MSK/Orthopaedics Flashcards
What are the classic signs of osteoarthritis on x-ray?
Loss of joint space
Subchondral sclerosis
Subchondral cysts
Osteophytes at joint margins
Give 4 differentials for a hot, swollen joint
Septic arthritis
Osteomyelitis
Gout
Charcot joint (diabetics)
What is a Charcot joint?
A joint which has become badly disrupted and damaged secondary to a loss of sensation (usually due to diabetes)
Red, swollen and warm
Less painful that would be expected for such a disrupted joint due to the sensory loss
Define a sprain. What is the most likely mechanism of injury in the ankle?
A stretching, partial or complete tear of a ligament. Usually due to inversion if in the ankle
How would a posterior hip dislocation present?
The affected leg is shortened, adducted, and internally rotated
Most common!
How would an anterior hip dislocation present?
abducted and externally rotated.
No leg shortening.
Give 4 complications of a hip dislocation
Sciatic or femoral nerve injury
Avascular necrosis
Osteoarthritis: more common in older patients.
Recurrent dislocation: due to damage of supporting ligaments
What is the management of a hip dislocation?
Short term =
A to E and Analgesia
Reduction under general anaesthetic within 4 hours to reduce the risk of avascular necrosis.
Long-term =
Physiotherapy to strengthen the surrounding muscles.
How would a fractured neck of femur present?
Typically elderly females
pain
shortened and externally rotated leg
patients with non-displaced or incomplete neck of femur fractures may be able to weight bear
Describe the difference between intra and extracapsular hip fractures
Intra = edge of the femoral head to the insertion of the capsule of the hip joint
extra= these can either be trochanteric or subtrochanteric (the lesser trochanter is the dividing line)
Which classification system is the one for fractured NOFs?
Garden
Vascular compromise associated with type 3&4
What is the management of intracapsular NOF fractures?
Undisplaced = internal fixation, or hemiarthroplasty if unfit.
Displaced = replacement arthroplasty
In terms of replacement arthroplasty for displaced hip fractures, when is a total hip replacement favoured over a hemiarthroplasty?
IF PATIENTS CAN:
Walk independently out of doors with no more than the use of a stick AND
No cognitive impairment AND
are medically fit for anaesthesia and the procedure.
Basically TRH if they’re healthy
What is the management of an extracapsular hip fracture?
dynamic hip screw
OR
if reverse oblique, transverse or subtrochanteric: intramedullary device
Give 6 ‘things’ that can occur due to falling on an outstretched hand
Wrist = scaphoid, colles
Forearm = Monteggia, Galeazzi (+dislocations)
Shoulder = dislocation of the humerus, clavicle fracture
which fracture occurs by falling on a flexed wrist? Describe the fracture
Smith’s fracture
fracture of the distal radius + volar angulation (wrist is flexed)
describe a colles fracture
FOOSH + elderly
distal radius fracture + dorsal angulation
what complication can occur due to a scaphoid fracture and why?
avascular necrosis as the blood supply runs distal to proximal
can predispose osteoporosis in later life (young people get scaphoid fractures)
describe a Monteggia fracture
Man Utd
Monteggia = ulna
Fracture of the ulnar shaft + dislocation of the proximal radial head
describe a Galeazzi fracture
Glasgow Rangers
Rangers = Radius
Fracture of the radial shaft and dislocation of the radioulnar joint
When does a supracondylar fracture occur and what is a complication of it?
FOOSH in a child
Can get damage to the brachial artery and therefore ischaemia to the forearm
How do anterior and posterior dislocations of the humeral head present?
anterior = more common.
Abducted and externally rotated
Posterior = seizure/electrocution
internally rotated and abducted
What structure can be damaged in a humeral head dislocation and what are the effects of this?
Axillary nerve
loss of sensation to the regimental badge
loss of innervation to the deltoid = unable to abduct
Which structure can be damaged due to a fracture to the surgical neck of the humerus?
axillary nerve
Which structure can be damaged due to a fracture of the humeral shaft and what can occur as a result?
Radial nerve + profunda brachii artery
Wrist drop = unopposed flexion of the wrist due to loss of extension from the triceps
Loss of sensation to the dorsum of the hand and the later 3.5 digits
Where is the clavicle most commonly fractured and what happens to the fragments as a result?
middle 1/3
medial 1/3 gets pulled superiorly due to sternocleidomastoid
lateral 2/3 gets pulled inferiorly due to pec major
Name the 4 muscles of the rotator cuff from superior to inferior and give their action
SUPRAspinatus = ABduction to 15 degrees
INFRAspinatus = external rotation
Teres minor = external rotation
Subscapularis = internal rotation
external rotation sandwich
How does a rotator cuff tear present?
pain over the lateral aspect of shoulder
can’t abduct the arm above 90 degrees
what is the management of a rotator cuff tear?
conservative = analgesia + physio. ? corticosteroid injections
surgical if >2 weeks since injury or symptomatic despite conservative = arthroscopic or open repair
What is the main complication of a rotator cuff tear?
adhesive capsulitis
Glenohumeral joint capsule becomes contracted and adherent to the humeral head
= pain and loss of range of movement
analgesia, physio, ?steroid injection ?surgery
What are the causes of carpal tunnel?
