Ortho Flashcards
Teen, dull ache on lower femur, XR shows “sunburst” pattern of subperiosteal bone?
Osteosarcoma
Compartment syndrome?
- if not complaining of pain, what should raise suspicion?
- why does presence of pulse not rule it out?
- does XR show any pathology?
- how long until muscle death?
- why might aggressive IV fluids be needed?
- what medications NOT to give as it makes it worse?
- excessive use of breakthrough painkillers (plus pallor, paraesthesia, loss of pulse, paralysis)
- pulse may still be felt as microvasculature compromise leads to muscle necrosis which can be compressed allowing pulse through
- no
- 4-6 hours
- In case of myoglobinaemia causing acute tubular necrosis
- DO NOT give anticoagulation, it makes it worse
Scaphoid fracture:
- signs? (5)
- Ix?
- initial management?
- orthopaedic management?
- what is the vascular compromise?
- Maximal tenderness over anatomical snuffbox
- Wrist joint effusion (not if <4 hrs or >4 days old)
- Pain in telescoping of thumb
- Tenderness of scaphoid tubercle (volar wrist)
- Pain on ulnar deviation of wrist
- XR: AP, lateral, oblique and Zilter view (ulnar deviation of wrist)
- MRI should be 1st line imaging but usually 2nd line after XR
- CT more sensitive than XR and may be used also if MRI not available
- Futuro splint or elbow backslab
- Referral to ortho for review and new imaging in 7-10 days
Undisplaced # of waist: cast for 6-8 weeks
All others: surgical fixation
(esp proximal pole, high risk of AVN)
Dorsal carpal arch of radial artery
Causes of gout?
XR features?
DARRT:
Diuretics Alcohol Renal disease Red meat Trauma
XR:
- ‘punched out’ lesions with sclerotic margins
- preservation of joint space (until late disease)
- Soft tissue tophi may be seen
- joint effusion
RF for AVF?
Imaging?
Long term steroids
Chemo
Alcohol abuse
Trauma
XR:
Early - may be normal or show osteopenia or micro fractures
Later - head collapse may show crescent sign
IX of choice - MRI
How to tell if hip pain in an adult is referred from lumbar spine?
Positive femoral nerve stretch test
Lie pt prone, extend hip with straight leg, then bend knee - elicits pain if referred from lumbar spine
Management of suspected osteoporosis in a patient with a suspected fragility fracture?
Age 75+ - start on oral bisphosphonate
<75 - perform a dexa scan, then enter the result into a FRAX calculator to determine risk
Imaging for spinal trauma?
XR first line if no neuro symptoms
CT if abnormal XR or if neuro signs present
Immediate management of open fracture?
IV Co-amoxiclav
Lavage and debridement within 6 hours in theatre
External fixation preferred due to infection risk - wait for soft tissue swelling to reduce before definitive management
Enchondroma?
Intramedullary metaphyseal cartilaginous tumour caused by failure of normal enchondral ossification at growth plate
Lucent with patchy sclerosis, risk pathological frac, asymptomatic
Osteoid osteoma
nidus of immature bone with sclerotic halo, intense pain esp at night, greatly relieved by NSAIDs
Simple vs aneurysmal bone cyst?
Simple:
Growth defect, asymptomatic, incidental finding, risk pathological frac
Aneurysmal:
AVM, locally aggressive, cortical expension and destruction (painful)
Curettage and bone graft
Osteosarcoma
Kids, usually around knee, peirosteal elevation and sunburst sign, assoc with retinoblastoma
Teenager with warm, boney swelling, fever and raised CRP - what tumour?
Ewing’s sarcoma
2nd most common, worse prognosis
Brodie’s abscess?
subacute osteomyelitis
Thin rim of sclerotic bone surrounding abscess
Brown’s tumour?
