Ortho Flashcards
1
Q
what age group does SUFE affect?
A
19-16y old
2
Q
What are the risk factors for SUFE?
A
- Obesity
- Family history
- Trauma (e.g., sports-related injury or fall)
- Endocrine or hormonal factors (e.g., hypothyroidism, pituitary tumors, down syndrome, renal osteodystrophy, craniopharyngioma)
3
Q
What is the typical presentation of SUFE?
A
Onset - acute , chronic (3wks to several mths), acute on chronic
Location - bilateral in 20-40% of cases
Symptoms - Dull pain in the medial thigh, knee, groin, or hip (often left > right)
- Limping
- reduced internal rotation and abduction
- May hold their leg in passive external rotation
4
Q
What sign is positive in SUFE?
A
Drehmann sign -
The Drehmann sign is positive if an unavoidable passive external rotation of the hip occurs when performing a hip flexion. In addition, an internal rotation of the respective hip joint is either not possible or accompanied by pain when forcefully induced
5
Q
How do you diagnose SUFE?
A
AP pelvis x-ray
Frog leg lateral view (supine position, flexion of 45° and abduction of 45° in the hip): It allows for better evaluation of both hips, femoral head and neck.
Findings:
- Widening of the joint space
- The femoral head is displaced posteriorly and inferiorly in relation to the femoral neck.
- Klein line not passing the femoral head: It is a straight line drawn along the superior border of the femoral neck that normally passes through the femoral head.
- Southwick method - refers to the tilt of the femoral neck in relation to the femoral head
6
Q
What is the treatment for SUFE?
A
Avoid weight bearing before stabilisation
Urgent surgical internal fixation with pinning of the femoral head
7
Q
What classification is used in perthes disease?
A
Lateral pillar classification / Herring classification
SEE notes
8
Q
What are the clinical features of perthes disease?
A
Antalgic gait (on weight-bearing leg)
Pain in the hip or the upper leg, sometimes projecting to the knee
- Insidious onset, pain may fluctuate depending on physical activity
- Often exacerbated by internal rotation
- FABER test (Flexion, ABduction, and External Rotation) might be positive.
9
Q
A 52-year-old male is referred to urology clinic with impotence. He is known to have hypertension. He does not have any morning erections. On further questioning the patient reports pain in his buttocks, this worsens on mobilising. On examination there is some muscle atrophy. The penis and scrotum are normal. What is the most likely diagnosis?
A
Leriche syndrome
10
Q
What is the triad of symptoms in Leriche syndrome?
A
- Claudication of the buttocks and thighs
- Atrophy of the musculature of the legs
- Impotence (due to paralysis of the L1 nerve)
11
Q
what is the commonest cause of fracture in patients falling with an outstretched hand?
A
Colles fracture
Dorsiflexed wrist
12
Q
What tests are positive for an anterior cruiciate ligament injury?
A
Positive lachman test
Positive anterior draw test
13
Q
What are the features of the unhappy tria?
A
Simultaneous injury of the ACL, MCL and medial meniscus
This injury typically occurs due to excessive valgus and external rotational stress with a fixed foot position
14
Q
A 21-year-old female football player comes to the walk in clinic with severe left knee pain. She states that she has landed awkwardly on her knee during a football game. She heard a ‘snapping sound’ when she injured her knee which was followed by significant swelling around the left knee joint. Physical examination reveals increased laxity on anterior drawer of the left tibia relative to the femur. Which of the following tests would be most appropriate in confirming the diagnosis?
A
Knee MRI
15
Q
What is the typical features of ACL injury and typical history?
A
ACL injuries often occur in sports that require pivoting or rapid changes in direction
Such patients will often complain of a popping sensation followed by rapid onset haemarthrosis
instability, feeling that knee will give way
Aanterior draw test: knee at 90 degrees
Lachman’s test: knee at 30 degrees - more reliable than anterior draw test
16
Q
What is the aetiology of osteomyelitis?
