MSK Orthopaedics Flashcards
Haversian system of bones
central Haversian canal surrounded by concentric rings of lamellar bone with embedded osteocytes
canaliculi within the lamellar bone supply blood and allow communication between osteocytes
macroscopic organisation of bone
outer region of compact bone where muscles attach and provides strength and protection
inner trabecular bone which contains bone marrow
assessing a fracture on xray
Describe the qualities of the x-ray (patient details correct? appropriate penetration and view?)
Site of fracture (which bone and which part of the bone? Examine entire cortex for any breaks)
Type of fracture (Transverse, oblique, spiral)
Simple or comminuted?
Displaced or not?
Angulated or not?
Is the bone of normal consistency or not?
general management of fractures
in simple fractures compression can improve bone healing
management options include casts/ splints, intramedullary devices, plates and screws, tension band wires, K-wires and external fixators
in more complicated fractures if the bone is salvageable surgical fixation can be performed; Open Reduction Internal Fixation is the most common method usually with plates and screws
Closed Reduction Internal Fixation can also be done
if bone not salvageable i.e. due to lack of blood supply then joint replacement needed
management of hip fractures
depends on intracapsular or extra capsular
intracapsular fractures can have compromised blood supply so usually need arthroplasty
extra capsular fractures can be fixed with a DHS or IM Nail
management also depends on severity of fracture (graded 1-4) where 1 and 2 can usually be done with screws and 3 and 4 would need a hip replacement
who is considered for a total hip replacement after a fracture
no cognitive impairment and are independently mobile
otherwise a hemi-arthroplasty is done instead just replacing the femoral component and femoral head
osteoarthritis x ray features
Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis
primary osteoarthritis
wear and tear” of the joint
the breaking down and rebuilding the joint tissues starts to become less efficient and joint integrity and function starts to gradually decline
secondary osteoarthritis
arthritis is due to an underlying cause such as rheumatological disease, trauma or infection
basis of management in osteoarthritis
Long term regular exercise and physiotherapy can help combat this with simple analgesia.
If this progresses, this can require orthopaedic intervention for joint replacement
what is septic arthritis
how does it present
infection in the joint fluid or tissues
presents with a single hot, red, swollen joint - needs a low index of suspicion and fast action - can lead to septic shock
management of septic arthritis
rapid referral to orthopaedics
joint aspiration needed and send sample for culture
then start empirical antibiotic treatment flucloxacillin for 4-6 weeks IV. If MRSA suspected, use vancomycin instead and if penicillin allergy, use clindamycin
prosthetic joints should only be aspirated in theatre
osteomyelitis presentation and management
can present similarly to septic arthritis but can also have a more subacute presentation on a background of a local infection
flucloxacillin +/- rifampicin for the first 2 weeks (duration about 6 weeks IV abx) (if penicillin allergic, clindamycin +/- rifampicin)
how should all acute swollen joints be managed
aspirate can be a form of treatment and also needs sending for culture, gram stain, cytology, and microscopy which will cover most causes of an acutely swollen joint
differentials acutely swollen joint
septic arthritis
osteomyelitis
crystal arthropathy
inflammatory process
treatment if swollen joint suspected inflammatory cause
intra-articular steroids - but must be avoided if patient unwell/septic
antibody tests useful in synovitis
anti-CCP
rheumatoid factor
typical appearance of the lower limb in a neck of femur fracture
Shortened and externally rotated
gold standard imaging in osteomyelitis
MRI
management of an open fracture
-gross contamination removed
-photograph the wound
-wound should be covered in a saline soaked gauze and the limb should be splinted, usually in a backslab
-IV antibiotics within 1 hour of injury then every 8 hours
-theatre for a wound washout and debridement, and stabilization of the fracture within 24 hours (unless highly contaminated or neuromuscular compromise which need urgent surgery)
neurovascular importance in knee dislocations
high rate of peroneal nerve and popliteal artery injuries as well as ligament injuries
consider CT angiogram to assess for artery involvement
how are soft tissues around joints assessed in injury
MRI
what is a pathological fracture
a fracture of abnormal bone i..e weakened or damaged already
general management of soft tissue injuries
conservative management - splinting and physiotherapy
direct surgical repair
some injuries need reconstruction with new tissue e.g. ACL tears
steps of the WHO analgesic ladder
principles; move up if pain not controlled, move down if signs of toxicity or severe side effects
step 1; non-opioid with or without adjunctive analgesic
step 2; mild to moderate pain opioid with non-opioid
step 3; moderate to severe pain opioid with non-opioid and can adder adjuncts
morphine administration in patient controlled analgesia
usual concentration of morphine is 2mg/ml and the lock-out time is 5 minutes. This means that once the patient has given himself a bolus of 1 mg (or 0.5ml), he/she will not be able to administer a further dose for the duration of the lock-out period
compartment syndrome
pressure within a fascial compartment exceeds the perfusion pressure within the compartment, causing ischaemia of the tissues within the compartment
severe pain after a fracture that’s not controlled by analgesia should raise suspicion
management in severe cases of compartment syndrome
surgical fasciotomy
what is delayed union
what factors contribute
failure to reach bony union at 6 months post injury
Local factors include location (scaphoid, distal tibia and base of 5th metatarsal are at risk due to the blood supply), stability, infection and pattern (segmental fractures are at higher risk)
Systemic factors include diet, Diabetes Mellitus, smoking, HIV and medications such as corticosteroids and NSAIDs.