AKA osteitis fibrosis cystica/osteoclastoma
Due to untreated hyperparathyroidism
Histologically exactly same as Giant Cell tumour
Giant cell tumour
Multinucleated giant cells within a fibrous stroma
20-40 y/o, epiphysis of long bones
soap bubble/souble bubble appearance
Paget’s disease?
Uncontrolled osteoclast activity - increased bone turnover
Bone pain (skull, spine, pelvis, femur) Isolated raised ALP
Deafness, fractures, skull thickening, high output cardiac failure
XR/isotope bone scan
Rx: bisphosphonates
Osteomyelitis pathophysiology?
Causative organisms?
Leucocyte enzymes -> local osteolysis/pus -> impaired blood flow -> difficult eradication -> sequestrum (dead bone) -> involucrum (new bone around)
Staph aureus most common
Salmonella in sickle cell
Ix: MRI
6 weeks fluclox/clinda
May need surgery and washout if not treating/if chronic (in chronic abx suppresses bacteria but not eradicate)
When each of the following cause septic arthritis:
- staph aureus?
- strep?
- h influenzae?
- neis gon?
- e coli?
Staph - most common
Strep - second commonest
H influenzae - was commonest in kids before vaccine
Gon - consider in young adults
E coli - elderly, IVDU, seriously ill
Ix septic arthritis?
Rx?
Joint aspirate BEFORE Rx
Fluclox/clinda 6 weeks +/- arthoroscopic lavage
Osteoporosis:
- what is it?
- common causes?
- what fractures are common?
quantitative defect of bone - low mineral density
Alcohol, steroids, smoking, menopause/low oestrogen, malabsorption, CKD, certain drugs, hyperthyroidism
NOF, vertebral crush, colles
Who should have osteoporosis risk assessed?
What scores are used?
When to reassess?
All women 65+ and men 75+
AND those younger but with risks e.g. steroid use, previous fragility fracture, low BMI
FRAX or QFracture - assess 10 year risk of fragility fracture
FRAX without DEXA gives low, med and high risk scores
With gives no rx, consider rx and recommend rx
Do not reassess again before 2 years unless significant change to circumstances
What to do if someone has a suspected fragility fracture?
If <75 - organise DEXA and put score into FRAX tool
If 75+ - treat regardless
Osteoporosis prevention in long-term steroids?
Just 7.5mg Pred for 3 months massively increases risk
If 65+ OR have previously had fragility fracture - treat
If <65 - DEXA
(if DEXA between 0 and -1.5, repeat scan in 1-3 years)
Ix of suspected spinal fragility fracture?
XR - may show wedge
2nd line - CT (shows bones) or MRI (shows if pathological frac e.g. from cancer)
If fracture organise DEXA
Management osteoporosis?
Calcium and Vit D
Alendronate 1st line Zolendronic acid once yearly IV Strontium (increased osteoblasts) Raloxifene (SERM) Denusomab (monoclonal AB against RANK ligand reducing osteoclast activity)
SE bisphosphonates?
Oesophagitis/ulcers
Osteonecrosis of jaw
Atypical stress fractures (esp prox femoral shaft)
Acute phase response may follow administration (fever, myalgia)
Hypocalcaemia (reduced efflux from bone, usually subclinical)
Osteomalacia?
Causes?
Qualitative defect - abnormal softening. Defective mineralisation of osteoid (immature bone) due to inadequate calcium/vitD
(Rickets in kids)
VitD deficiency
CKD
Drugs e.g. anticonvulsants
Liver disease
Bone pain, bone/muscle tenderness, fractures (esp NOF), proximal myopathy (waddling gait)
Bloods:
- low vitD, Ca, Phos
- Raised ALP, PTH
XR: translucent bands (Looser’s zones, or pseudofractures)
Rx: VitD supplementation, Ca supplementation, possibly phosphate supplementation
What is renal dystrophy?
Bone changes due to CKD. Reduced phosphate excretion and VitD activation -> secondary hyperparathyroidism, sclerosis of bone, calcification of soft tissues
Mechanical back pain?
