplaced extra‐articular fractures = below‐elbow cast for a total of 6 weeks.
displaced extra‐articular = closed reduction may be attempted with a trial of conservative treatment in plaster. there is a risk of redisplacement! so monitor with weekly X‐rays. If there is sig-nificant instability, K‐wires may be used to hold the distal fragment in position.
Intra‐articular fractures require anatomical reduction by ORIF using a plate and screws
What are the red flag symptoms for back pain
>65 thoracic pain recent cancer fever weight loss night sweats night pain neurological sx
State the yellow flags for back pain
A negative attitude that back pain is harmful or potentially severely disabling
Fear avoidance behaviour and reduced activity levels
An expectation that passive, rather than active, treatment will be beneficial
A tendency to depression, low morale, and social withdrawal
Social or financial problems
What are yellow flag symptoms
pyschosocial factors shown to be indicative of long term chronicity and disability
define radiculopathy
compression of a nerve root leading to shooting pain, numbness or weakness
= sciatica!
describe the pathophysiology of disc hernitaion
annulus fibrosis degeneration, splits
nucleus pulposus herniates out
What are the signs and symptoms of L4 disc compression
weakness of ankle dorsiflexion
loss of sensation on medial aspect lower leg
loss of patellar reflex
What are the signs and symptoms of L5 disc compression
weakness of great toe dorsiflexion
loss of sensation to lateral aspect lower leg and dorsum of foot
What are the signs and symptoms of S1 disc compression
weakness of ankle plantarflexion
loss of sensation to sole of foot
loss of ankle reflex
What is the management of a disc hernation
conservative
MRI if >6 weeks of symptoms
consider discectomy if sx have lasted >3m
What can cause cauda equina
disc herniation spinal stenosis cancer trauma epidural abscess
Describe the pathophysiology of cauda equina
compression of cauda equina LMN L2-34
What are the examination findings in cauda equina
palpable bladder - due to urinary retension lower extremity weakness or sensory loss decreased leg reflexes perianal loss of sensation decreased rectal tone on DRE
What is the investigation and management of cauda equina
MRI
urgent surgical decompression <48Hrs
What can cause spinal stenosis
osteophytes
hypertrophic ligamentum flavum
spondylolisthesis
bulging disc
DEscribe the pathophysiology of spinal stenosis
narrowing of spinal canal and neural foramina leads to root ischaemia and neurogenic claudication
What tumours can occur in the spine
primary - mulitple myeloma
secondary - breast, prostate, lung, kidney, thyroid
which tumours most commonly metastasis to bone
breast prostate kidney thyroid lung
What makes a vertebral fracture unstable
if more than one of the columns of the spine are fractured
What makes up the ankle ring
medial malleolus deltoid ligament calcaneus lateral ligaments lateral malleolus syndesmosis tibial plafond
Name the lateral ligaments of the ankle joint
anterior talofibular - most important for stability!
posterior talofibular
calcaneofibular
Describe the Weber classification
A - # below level of syndesmosis, deltoid intact
b - # at level of syndesmosis
C - # above level if syndesmosis
What features deem an ankle fracture to be unstable
presence of a medial malleolar fracture,
presence of a posterior malleolar fracture
presence of talar shift.
Describe the management of an ankle fracture
weber A - stable so weight bearing below knee cast or boot
Weber B - stable :non‐weightbearing below‐knee cast for 6–8 weeks
- unstable: ORIF
Weber C - ORIF
What are the actions of the rotator cuff muscles
supraspinatus - first 30 degrees abduction
infraspinatus - external rotation
teres minor - external rotation
subscapularis - internal rotation
How do you test the rotator cuff muslces
supraspinatus - empty can test
infraspinatus and teres minor - resisted external rotation
subscapularis - belly press
What is a Bankart lesion
loss of anterior/inferior portion of glenoid labrum due to dislocation of head of humerus anteriorly
What is a Hil-sachs lesion
depession in posterosuperior head of humerus due to hitting glenoid rim causing chondral impaction injury
Calcualate the beighton score
extension little finger beyong 90 degrees /2
extension elbow >10 /2
thumbs to flexor surface /2
hyperextension knees /2
touch floor with hands flat with straight knees /1
> 4 = abnormal
Describe how to do a Hawkin’s test and what it shows
shoulder flexion to 90
elbow flexed to 90
move forearm down
pain = subacromial impingement
How should i assess a bite injury?
when/what/how location and depth ?damage to nerves, vessels or tendons /redness, swelling, discharge, cellulits lymphadenopathy or fever ROM of adjacent joints tetanus profile
What immediate management should be given in a bite injury
analgesia
tetanus prophylaxis
irrigation
Abx - co-amoxiclav or doxycycline+metronidazole
What is the most common infection due to a bite injury
Pastuerella multocida
How might a displaced tibial shaft fracture be managed?
reduction and stabilisation.