classification of nerve injuries
Neuropraxia (reversible conduction block due to injury to the axon sheath)
Axonotmesis (disruption to the myelin sheath and the axon)
Neurotmesis (complete nerve division and disruption of the endoneurium)
nerve supply of the muscles of the anterior leg
common peroneal nerve divides into the superficial and deep peroneal nerves.
deep supplies the anterior compartment muscles.
The superficial peroneal nerve is a sensory nerve.
definition of
- osteopenia
- osteoporosis
osteopaenia- bone mineral density one standard deviation below that of an average young subject from the same race and sex
osteoporosis - bone density 2.5 standard deviations below that of a young subject from the same race and sex
fragility fracture
fracture that results from a fall from standing height or less
what is the most accurate clinical sign for diagnosing compartment syndrome
pain exacerbated by passive stretch
what compartment is most commonly affected in compartment syndrome
anterior compartment
fracture of the upper limb with pallor and no pulse in the hand?
suspect brachial artery may be trapped, kinked or torn
if doesn’t resolve after fracture surgically fixed then urgent surgical exploration by vascular of the brachial artery needed
surgery of supracondylar fracture
under GA fracture reduced and held using K wires and a plaster cast
K wires removed in clinic at 4 weeks along with plaster cast and mobilisation now encouraged
immobilisation in paediatric fractures
4 weeks upper limb
6-8 weeks lower limb
what is the growth plate
An area of cartilage which proliferate or enlarges, effectively growing, the leading edge calcifies
significance of a growth plate injury
Growth may cease, the limb is shortened. If asymmetrical with growth on one side deformity and angulation may occur
common paediatric fractures
Wrist, buckle; Clavicle; distal humerus and supracondylar fracture
back pain history
SOCRATES
variation in the day ?inflammatory
acute or insidious onset
duration
cauda equina symptoms?
systemic features ?malignancy
pain from other origin ?renal ?leaking AAA or other abdominal pathology
?immunosuppressed
?occupation and functional impairment
?PMH inc malignancy and trauma
?FHx inc IA
?patient concerns
back pain red flags
- fever
- night sweats
- age <20 or >50
- night pain, constant pain or pain lying flat
- trauma
- weight loss
- reduced appetite
- weakness or numbness
- bladder or bowel involvement
- history of cancer
what is the schober test
test of lumbar flexion for ankylosing spondylitis - pen mark above and below L5 and when patient flexes back (touches toes) fingers should move apart when placed on pen marks
what signs suggest psychological or socioeconomic contributions to back pain
superificial tenderness esp over a wide area
pain on movements that shouldn’t be painful
distraction; able to perform a movement when distracted
regionalisation; symptoms that don’t fit with neuroanatomy
overreaction
non-invasive treatments for mechanical or musculoskeletal back pain
Education warn about red flags
Return to normal activities and avoid bed rest
Avoid precipitants
Physiotherapy and advised to mobilise
what features indicate musculoskeletal or mechanical back pain
lack of red flags
no nerve root tension signs
features of sciatica
most common cause
positive nerve tension signs; i.e. positive straight leg stretch test (can’t raise leg to 90degrees)
shooting pain down leg
most likely due to a prolapsed disc
what patient age are disc herniations more common
<50
in those >60 spinal stenosis is more common
imaging for lumbar disc disease
MRI is imaging of choice - but ensure to match with clincial signs as some can have abnormalities on MRI but no symptoms
X-rays not particularly useful, may show may show degenerative changes such as narrow joint spaces and osteophyte formation but not clinically useful
management for chronic lower back pain
MDT pain management clinic; physio, OT, psychotherapy
can prescribe topical treatments such as capsaicin and lidocaine and also pain modifying treatments such gabapentin and amitriptyline
how does capsaicin work to reduce pain
reduces substance P in small nociceptors
what injections can be given in chronic lower back pain
corticosteroid injections for facet joint pain
epidural injections for radicular symptoms (nerve root)
what is TENS?