Recurrent, relapsing, reciting pain with NO neurological symptoms, worse with movement, relieved by rest
Obesity, inactivity, poor lifting technique, facet joint OA, spondylosis (water loss from disks causing secondary OA)
NSAIDs, continue normal activity, physio
DO NOT offer spinal XR for low back pain without trauma
MRI for back pain?
Only id it is likely to change management and where malignancy, infection, fracture, caudal equine or ank spond is suspected
57 y/o man sudden onset severe lumbar back pain when lifting lawn mower out of shed, worse on coughing?
Acute disc tear
Tear in annulus fibrosis which is richly innervated, MRI if suspect herniation, resolves in 2-3 months with analgesia/physio
Sciatic stretch test?
Straight leg raise causes pain in buttocks
Also cross over sign - stretch on opposite side causes pain on affected side
Due to impingement on nerve root (pain and weakness) from disc herniation or OA osteophytes
Analgesia (+ amitriptyline/gabapentin) physio +/- discectomy if severe
Herniation relates to which nerve root in relation to it?
Usually one of the 2 lower vertebrae
- lateral herniation or osteophyte will compress the upper one (e.g. in L4/5 herniation will affect L4 root)
- more central ones will compress the lower one (in L4/5 herniation will affect L5)
- If very central and large can compress cord/cauda equina
L3/4 prolapse, which nerve usually and symptoms?
L4 root entrapment :
Pain to medial ankle, loss of quadriceps power, reduced knee jerk
L4/5 prolapse, which nerve usually and symptoms?
L5 entrapment:
Reduced power extensor hallucis longs and tibialis anterior, pain to lateral leg/dorsal foot
L5/S1 entrapment which nerve usually and symptoms?
S1 entrapment:
Pain to sole of foot, reduced power plantarflexion, reduced ankle jerk
Upper or lower motor neurone signs in cauda equine?
Lower
Ix for spinal stenosis?
Rx?
MRI
Conservative or laminectomy
What does each rotator cuff muscle do?
Supraspinatus - initiate abduction
Infraspinatus - ext rotation
Teres minor - ext rotation
Subscapularis - int rotation
subscapularis odd one out - only one below scapula, only one to do internal rotation, only one to insert into lesser tuberosity (rest are in greater)
Collectively - pull humeral head into glenoid to provide stability for deltoid to abduct arm
Causes of shoulder impingement?
Rx?
Tests for impingement?
Tendonitis, subacromial bursitis, ACJ osteophyte, hooked acromion
Conservative
Sub-acromial steroid injections x3
Subacromial decompression surgery
Hawkins kennedy - internally rotate a flexed shoulder, recreates pain
Adhesive capsulitis classic history?
First sign?
Cause?
Rx?
40+ y/o, progressive pain 2-9 moths, then progressive stiffness 4-12 months, eventually recovers well
Loss of external rotation first sign
Due to capsule + glenohumeral ligament becoming inflamed
Rx:
physio/analgesia
IA injections
Surgical release if loss of function
Acute calcific tendonitis?
Ix?
Rx?
Acute onset, severe shoulder pain with calcium deposit in supraspinatus tendon
XR shows calcium
Rx: subacromial steroid + local anaesthesia
Causes of shoulder instability?
Previous traumatic anterior dislocations
(Bankart lesions)
Atraumatic - idiopathic, Marfan’s, Ehlers-Danlos
If traumatic, bankers repair can stabilise
Tinel’s test?
Phalen’s test?
Ix for this?
Rx?
Tapping = paraesthesia
Wrist flexion = symptoms
Ix - nerve conduction studies - slowed sensory and motor conduction
Rx: wrist splint, steroid injections, splitting of flexor retinaculum
Signs of cubital tunnel syndrome?