A
- Haematogenous osteomyelitis
- Most common in children
- verterbral osteomyelitis is the common form of haematogenous spread in adults
- Risk factors: Sickle cell anaemia, intravenous drug user, immunosuppression due to either medication or HIV, infective endocarditis - Exogenous osteoyelitis -
- Posttraumatic - infection following deep injury
- Secondary to infected foot ulcer in diabetic pts
- Iatrogenic - postoperative infection of a prosthetic joint implant
- Risk factors include: diabetic foot ulcers/pressure sores, diabetes mellitus, peripheral arterial disease
17
Q
What is the organism that causes osteomyelitis?
A
Staph. aureus is the most common cause except in patients with sickle-cell anaemia where Salmonella species predominate
18
Q
What is the investigation required when osteomyelitis is suspected?
A
MRI is the imaging modality of choice
19
Q
What is the Tx for osteomyelitis?
A
Flucloxacillin for 6 weeks
Clindamycin if penicillin-allergic
20
Q
Commonest cause of osteomyelitis in pts with prosthetic joints?
A
Staph epidermidis
21
Q
Commonest cause of osteomyelitis in IV drug users?
A
Pseduomonas aeruginosa
22
Q
Commonest cause of osteomyelitis in pts with bites from dogs or cats?
A
Pasterualla multocida
23
Q
A 71-year-old man with a history of type 2 diabetes mellitus and hypertension presents to his GP with an ulcer on his left foot. On examination, there is a sloughy punched-out ulcer on the sole with significant erythema around it. The left foot is grossly oedematous and tender to palpation throughout, especially across the metatarsals.
What is the most appropriate imaging to arrange of his foot?
A
MRI is the imaging modality of choice
Diabetic patient with a foot ulcer which has likely led to osteomyelitis
24
Q
You review a femoral X-ray of a 13-year-old boy which you requested yesterday. He presented with bony pain in his distal femur which had been constant over 1 month. The X-ray shows medullary and cortical bone destruction of the distal femur. How should this X-ray be followed up?
A
Ensure patient is seen by specialist within 48hrs
X‑ray which could suggest bone sarcoma
25
What are the 3 types of malignant bone tumours?
- Osteosarcoma
- Ewings sarcoma (although non bony sites recognised)
- Chondrosarcoma - originate from Chondrocytes
26
What age group and sex is most at risk of Ewing sarcoma?
10-20yrs of age
Second highest cause of bone tomour in children after osteosarcoma
Commoner in males
27
What is the commonest site of Ewing sarcoma?
Primary tumor: often diaphyses of long bones (particularly femur, tibia, fibula, and humerus) and bones of the pelvis
However, Ewing sarcoma can occur in any bone and even in soft tissue.
Mets - lungs, skeletal system and bone marrow
28
What is the common prestation of Ewing sarcoma?
Manifests with
- localized pain (progressive, worsens at night)
- hyperthermia
- swelling after trauma to the bone (tissue mass that is tender to palpation and accompanied by erythema)
29
What is seen on Xray in Ewing sarcoma?
Lytic bone lesions
| Onion skin appearance of the periosteum
30
What is the cause of osteosarcoma?
Primary osteosarcoma: unknown
Secondary osteosarcoma: Paget disease of bone, radiation injury, bone infarction
increased risk in individuals with retinoblastoma
31
What are the clinical features of osteosarcoma?
- Frequently first manifests with pain (progressive, worsens at night and with activity)
- Progressive swelling (tissue mass that is tender to palpation and accompanied by erythema)
- Pathological fractures
- Limping , decreased range of motion
32
What is the X-ray findings of osteosarcoma?
- Sunburst appearance of lytic bone lesions and/or Codman triangles
- Signs of osteolysis adjacent to osteosclerosis (moth-eaten appearance)
Remember to wear your SOCK (Sunburst, Osteosarcoma, Codman, Knee region).
33
Who is at most risk of rib fractures?
Those with a PMH of osteoporosis, steroid use or chronic obstructive pulmonary disease
34
What is are the complications to look out for in rib fractures?
- Auscultation of the chest may reveal crackles or reduced breath sounds if there is an underlying lung injury
- Pain and underlying lung injury can also result in a reduction in ventilation causing a drop in oxygen saturation --> chest infections
- Pneumothorax - a serious complication of a rib fracture and presents with reduced chest expansion, reduced breath sounds and hyper-resonant percussion on the affected side
35
What is the best investigation for rib fractures?
