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Surgery > Musculoskeletal and Neurology > Flashcards

Musculoskeletal and Neurology Flashcards

1
Q

Key ortho history elements

A
  • pain
  • loss of function
  • stiffness
  • deformity
  • swelling
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2
Q

Muscle groups for hip movement

A
  • Flexion: iliopsoas, rectus femoris, tensor fascia lata, quad
  • Extention: Gluteus maximus and hamstrings
  • Abduction: Gluteus medius and minimus
  • Adduction: Adductors (longus, brevis, magnus)
  • Internal rotation: Gluteus medius, minimus, iliopsoas
  • External rotation: Gluteus maximus
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3
Q

How should suspected hip OA be investigated?

A
  • Bloods: FBC, U+Es, LFTs, ESR, RhF, ANA

- AP + Lateral X-rays of hip and pelvis

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4
Q

X-ray features of hip OA

A
  • Loss of joint space
  • Osteophyte formation
  • Subchondral sclerosis
  • Subchondral cysts
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5
Q

Hip OA treatment

A
  • lifestyle mods: diet, exercise, weight loss
  • physiotherapy
  • OT: mobility aids and advice
  • analgesia: WHO pain ladder
    Surgical options
  • osteotomy
  • arthroplasty
  • arthrodesis
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6
Q

Indications for total hip replacement

A
  • instability
  • severe pain or disability not relieved by non-surgical options
  • rest pain or pain with movement
  • loss of mobility
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7
Q

Complications of total hip replacement

A
  • Intraoperative: # of acetabulum or femur
  • Immediate: dislocation (malalignment), damage to local structures
  • Early: DVT, PE, sciatic nerve palsy, infection, fat embolism
  • Late: infection, loosening, heterotopic ossification, leg-length discrepancy, periprosthetic #, thigh pain
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8
Q

How to prevent total hip replacement postop DVT?

A

Prevention impossible

  • pre-op: TEDs
  • peri-op: TEDs, compression boots, minimise length of surgery
  • post-op: LMWH, early mobilisation with physio
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9
Q

Knee OA treatment

A
  • lifestyle mods: diet, exercise, weight loss
  • physio: strengthen quads
  • OT: mobility aids, advice, elastic support
  • Analgesia: WHO pain ladder
  • Intra-articular steroid injections: temporary relief, if repeated causes cartilage and bone destruction
  • Viscosupplementation: hyaluronic acid
    Surgical
  • arthroscopic debridement + washout
  • Patellectomy: PFOA
  • Realignment osteotomy: <50
  • Unicompartmental or total knee replacement: older pts
  • Arthrodesis: if strong CI to arthroplasty or as salvage
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10
Q

Complications of total knee replacement

A
  • Intraoperative: # tibia or femur
  • Immediate: vascular injuries
  • Early: DVT, PE, peroneal nerve palsy, infection, fat embolism
  • Late: infection, loosening, patellar instability/#, periprosthetic #s
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11
Q

Clinical features of knee RA

A

Stage 1 - proliferative: effusions, thicken synovium, stable joint

  • Stage 2 - destructive: instability, muscle wasting, reduced movement range
  • Stage 3 - reparative: severe pain + instability, fixed flexion + valgus
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12
Q

Surgical options for knee RA

A
  • Synovectomy + debridement: for failed medical treatment
  • Supracondylar osteotomy: if knee stable + pain-free but valgus + flexion deformity
  • Total knee replacement: for advanced joint destruction
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13
Q

Dupuytren’s contracture differential

A
  • skin/scar contracture
  • tendon contracture: moves on passive flexion
  • congential contracture: PIPJ little finger
  • ulnar nerve palsy: ring and little fingers hyperextended MCPJ, flexed PIPJ
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14
Q

Conditions associated with Dupuytren’s

A
  • Idiopathic
  • Diabetes
  • Alcoholic liver disease
  • Epilepsy + meds (phenobarbitone)
  • Age
  • Smoking
  • Family history (AD)
  • AIDS
  • Fibromatoses
  • Peyronie’s disease (3%)
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15
Q