MEDIAN TRAP
Myxoedema (hypothyroid) oEdema Diabetes mellitus Idiopathic Acromegaly Neoplasia
Trauma
Rheumatoid arthritis
Amyloidosis
Pregnancy
What are the 2 tests for carpal tunnel?
Tinnels Test (tap the median nerve)
Phalen’s Test (hold wrist in full flexion for one minute = parasthesia)
How does carpal tunnel present?
pain, numbness, and/or paraesthesia throughout the median nerve distribution
sx usually worse at night
wasting of the thenar evidence
weakness of thumb abduction
How would an ACL tear present?
Hx of twisting the knee whilst weight bearing
Rapid joint swelling
Can’t weight pain
Pain +++
Which tests can be done to identify ACL damage?
Anterior draw (flex knee at 90 degrees + apply force anteriorly)
Lachman (flex knee 30 degrees + pull tibia forward)
MRI scan is gold standard
How would a meniscal tear present?
Tearing sensation in knee
Sudden onset pain +++
Slow swelling
Knee locking
joint line tenderness
Which tests can be done to identify meniscal damage?
McMurray’s
What is the classification system used for lateral malleolus fractures?
Weber’s
a = below syndesmosis + usually transverse
B = at the level of the syndesmosis + usually spiral
C = above level of syndesmosis
more proximal = increased risk of instability
What are the Ottawa rules?
if there is diagnostic uncertainty in ankle fractures e.g. can mobilise and has no deformity
presence of:
bone tenderness at posterior edge/tip of lateral OR medial malleolus
can’t weight bear for 4 steps
= get a plain radiograph
When should surgical management be used in a patient with an ankle fracture?
Displaced bimalleolar or trimalleolar fractures
Weber C fractures
Weber B fractures with talar shift
Open fractures
What is the surgical management of osteoarthritis and when should it be offered?
Osteotomy, joint fusion or joint replacement
if conservative and medical interventions don’t manage the condition
What is compartment syndrome?
a critical pressure increase within a confined compartmental space
fascial compartments are rigid and can’t distend so excess fluid = increase in intracompartmental pressure
compresses veins and nerves
compromises arterial inflow = ischaemia
How does compartment syndrome present?
5Ps
Parasthesia + paralysis
Pain (disproportionate to injury and not improved with analgesia)
Pallor
Perishingly Cold
Pulselessness
How is compartment syndrome managed?
A-E
Remove splints/casts/etc
Analgesia
Monitor renal function
URGENT FASCIOTOMY
What is septic arthritis?
Infection of a joint, usually due to staph aureus
Bacteria seeds to the joint from a bacteraemia, direct inoculation or spreading from near osteomyelitis
What are the risk factors for septic arthritis?
non-modifiable: age >80 pre-existing joint disease e.g. RA diabetes/immunosuppressed chronic renal failure
modifiable:
IVDU
Joint prosthesis
How does septic arthritis normally present?
Red, swollen, hot joint
pain on active and passive joint movement
pyrexia
can’t wait bear
Which investigations should be done to manage septic arthritis?
Bed - a-e
Bloods - FBC, U&E, CRP, Urate, Blood cultures
Imaging - plain radiograph xray
Other - joint aspiration!!! Before abx. if have joint prosthesis then do it in theatre
What is the management of septic arthritis?
Empiral abx ASAP. give these IV and long term
Surgical irrigation and debridement for native joints
Washout and revision surgery for prosthetic
Give 2 complications of septic arthritis
Osteoarthritis and osteomyelitis
What is osteomyelitis and how is it caused?
Infection of the bone
haematogenous spread
direct inoculation
direct spread from nearby infection
usually bacterial by staph aureus
pseudomonas in IVDU
salmonella in sickle cell
How does osteomyelitis present?
Severe pain
low grade fever
tender to palpate + overlying erythema and swelling
Long bones normally infected in children
What are the risk factors for osteomyelitis?
Non modifiable:
Immunosuppressed
Diabetes mellitus
modifiable:
alcohol excess
IVDU
How should osteomyelitis be investigated?
Normal bloods
MRI = definitive diagnosis
Gold standard = bone biopsy when derided
What is the management of a patient with osteomyelitis?
Long term IV abx
curettage if deteriorate
What are 3 complications of osteomyelitis?
SEPSIS + DEATH
Septic arthritis
growth disturbance in children
can become chronic
What counts as a tetanus prone wound?
Needs surgery but has been delayed for >6 hours
Significant degree of devitalised tissue/Puncture-type injury
Foreign body in situ/ significant contact with spores likely to contain tetanus e.g. manure or soil
Compound fractures
Systemic sepsis is present
(Give these all tetanus immunoglobulin)
Which abx prophylaxis is required for an infected wound?
Contaminated = co-amoxiclav
Clean = Flucloxacillin
*** swab wound before abx
How does adhesive capsulitis normally present?
Middle aged women
external rotation is affected more than internal rotation or abduction
both active and passive movement are affected
What is Paget’s disease of bone?
increased bone turnover + remodelling
defective mineralisation
Give 3 investigations for Paget’s disease of bone?
Xrays of affected areas
serum calcium, phosphate and alk phos
serum hydroxyproline
What is the management of Paget’s disease of bone?
Analgesia and rest
bisphosphonates