Intramedullary nailing - nail is inserted proximally, through or adjacent to the patellar tendon.
The nail allows the patient to be free of plaster, and depending on fracture configuration, weightbearing may be allowed immediately!
How might an undisplaced tibial shaft fracture be managed?
above‐knee cast for 6–8 weeks
converted to a below‐knee cast for a further 6–8 weeks.
Regular monitoring with X‐rays is essential to ensure alignment is maintained
What is the difference between an upper and lower motor neuron lesion
UMN - within spinal cord, cellbody in cortex/brain stem
present with increased tone, hyperrelfexia, extensor plantar response
LMN - outside spinal cord. cell body in ventral horn of spinal cord
presents with decreased tone, weak reflexes, normal plantar reflex, fasciculations
What is the difference between nerve root impingement and peripheral nerve entrapment
nerve root impingement - affects dermatomes/myotomes of the nerve root
peripheral nerve entrapment - signs are in distribution of perioheral nerve
What is myelopathy
compression of the spinal cord
should you xray patients with back pain
do not xray to diagnose non-specific mechanical back pain if no red flags to suggest malignancy or infection
What is a root block
injection of local anaesthetic adn steroid into nerve root as it exits vertebral foramen
What is an epidural
epidural needle inserted into epidural space between ligamentum flavum and dura to administer anaesthetic
What are the signs of RA on xray
loss of joint space juxtaarticular osteopenia joint deformity soft tissue swellings marginal erosions
What questions need to be asked in a history of OA
pain - site, intensity, timing, aggravating, relieving night pain stiffness neuro probs? - tingling, weakness ADLs - walking, shoes and socks, wa;king aids prev surgery prev trauma occupation
When asking about PMH what is it important to know about eh conditions
how long they’ve had it
how was it picked up
what the treatment is
how well controlled
What should i look for on examination in OA
muscle wasting varus/valgus pelvis tilted antalgic gait/Trendelenberg walking aids scars external rotation fixed flexion adduction contracture
reduced ROM
pain on movement
How should a walking stick be held
on contralateral side, furthest point away from body
takes weight off affected side and help to balance
What should be done at pre-assessment clinic
consent form drug histroy - change/stop pre-op? write drug chart up allergies? reaction to anaethetic? general examination ECG, urine dipstick, BP, height and weight FBC, U+E, HbA1c, G+S, xray joint, CXR
MRSA screen!!!!
What are the risks of THR
infection 1% DVT 15% with prophylaxis PE death <1% in 30 days blood trasnfusion - 10-15% no relief of pain bleeding damage to nerves dislocation re-operate due to wear
What is the 30 day mortality following THR
30%
What is the risk of infection following THR
1%
What should be prescribed on the srugs chart pre-op in THR
LMWH SC 6pm on day of surgery TED stockings analgesai regular meds prophylactic Abx laxatives - fybogel and senna antiemetics
What antibiotics are given prophylactically in THR
IV co-amoxiclav in induction room on day of surgery
then at 8h and 16h post op
If the patient is penicillin allergic, What antibiotics are given prophylactically in THR
IV teicoplanin and gentamicin in induction room
only given once
On teh day of surgery what question should you ask the patient when you review them on the ward
how have you been? doctor/dentist visits check procedure + understanding check consent form check NBM have they taken meds today? baseline obs examine joint check blood results check drug chart
What is hte plan post THR
obseve every 4 hours pain relief FBC/U+E after 2 days thromboprophylaxis IV Abx xray mobilse wound check
What is the suggested management of OA
weight loss, given advice about local muscle strengthening exercises and general aerobic fitness
first line = paracetamol and topical NSAIDs - only for OA of the knee or hand
second-line treatment = oral NSAIDs/COX-2 inhibitors, opioids, capsaicin cream and intra-articular corticosteroids. A proton pump inhibitor should be co-prescribed with NSAIDs and COX-2 inhibitors.
