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AKT revision > MSK/Ortho > Flashcards

MSK/Ortho Flashcards

1
Q

what is the pathophysiology of carpal tunnel syndrome?

A

compression of the medial nerve by the carpal tunnel within the wrist

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2
Q

how does carpal tunnel present?

A

tingling/pain/numbness usually of the hand, and within the median nerve distribution - thumb/1st/middle fingers
can present with pain radiating to the forearm
can have muscle wasting in the thenar eminence + weakness of thumb abduction

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3
Q

what are some causes of carpal tunnel?

A

usually idiopathic however can be more likely in -
pregnancy
oedema e.g. HF
lunate fracture
RA

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4
Q

what are two signs on examination of carpal tunnel?

A

Tinels sign - tapping causes parasthesia
Phalens sign - flexion of the wrist recreates the symptomsm

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5
Q

management of carpal tunnel if mild-moderate?

A

wrist splint - at night
corticosteroid inj

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6
Q

management of carpal tunnel if severe?

A

surgical decompression

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7
Q

who should be assessed for osteoporosis risk?

A

women > 65 years
men > 75 years
Those younger with risk factors for poor bone mineral density i.e. px fragility fracture, long term steroid use, history of falls, FH of NOF, hypogonadism, endocrine conditions, RA, low BMI, smoking
ETOH intake

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8
Q

how do you assess risk of oesteoporosis?

A

use a clinical prediction tool such as FRAX or QFracture

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9
Q

how do you interpret the results of the Qfracture score?

A

if 10 year fracture risk if > 10% - DEXA should be arranged

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10
Q

how do you interpret the results of the FRAX score?

A

if risk is orange or red - DEXA to be done

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11
Q

how do you interpret the DEXA scan results?

A

> -1.0 = normal
-1.0 to -2.5 = osteopaenia
< -2.5 = osteoporosis

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12
Q

first line management of patient with confirmed osteoporosis or high risk of fragility fracture?

A

oral bisphosphonates - alendronate, risedronate

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13
Q

management of patient who has had a hip fracture and is then recognised as having high risk of fragility fractures?

A

IV zoledronate - once yearly

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14
Q

What is some general advice to give patients who have osteoporosis or are at risk of developing oesteoporosis?

A

lifestyle changes: a healthy, balanced diet, moderation of alcohol consumption and avoidance of smoking

a sufficient dietary calcium and vitamin D intake: supplementation should be offered to all women unless the clinician is confident they have adequate calcium intake and are vitamin D replete

encourage a combination of regular weight-bearing and muscle strengthening exercise

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15
Q

how should you manage a patients fragility fracture risk who is postmenopausal (or man > 50) and being treated with glucocorticoids?

A

if starting > 7.5mg/day prednisolone or equivalent for the next 3 months - start bone protective treatment at the same time , no need to wait for DEXA scan

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16
Q

how to manage the fragility fracture risk of a patient who is A postmenopausal woman, or a man age ≥50 has a symptomatic osteoporotic vertebral fracture?

A

start oral bisphosphonates straight away
general osteoporosis advice

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17
Q

how long should oral bisphosphonates be commenced for?

A

Plan to prescribe oral bisphosphonates for at least 5 years, or intravenous bisphosphonates for at least 3 years and then re-assess fracture risk.

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18
Q

how do oral bisphophonates work?

A

bind to hydroxyapatite in bone, inhibiting osteoclast-mediated bone resorption

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19
Q

what are some side effects of oral bisphosphonates?

A

gastrointestinal discomfort, oesophagitis, and hypocalcaemia. Atypical femoral fractures and osteonecrosis of the jaw are rare but serious risks.

20
Q

what is the second line management of osteoporosis?

A

IV denosumab

21
Q

how does denosumab work?

A

human monoclonal antibody that inhibits RANK ligand, which in turn inhibits the maturation of osteoclasts

22
Q

how is denosumab given?

A

SC injection ever 6 months

23
Q

how should you manage patients who have a high risk of fragility fractures when calculated by the FRAX score, but have had a DEXA which is more than -2.5?

A

T-score is greater than -2.5, modify risk factors where possible, treat any underlying conditions, and repeat the DXA at an interval appropriate for the person based on their risk profile, using clinical judgement (but usually within 2 years).

24
Q

how should you manage patients who have an intermediate risk of fragility fractures calculated by the FRAX score i.e. their risk is close to the threshold?

A

if they also have risk factors that may be underestimated by FRAX® , arrange a DXA scan to measure their bone mineral density (BMD) and offer drug treatment if the T-score is -2.5 or lower.