Pain, paraesthesia, hypothenar wasting, weakness in index finger abduction
Tinel’s (behind medial epicondyle)
Froment’s sign - hold paper between thumb and index finger in fist - pull paper and weakness causes thumb flexion to compensate
Nerve conduction studies, surgical release may be necessary
Rx trigger finger?
Steroid injection or division of A1 pulley
Dupuytren’s cause?
Where?
Rx?
Abnormal hyperplasia of type 3 collagen in palmar fascia, skin becomes adherent causing pits/cords, and palpable nodules may be present
Most commonly 4th finger, 50% bilateral
Mild contractors up to 30 degrees at MCP, but >30 requires fasciotomy or fasciectomy
Others = peyronie’s disease of penis or Ledderhose disease (feet)
De quervain’s tenosynovitis?
Symptoms/signs/tests?
Rx?
Inflammation of tendon sheath containing extensor pollicis brevis and aductor pollicis longus
Pain on radial side of wrist, tenderness at radial styloid, pain on resisted thumb abduction
Finkelstein’s test - trip thumb and shortly ulnar deviate hand, recreating symptoms
Analgesia, immobilisation with spica thumb splint
Steroid injection
Surgery
Why can hip pain be felt in the knee?
Obturator nerve supplies both joints
Loss of internal rotation often first sign of hip pathology
Ix hip AVN?
Rx?
MRI in early stages - oedema etc
XR later - head collapse, lytic lesions, sclerotic margin, hanging rope sign
If detected early can drill holes in bone to relieve pressure
If not THR needed
Function of the 4 knee ligaments?
ACL - resists internal rotation + anterior translation of tibia
PCL - resists posterior + anterior translation of tibia
MCL - resists valgus stress
LCL - resists varus stress + external rotation of tibia
1st line Ix for knee soft tissue injuries?
MRI
Rule of 1/3 for ACL?
1/3 compensate and continue sports
1/3 manage by avoiding certain movements - no sports
1/3 struggle with daily activities
Rx: physiotherapy to strengthen quads, ACL reconstruction with tendon graft from patellar tendon, semitendinosus or gracilis
What ligaments are commonly ruptured together in tibial plateau frackers?
MCL + ACL
Management of knee dislocation?
External fixation then multi-ligament reconstruction
Popliteal injury common and reperfusion injures
Extensor mechanism rupture - which ligaments and predisposing factors?
Rule for tendonitis?
Ix?
Rx?
Cause - rapid contractile force (high impact fall or spontaneous if degeneration)
Patella tendon <40 y/o
Quadriceps tendon >40 y/o
Predisposing: tendonitis Steroids Diabetes RA CKD Quinolones
DO NOT use steroid injection for extensor mechanism tendonitis
XR or USS if obese
Surgery
What does patellofemoral syndrome encompass?
Who does it affect?
Symptoms?
Rx?
Encompasses chondromalacia patellae (softening of cartilage), lateral patellar compression syndrome and anterior adolescent knee pain
Adolescent females - wider hips = more lateral pull on patella
Anterior knee pain, worse downhill +/- clicking/grinding sensation +/- pseudo-locking (stiffness)
Self-limiting (surgery last resort)
Predisposing factors for patellar instability?
What side is dislocation?
Female Laxity Shallow trochlear groove Genu valgum High riding patella
Usually lateral due to lateral pull of quads
Surgical Rx of hallux valgus?
Hallux rigidus?
Osteotomy - realignment
Arthrodesis - surgery gold standard for hallux rigidus
Stress fray usually affects which bone?
When is callus seen on XR?
2nd metatarsal (or 3rd)
After 3 weeks
Where does tibias posterior tendon insert?
Medial navicular - supports medial arch
Tendonitis (repetitive strain) risks rupture
Loss of medial arch will heal valgus
Splintage avoids surgery,, predisposes to OA (arthrodesis)
Pes planus?
Pas cavus?
Flat foot - normal variant in 20% population
High arched foot - often related to NMD
4 toe deformities?