Surgical options for Dupuytren’s

A

If >30 degrees MCPJ contracture

  • fasciotomy
  • partial fasiectomy + Z-plasty + physio + splintage
  • dermofasciectomy + full thickness skin graft
  • arthrodesis/amputation: for late presentations and repeated recurrences
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16
Q

Causes of carpal tunnel syndrome

A
  • idiopathic
  • anatomical abnormalities: bone (wrist #s, acromegaly), soft tissues (lipoma, ganglia)
  • physiological abnormalities: inflammatory (RA, gout), fluid balance (preg, meno, hypothyroid, obesity, amyloid, CRF), neuropathic (DM, alcoholism)
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17
Q

Non-surgical option for Dupuytren’s

A
  • If no contracture yet, watch and wait or corticosteroid injections (triamcinolone acetonide)
  • <30 degrees MCPJ and no PIPJ contracture: collagenase, corticosteroids
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18
Q

Carpal tunnel treatment

A
  • remove underlying causes
  • splint wrists as night
  • proximal steroid injections
  • carpal tunnel decompression (flexor retinaculum division)
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19
Q

Complications of carpal tunnel decompression

A
  • scar formation (keloid/hypertrophic)
  • scar tenderness
  • wound infection
  • nerve injury: palmar cutaneous branch + motor branch to thenar muscles
  • failure to relieve symptoms (incomplete division)
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20
Q

Boundaries of carpal tunnel

A
  • ulnar aspect: pisiform + hook hamate
  • radial aspect: scaphoid + trapezium
  • volar aspect: transverse carpal ligament
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21
Q

Where else can median nerve be compressed?

A
  • pronator syndrome: ligament of Struthers, pronator teres or flexor digitorum superficialis
  • anterior interosseous syndrome: branch at deep head of pronator teres. Supplies flexor pollicis longus, pronator quadratus, radial FDP (weak OK sign) NO sensory signs
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22
Q

Extra-articular manifestations of RA

A
  • Opthalmic: episcleritis, scleritis, keratoconjuctivitis sicca
  • Respiratory: effusions, fibrosis
  • Cardiac: pericarditis
  • Reticuloendothelial: lymphadenopathy, splenomegaly, felty’s
  • Neurological: carpal tunnel, multifocal neuropathies
  • Vascular: Vasculitis
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23
Q

Investigations to confirm RA

A
  • FBC: anaemia chronic disease
  • ESR
  • RhF + in 75%
  • Anti CCP + 70%
  • HLA-DR3/DR4 in 1/3
  • ANA + in 30%
  • X-rays
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24
Q

Radiological stages of RA

A

Stage 1 - soft tissue swelling, periarticular osteoporosis
Stage 2 - joint space narrowing, small periarticular erosions
Stage 3 - marked articular destruction

25
Q

Treatment of hand OA

A
  • physio to maintain function
  • analgesia: WHO ladder
  • arthrodesis: trapeziectomy for thumb CMCJ OA
  • arthroplasty: rare
  • arthrodesis: if joint unstable or very painful
26
Q

Which joints in hands often affected by OA?

A
  • DIPJ: Heberden’s nodes
  • PIPJ: Bouchard’s nodes
  • CMCJ: ‘square hand’
27
Q

Ulnar nerve palsy causes

A
  • Anatomical: cubital tunnel syndrome at elbow
  • Trauma: anywhere along nerve, supracondylar #s, elbow dislocations
  • Degenerative arthritis: compression from synovitis, osteophytes
  • Rare: compression from fascia, ligaments, tumours, aneurysms, anatomical variants
28
Q

How do you clinically differentiate between high and low ulnar nerve lesion?