how is it used in back pain
Transcutaneous Electrical Nerve Stimulation
via superficial skin electrodes; stimulates large unmyelinated fibres on the basis that this inhibits transmission of pain via small myelinated fibres
what kind of discomfort do osteoporotic fractures cause
can be minimal even if multiple present
special tests in shoulder examination
empty can test (abduction to 70-80degress in 15 degrees forward flexion and examiner attempts to depress arms) - supraspinatus
lift off test (palms on lower back then lift them off unaided) - subscapularis
scarf test (touch opposite shoulder with hand) - acromioclavicular joint pathology
Hawkins-Kennedy test (at 90 degrees abduciton and elbow flexed then internally rotate shoulder) - supraspinatus impingement
predominant features of rotator cuff disease
pain (esp on abudction between 60 and 120 degrees)
weakness
history of trauma but can also be degenerative
tears can be full or partial and more likely to be full in older age
only symptomatic tears should be treatment and treatment depends on the degree of symptoms
shoulder pain referred from the neck
cervical disc disease or cervical spine stenosis can present with shoulder pain
frozen shoulder
predominant symptom of stiffness particularly of external rotation
initially may have pain but this usually settles
muscles of the rotator cuff
supraspinatus
infraspinatus
subscapularis
teres minor
supraspinatus action and innervation
action - abduction
innervation - suprascapular nerve
infraspinatus action and innervation
external rotation
supra scapular nerve
teres minor action and innervation
external rotation
axillary nerve
subscapularis action and innervation
internal rotation
upper and lower subscapular nerves
USS as a shoulder investigation
not first line but can demonstrate rotator cuff injuries, bursitis and fluid in the joint space
can show movements while assessing
first line investigation in shoulder pathology
plan film xray - rule out bone pathology
MRI in joint pathology
not first line but will demonstrate any soft tissue injury
disadvantage of not being dynamic - i.e. only shows still image
what is cuff arthropathy
torn rotator cuff tendon/muscle pathology means joint not held in place correctly and movements restricted
bone and surrounding tissue not held in place correctly causes pain
rotator cuff injury conservative management
analgesia
physiotherapy to help the deltoid muscle achieve abduction
rotator cuff injury medical management
injection with steroid and local anaesthetic into the subacromial space will act as both analgesia and anti-inflammatory
+ physiotherapy
rotator cuff injury surgical management
repair using sutures and bone anchors to re-attached the torn cuff to the greater tuberosity
subacromial decompression is also usually performed
arthroplasty (shoulder replacement) is sometimes required especially in cases of rotator cuff arthopathy but risks associated and outcome not same as a normal shoulder
what factors to consider if giving injections into joints
Anticoagulation, diabetes (injection could increase blood sugars, higher risk of infection) check systemically well i.e. not on antibiotics, check allergies
also counsel patient:
Failure to work
Infection (1 in 10,000)
Pain
Worsening of symptoms temporarily
Bruising, bleeding, skin dimpling
how does injecting a joint affect opportunity for surgical intervention
precludes surgical intervention with implants for a period of 3 months minimum due to the risk of infection
need to be clear that you definitely don’t want to pursue a surgical option in the near future prior to administering an injection
what large muscles cross the shoulder joint
deltoid
pectoralis major
biceps
triceps
latissimus dorsi
what symptom is caused by a tendon rubbing against nearby tissue
impingement - very painful
what diseases increase risk of a frozen shoulder
diabetes or thyroid disease
what nerve is most commonly injured in shoulder dislocation
axillary nerve - wraps around humerus
test with sensation in the regimental badge area and through deltoid contraction - before and after reduction of a dislocated shoulder
what type of shoulder dislocation is more common
anterior dislocation
features of fibromyalgia
chronic widespread pain; >3 months, found on both sides of the body, above and below the waist and along the axial spine
sleep difficulties and poor concentration/memory are other common features