Rx?
Claw toe - hyperextend MTP, flexed both IP
Mallet - 90 degree bend DIP
Hammer - Boutoinniere but of toe
Curly - flat MTP, both IP curved so bottom of toe underneath
Painful rubbing -> corns/skin breakdown
Rx:
- ‘toe sleeves’
- Surgery to relieve tight tendons/arthrodesis/amputaton if painful/rubbing on shoe
Is charcot joint inflamed?
Yes can be swollen/hot/red, but typically not sore
Spinal shock?
Spinal shock:
- Physiological response to trauma - typically resolves in a day
- Loss of motor + sensory + reflexes below injury
- bulbocarvenous reflex absent until resolution
Neurogenic shock:
- temporary shutdown of sympathetic outflow (T1-L2)
- Vasodilation (hypotension) and bradycardia (IV fluid)
- High level injuries - typically resolves in 1-2 days
- Priapsim due to unopposed parasympathetic
Primary vs secondary bone healing?
Primary - minimal fracture gap (<1mm) and bone bridges gap with osteoblasts - occurs in hairline fracs and when fixed with compression screws/plates
Secondary - inflammatory response with pluripotent stem cell recruitment which differentiate into different cells. 4 stages:
- inflammation
- soft callus
- hard callus
- remodelling
Investigating a frac:
- views on XR?
- tomogram?
- CT?
- MRI?
- Technetium bone scan?
AP and lateral + oblique for complex bones e.g. scaphoid, acetabulum, tibial plateau
Mandibular frac
CT - vertebrae, pelvis, calcaneus, scapular glenoid frac, ?articular damage
MRI - occult frat where clinical suspicion but normal XR
Technetium - stress frac (hip, femur, fibula, 2nd met)
Indications for ORIF?
Unstable Displaced Neurovascular compromise Irreducible Pathological Intra-articular
CRPS:
- features?
- Rx?
Constant burning/throbbing, allodynia, swelling, stiffness and skin colour changes
Specialist pain team
Drugs - amitriptyline, gabapentin, steroids
TENS, physio, lodicaine, nerve block
Light bulb sign on shoulder XR?
Posterior dislocation
Less common, 5%
Due to posterior force on adducted and internally rotated arm
Management of ACJ dislocation?
Common in sports
Grade 1 - sprain
2 - sublimed
3 - dislocated
Conservative management (sling/physio)
Reconstruction if chronic pain or early in young athletes
Elbow injuries:
- management of olecranon frac?
Anterior fat pad sign?
ORIF with tension band wiring
radial head + neck frac
ORIF
Combined ulnar + radial frac?
ORIF
Colles management?
What can be damaged?
Stable - splint
Displaced simple - MUA + plaster
Displaced unstable - MUE + k-wires or ORIF
Median nerve damage
Extensor pollicis longus rupture
Smiths management?
ORIF
These are unstable
What is a barton’s?
intra-articular with dorsal/volar displacement if rim. Carpal bones sublet with displaced rim fragment
ORIF
Management of scaphoid frac?
XR (4 views) - may not be visible for 2 weeks
Futura splint 2 weeks then review
Review by ortho for confirmation - CT if still clinical but no XR signs
- If non-displaced - plaster cast 6-12 weeks
- displaced - compression screw
Non-union - screw fixation and bone graft
Mallet finger Rx?
Mallet splint 4 weeks minimum
Metacarpal frac rx?
Conservatively - strap to adjacent finger
Unless severe rotational malalignment - then K wire fixation
What is mandatory in pelvic fracture?
PR exam to assess sacral nerve root function and look for presence of blood. General surgical review mandatory if blood - rectal tear
Acetabular frac rx?
Posterior frac associations w hip dislocation
Oblique view radiograph required + CT may be required
Conservative > reduction/fixation > THR (older patients)
Gout Rx in an old person taking warfarin?
Colchicine, because of risk of GI haemorrhage