A
  • Low (below elbow): marked clawing as FDP to ring and little fingers still functioning
  • High (above elbow): less marked clawing as paralysis of FDP (ulnar paradox). Also decreased sensation over ulnar border of hand
29
Q

Ulnar nerve palsy treatment

A

Non-surgical
- for mild, intermittent symptoms, avoid prolonged and repetitive flexion, night splints in extension
Surgical
- for persistent, significant symptoms or neuro deficit
- ulnar nerve decompression (roof of cubital tunnel)
- ulnar nerve anterior transposition
- medial epicondylectomy

30
Q

1 investigation for hallux valgus

A

Plain weight bearing x-rays to assess

  • degree of valgus deformitiy
  • 1st/2nd intermetatarsal angle and distal metatarsal angle
  • presence of OA in 1st MTPJ
31
Q

Aetiology of hallux valgus

A
  • essentially unknown
  • strong familial trait
  • associated with enclosed footwear
  • associated with RA
  • can be secondary to prior deformity
32
Q

Treatment options for hallus valgus

A 
Non-surgical
- appropriate footwear (wide, soft)
- physiotherapy
Surgical
- Bunionectomy
- 1st metatarsal realignment osteotomy
- excision arthroplasty (Keller's procedure)
- Fusion: for degenerative joint disease
33
Q

Aetiology of hammer toes?

A
  • imbalance between intrinsic (lumbricals + interossei) and extrinsic (long flexors + extensors) muscles of lesser toes
  • Commoner in females, elderly, RA
34
Q

Hammer toes treatment

A
  • appropriate footwear
    Surgical
  • Mobile deformity: flexor-to-extensor tendon transfer
  • Fixed deformity: partial or total proximal phalangectomy +/- flexor extensor release, or PIPJ arthrodesis
  • Painfull callosities: terminal phalangectomy
35
Q

Aetiology of mallet toes?

A
  • imbalance between intrinsic (lumbricals + interossei) and extrinsic (long flexors + extensors) muscles of lesser toes
  • Commoner in females, elderly, RA and DM with peripheral neuropathy
36
Q

Mallet toes treatment

A
  • appropriate footwear
    Surgical
  • Mobile: flexor digitorum longus tenotomy
  • Fixed: flexor tenotomy + middle phalangeal head + neck resection, or DIPJ fusion, or terminal phalanx amputation
37
Q

Aetiology of claw toes?

A
  • imbalance between intrinsic (lumbricals + interossei) and extrinsic (long flexors + extensors) muscles of lesser toes
  • Commoner in females, elderly, RA
  • May be secondary to peripheral neuropathy (DM, CMT), LMN (poliomyelitis), or UMN (cerebral palsy, MS, stroke)
38
Q

Claw toes treatment

A
  • appropriate footwear
    Surgical
  • Mobile: flexor-to-extensor transfer
  • Fixed: partial proximal phalangectomy +/- flexor extensor release, or extensor tenotomy, or metatarsal head resection
39
Q

Aetiology of mallet finger

A
  • damage to extensor tendon to terminal phalanx +/- avulsed bone fragment
  • from forced flexion, usually catching a ball
40
Q

Acute management of mallet finger

A
  • x-ray to exclude #
  • mallet splint for 6 weeks with DIPJ in extension
  • if avulsed bone >1/3 width joint, reposition with Kirschner wire
41
Q

Aetiology of trigger finger

A

aka stenosing tenovaginitis: fibrosis + thickening of flexor tendon sheath as tendon enters digit

  • idiopathic
  • trauma
  • congenital
  • RA (similar)
42
Q

Trigger finger treatment

A
  • steroid injection of nodule

- tendon release by incising sheath

43
Q

Treatments for ingrowing toenails

A
  • good nail care, chiropodist, transverse trimming, cotton wool to lift up nail, keep foot clean and dry
  • simple nail avulsion: best for acute infection, reduces risk of osteomyelitis but likely recurrence
  • wedge excision of nail and nail-bed down to periostum
  • Zadek’s procedure: total excision of nailbed including germinal matrix
44
Q

Complications of ingrowing toenail surgery

A
  • infection
  • regrowth
  • osteomyelitis
  • septic arthritis
45
Q

Causes of knee haemarthrosis

A 
Primary spontaneous haemarthrosis
- without trauma
- may be secondary to coagulation disorder or vascular malformations
Secondary haemarthrosis
- secondary to trauma
- 80% ACL
- 10% patellar dislocation
- 10% tears in peripheral vascularised third of menisci, capsule, or osteochondral/osteophyte #s
46
Q

History factors suggesting ACL injury

A
  • valgus/external rotation, hyperextension, deceleration, rotational movements
  • audible ‘pop’ or feels something tear
  • inability to continue
  • effusion within 4-6 hrs
47
Q

Problems associated with ACL rupture

A
  • meniscal tears
  • collateral ligament injur
  • progressive premature OA
48
Q

How do you treat a meniscal tear?