differential diagnoses in symptoms of fibromyalgia
Endocrine; Addison’s, hyperparathyroid, hypothyroid, vit D def
Infection; HIV, Hep C
Rheum; RA, SLE, polymyalgia reumatica
Malignancy esp lymphoma
also need to exclude synovitis and myositis/muscle weakness
what examination is most useful in diagnosis fibromyalgia
examine 18 recognised ‘tender points’ which exist an 9 pairs spread over the anterior and posterior body
palpate each with the amount of pressure that the thumb nail goes white
tenderness at 11 or more out of 18 is in keeping with fibromyalgia
what two scales are used in fibromyalgia diagnosis
what must the scores be
Widespread Pain Index; number if areas of pain in last week out of 19
Symptom Severity Scale; rates fatigue, waking unrefreshed, cognitive symptoms, headaches, abdominal pain and depression
WPI 7 or more and SSS 5 or more
OR
WPI 4-6 and SSS 9 or more
what investigations are useful in fibromyalgia
TSH
Vit D level
B12 level
Iron studies
Magnesium
ESR/CRP
CK level - determine if muscle breakdown
management of fibromyalgia
biopsychosocial approach
- patient education
- exercise (strongest evidence)
- CBT
- screen for psychiatric conditions and treat if present
- pharmacological in severe pain/sleep disturbance; can use medications such as gabapentin, amitriptyline, duloxetine, tramadol (note NSAIDs harmful in FM)
if severe multimodal rehab programme
prognosis of fibromyalgia
no cure but many patients can reduce symptoms and the impact of them on their life
there are ‘yellow flags’ that indicate progression to long term distress
including biological, psychological and social factors
fibromyalgia risk factors
low household income
lack of further education
female sex
family history of fibromyalgia
having been through a traumatic event (e.g. a car crash)
having certain conditions such as Rheumatoid arthritis.
theories of pathophysiology in fibromyalgia
central sensitisation - increased excitability and efficacy of central nociceptor pathways
parallel processing - psychosocial factors interfering with pain perception
Colle’s fracture
fracture of the distal radius
pathological fracture underlying causes
tumour (primary or metastasis)
osteoporosis
Paget’s disease of the bone
T scores osteopenia/osteoporosis
> -1 normal
-1 to -2.5 osteopenia
< -2.5 osteoporosis
< -2.5 + fracture ; severe osteoporosis
how to achieve alignment of a fracture
closed reduction - mechanical manipulation of the limb
open reduction - via surgery
principles of fracture management
mechanical alignment of the bones
provide relative stability for healing to occur
head of femur blood supply
retrograde from the medial and lateral femoral circumflex arteries
if damaged lead to avascular necrosis of the femoral head - this happens in a displaced intracapsular fracture - needs a total or semi arthroplasty
what is replaced in a hemiarthroplasty compared to a full hip replacement
hemi - only femoral head replaced
full - head of the femur and the socket replaced
non displaced intracapsular fracture management
internal fixation
types of extra capsular hip fracture and management
Intertrochanteric fracture - dynamic hip screw
subtrochanteric fracture - intramedullary nail
non surgical hip fracture management
analgesia
investigations to establish diagnosis and underlying conditions/causes
VTE prophylaxis
preoperative assessment of fitness for surgery - bloods, ECG
involve orthogeris
most common cause of osteomyelitis
staphylococcus aureus
imaging for osteomyelitis
MRI
osteomyelitis management
surgical debridement and antibiotics
Baker’s cyst
swelling behind the knee in the popliteal fossa
in children self resolving
in adults the underlying cause should be treated e.g. osteoarthritis
Paget’s disease of bone
- presentation
- management
often asymptomatic with isolated raised ALP
may have headaches and bone pain
typically older male
treated with bisphosphonates
if pain or fractures
what are tendons made up of
predominantly type I collagen fibres arranged in bundles
how do tendons heal
3 phases: inflammation, proliferation, and remodelling, where type III collagen replaced with type I
how can tendonitis develop
either from acute overloading or via a degenerative process
what is Tredelenburg’s test
stand on one leg at a time - tests for weak hip abduction
pt leans away from their painful side to compensate for weak hip abductors
what is Thomas’ test
tests for fixed flexion deformity of the hip