non-pharmacological treatment options include supports and braces, TENS and shock absorbing insoles or shoes
if conservative methods fail then refer for consideration of joint replacement
What tests should he done in a patient with suspected bone metastasis
ECG
FBC, U+E, PTH, calcium, phosphate, ALP, CRP, ESR
xray, urine electrophoresis
CTCAP
Nasme some primary bone cancers
multiple myeloma
osteosarcoma
ewing’s sarcoma
chondrosarcoma
What is the most common site for osteosarcoma
proximal tibia
distal femur
Which bone tumours are common in children
osteosarcoma
chondrosarcoma
Describe hallux valgus
medial deviation first metatarsal
lateral deviation proximal phalanx of great toe
DEscribe hallux rigidus
OA of first MTPJ
dorsal osteophytes adn irregular joint articulation
What causes flat foot?
physiological
tibialis posterior insufficiency, would normally attach to plantar surfaceof midfoot bones to maintain arch
What are the signs of flat foot
loss of longitudinal arch
-ve heel raise test
too many toes sign - abduction forefoot
valgus hindfoot
What is seen on examination of Tennis elbow
tenderness at lateral epicondyle
pain on resisted wrist extension
What is seen on examination of Golfer’s elbow
tenderness at medial epicondyle
pain on resisted pronation and wrist flexion
What can cause greater trochanteric pain syndrome
tendinopathy gluteus medius
muscular tear gluteus medius
trochanteric bursitis
Describe the symptoms of greater trochanteric pain syndrome
pain on lateral side of leg - worse on lying on side or with activity
What can cause osteomyelitis
haematogenous spread
direct inoculation
contiguous spread
What organism most commonly causes osteomyelitis
Staphylococcus aureus
Describe the pathophysiology of osteomylitis
infection of bone leading to progressive inflammatory destruction
What are the most common sites for osteomyelitis to occur. Why?
adults: spine
children: proximal tibia, distal femur
slow blood flow!
What are the risk factors for osteomyeleits
diabetes steroids immunosupression IVDU renal disease children vascular/neurological compromise
How are acute, subacute and chronic osteomyelitis defined?
<2weeks
subacute one-3m
chronic >3m
What are the symptoms of osteomyelitis
pain, worse on movement
fever
immobile limb
What are the signs of osteomyelitis
walk with limp erythema tenderness oedema draining sinus tract if chornic effusion of neighbouring joints
What investigations should be done in osteomyelitis
urine dipstick
FBC, U+E, CRP
blood culture
xray
What is seen on xray in osteomyelitis
lytic lesions surrounded by sclerosis
sequestrum in centre = dead devitalised detached bone
involucrum = new bone that form around the sequestrum
What is the management of osteomyeleits
conservative: IV Abx for 3-6 weeks Flucloxacillin
operative: irrigation and debridement
Hoe should a fracture be described on xray
Pattern - transverse, oblique, spiral Angulation Rotation Translation Shortening (impaction if no loss of alignment)
Describe the features of slipped upper femoral epiphysis
pain in hip/groin/medial thigh/knee
acute: cannot walk/stand, ext rot, reduced ROM
What are the risk factors for slipped upper femoral epiphysis
obesity
hypothyroid
Describe the management of slipped upper femoral epiphysis
immobilise
analgesia
screw fixation across growth plate
What is a Salter Harris fracture
one that occurs across a growth plate
Describe a type I Salter Harris #
transphyseal slip
stem cells undamaged
growth disturbance unlikely
Describe a type II Salter Harris #
along growth plate, extends into metaphysis
stem cells undamaged
growth disturbance unlikely
Describe a type III Salter Harris #
along growth plate, extends into epiphysis
risk of stem cell damage
angular deformity
Describe a type IV Salter Harris #
crosses growth plate into metaphysis and epiphysis
risk of stem cell damage
angular deformity
Describe a type V Salter Harris #
crush injury of growth plate
stem cells crushed and damaged
complete growth arrest
What is Perthes disease
idiopathic AVN femoral head
collapses, loss of spherical shape
What are the typical features of perthes disease
caucaisan
4-8y
pain in hip/groin
antalgic gait
Describe the stages of Perthes disease seen on xray
initial - widened joint space
fragmentation - crescent sign, subchondral #
reossification - new bone laid down
remodelling
What is the tx of perhtes
activity modification
partial weight bearing
osteotomy if head not contained within acetabulum
pathophysiology of De Quervain’s tenosynovitis
the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed
What are the features of De Quervain’s tenosynovitis
pain on the radial side of the wrist
tenderness over the radial styloid process
abduction of the thumb against resistance is painful
Finkelstein’s test: with the thumb is flexed across the palm of the hand, pain is reproduced by movement of the wrist into flexion and ulnar deviation