25
Q

which bisphosphonates are licensed in men?

A

alendronate (once-daily tablets) and risedronate (once-weekly tablets)

26
Q

what should you do if a patient does not tolerate oral bisphosphonates due to side effects?

A

If an oral bisphosphonate is not tolerated or is contraindicated, consider specialist referral. Specialist treatment options include zoledronic acid, strontium ranelate, raloxifene, denosumab, and teriparatide.

27
Q

what should you prescribe for a patient who has a high fragility risk score, is on oral bisphosphonate and has adequate oral calcium intake?

A

10 micrograms (400 international units) of vitamin D (without calcium) for people not exposed to much sunlight.

28
Q

what should you prescribe for a patient who has a high fragility risk score, is on oral bisphosphonate and has inadequate oral calcium intake?

A

Prescribe 10 micrograms (400 international units) of vitamin D with at least 1000 mg of calcium daily.
Prescribe 20 micrograms (800 international units) of vitamin D with at least 1000 mg of calcium daily for elderly people who are housebound or living in a nursing home.

29
Q

how should bisphosphonates be taken?

A

tablet must be swallowed whole w/ plain glass of water of at least 200mls
30 mins before meals
on an empty stomach
remain upright after taking
must not be taken at bedtime or before getting up in the morning
once weekly preparations should be taken on the same day each week

30
Q

what specific advice should be given to patients who are taking Risedronate regarding how to take them?

A

should be taken 30 mins before breakfast

if this is not practical -

Between meals — should be taken at least 2 hours before or at least 2 hours after any food, other medicinal product, or drink (other than plain water).

In the evening — should be taken at least 2 hours after any food, other medicinal product, or drink (other than plain water).

31
Q

what specific advice should be given to patients who are taking alendronic acid?

A

must be taken at least 30 minutes before the first food, other medicinal product, or drink (other than plain water) of the day.

32
Q

what should you do after a patient has been on bisphophonates for 3-5 years?

A

re-asses risk
if risk remains high - continue treatment with alendronic acid for up to 10 years, and risedronate for up to 7 years

if risk is intermediate or unclear - arrange repeat DEXA scan and review depending on T score results

33
Q

if a patient had an intermediate risk of a fracture, when should they be re-assessed again?

A

minimum 2 years interval

34
Q

a patient presents with pain in the wrist. On examination, she is tender over the base of her right thumb, and also over the radial styloid process. ulnar deviation recreates the pain - what is the diagnosis?

A

De Quervains tenosynovitis

35
Q

what is De Quervains tenosynovitis?

A

swelling and inflammation of the tendon sheath covering the extensor pollicis brevis and abductor pollicis longus tendons

36
Q

what are the symptoms of De Quervains tenosynovitis?

A

pain on the radial side of the wrist
tenderness over the radial styloid process
abduction of the thumb against resistance is painful

37
Q

how can you test for De Quervains tenosynovitis?

A

Finkelstein test - place thumb in closed fist, tilt hand down

38
Q

what is the management of De Quervains tenosynovitis?

A

analgesia
steroid injection
immobilisation with a thumb splint (spica) may be effective
surgical treatment is sometimes required

39
Q

a patient presents with pain at the front of the foot, which is worse on walking, associated with the sensation of having a pebble in the shoe - most likely diagnosis?

A

mortons neuroma

40
Q

what is mortons neuroma?

A

thickening of the tissue that surrounds the digital nerve leading to the toes.

41
Q

which area is most commonly affected in mortons neuroma?

A

third inter-metatarsophalangeal space

42
Q

management of mortons neuroma?

A

usually footwear modifications + analgesia

if ongoing for > 3 months - referral to ortho for consideration of corticosteroid inj or neurectomy of the involved nerve

43
Q

45 year old man presents with 2- day history of groin pain, following playing a rugby match. During the match, he felt the sensation of snapping deep in the groin/hip. able to weight bear, however external rotation particularly limited due to pain. what is the diagnosis?

A

acetabular labral tear

44
Q

management of an acetabular labral tear?

A

physio

Nonoperative trial to include NSAIDs, rest and physical therapy.

Arthroscopic labral debridement versus repair for patients with progressive symptoms who failed nonoperative management.

Rest and activity modification to reduce or eliminate movements that cause pain and aggravate the injury.

45
Q

management of bakers cyst in children?

A

usually no intervention required - resolve spontaneously

if symptomatic - refer to paediatric orthopaedic surgeon

46
Q

management of symptomatic bakers cyst in adults?

A

simple analgeisa
physiotherapy
referral to ortho if particularly large or troublesome

47
Q
A

AKT revision (10 decks)

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