A 
Depends on age, chronicity, activity, location, type, length.
- symptomatic only
Arthroscopic or open:
- partial meniscectomy
- meniscal repair
- meniscal transplant
- meniscal replacement
49
Q

Anatomy of medical meniscus

A
  • semicircular
  • anterior horn attaches to anterior intercondylar fascia of tibia
  • posterior horn attaches posteriorly to intercondylar fascia
  • bound to joint capsule peripherally
  • bound to femur and tibia at midpoint by deep medial collateral ligament
50
Q

Anatomy of lateral meniscus

A
  • nearly circular
  • covers greater area than medial menicus
  • anterior horn attaches to tibial eminence
  • posterior horn attaches behind tibial eminence
  • loosely attached to tibial plateau by coronary ligament
  • bound to medial meniscus via transverse ligament
51
Q

Anatomy of ACL

A
  • intracapsular
  • originates from medial aspect of lateral femoral condyle
  • inserts into anterolateral aspect of medial tibial plateau
  • stops tibia moving forward in relation to femur
  • consists of two bundles, anteromedial + posterolateral
52
Q

Anatomy of PCL

A
  • intraarticular but extrasynovial
  • broad origin on lateral aspect of medial femoral condyle
  • inserts inferior to articular surface between medial and lateral tibial plateaus
  • stops tibia moving backwards in relation to femur
  • two components, anterolateral group, anteromedial group
53
Q

How to treat ACL ruptures?

A

Non-surgical
- intensive physiotherapy focusing on quads and hamstrings
Surgical
- intraarticular reconstruction: autologous hamstring tendon or bone-patellar tendon-bone graft
- extraarticular reconstruction: MacIntosh tenodesis
- combination of above

54
Q

Causes of a locked knee

A
  • Childhood: discoid meniscus, hip pathology, osteochondritis dissecans
  • Adolescent: meniscal tear, cruciate ligament injury, osteo diss, synovial chondromatosis
  • Adult: meniscar tear, crucial ligament injury, loose body, osteochondral #, synovial chondromatosis
  • Elderly: meniscal tears, loose body, intraarticular tumour (rare)
55
Q

Causes of a radial nerve lesion

A
  • High (brachial plexus): crutches, saturday night palsy
  • Mid (radial groove): humerus #, tourniquet
  • Low (elbow): wounds, surgery, #, dislocation. Only posterior interosseus branch involved = loss of MCPJ extension only
56
Q

Causes of a painful shoulder

A
  • Tendon (rotator cuff) disorders: tendinitis, rupture, frozen shoulder
  • Joint disorders: glenohumeral arthritis, ACJ arthritis
  • Referred pain: cervical spondylosis, cardiac ischaemia, mediastinal pathology
  • Instability: dislocation, subluxation
  • Bone lesions: infection, neoplasm
  • Nerve lesions: suprascapular nerve entrapment
57
Q

Aetiology of rotator cuff impingement

A
  • repetitive rubbing of tendons under coracoacromial arch
  • worse in ‘impingement position’ abduction, slight flexion, internal rotation
  • critical area of poor vascularity in supraspinatus tendon
  • contributing factors: ACJ osteophytes, rotator cuff swelling, subacromial bursitis
58
Q

Impingement syndrome treatment

A
  • avoid aggravating activity
  • physiotherapy
  • short course NSAIDs
  • subacromial corticosteroid injections
  • open or athrhoscopic subacromial decompression
59
Q

Rotator cuff tear treatment

A
  • physio to improve shoulder strength
  • open or arthroscopic cuff repair and subacromial decompression
  • open or arthroscopic cuff debridement (if unable to repair) and subacromial decompression

Surgery (4 decks)

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