CT scan of the chest
36
What is the Mx of rib fractures?
- Majority of cases are managed conservatively with good analgesia to ensure breathing is not affected by pain
- Inadequate ventilation may predispose to chest infections
- Surgical fixation - can be considered to manage pain
37
What is the use of the Ottawa ankle rules?
Used to indicate whether x-ray for ankle and midfoot injuries is necessary
38
What are the Ottawa ankle rules?
Patient experiences pain in the malleolar region and one of the following:
1. Tenderness at the posterior border or tip of the lateral malleolus - fibula
2. Tenderness at the posterior border or tip of the medial malleolus - tibia
3. Inability to weight bear for 4 steps
39
What is the classification of ankle fractures used?
Weber classification
Type A is below the syndesmosis
Type B fractures start at the level of the tibial plafond and may extend proximally to involve the syndesmosis
Type C is above the syndesmosis which may itself be damaged
40
What is a maisonneuve fracture?
Spiral fibular fracture that leads to disruption of the syndesmosis with widening of the ankle joint, surgery is required.
41
A 25-year-old male presents to the emergency department (ED) having twisted his ankle playing football. On arrival at the ED, he cannot walk more than 2 steps and has bony tenderness at the lateral malleolus. An x-ray is performed showing an undisplaced fracture of the fibula, just distal to the syndesmosis.
How should this patient be treated?
Weber A fracture - pateints with minimally displaced stable fractures
Analgesia and encourage to weight bear as tolerated using a controlled ankle motion boot
42
What is De quervain's tenosynovitis?
The sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed.
43
What are the features of de quervain's tenosynovitis?
- Pain on the radial side of the wrist
- Tenderness over the radial styloid process
- Abduction of the thumb against resistance is painful
- Positive Finkelstein test : examiner grasps the affected thumb and exerts longitudinal traction across the palm of the hand towards the ulnar side, which causes pain
44
What is the management of de quervain's tenosynovitis?
1. Analgesia
2. Steroid injection
3. Immobilisation with a thumb splint may be effective
4. Surgical treatment is required
45
A 57-year-old woman reports to the emergency department complaining of right-sided wrist pain following a fall on her outstretched right hand.
On examination, there is tenderness over her right anatomical snuffbox and pain on ulnar deviation of the right wrist.
An X-ray is arranged and confirms and un-displaced scaphoid fracture in the right wrist.
Based on the information provided, what is the most appropriate management option?
Undisplaced fractures of the scaphoid waist are typically managed with a cast for 6-8 weeks
46
Colin is a 77-year-old man who attends for a review of his left wrist in fracture clinic 2-weeks after a fall on an outstretched hand. His X-ray at the time of injury was normal but his wrist was immobilised in a Futuro splint as he was tender in the anatomical snuffbox. Follow-up imaging today reveals a fracture of the proximal scaphoid pole.
What is the appropriate definitive management of this?
All pole fractures of the scaphoid - need surgical fixation
47
A 25-year-old man attends the emergency department after being involved in a road traffic accident. He was in the driver's seat when a lorry in front lost control and became trapped when the dashboard and footwell were pushed forward on impact.
He is currently stable but has significant pain in his right leg. His right leg is shortened, internally rotated, slightly flexed and adducted compared to the left.
What is the diagnosis?
Posterior hip dislocations present with a shortened and internally rotated leg
48
What is the management of hip dislocation
- ABCDE approach.
- Analgesia
- A reduction under general anaesthetic within 4 hours to reduce the risk of avascular necrosis.
- Long-term management: Physiotherapy to strengthen the surrounding muscles.
49
What are some external compressing forces causing compartment syndrome?
Trauma related :
- Burn eschars
- Constrictive bandage/cast
Non-traumatic - incorrect positioning of limbs (immobile patient)
50
What are some internal compressing forces causing compartment syndrome?
Traumatic:
- Hematoma and edema from long bone fractures
- Blood vessel injury with hemorrhage
- Repetitive muscle use (esp. excessive running, seizures)
- Crush injury
- Penetrating injuries (e.g., gunshot and stab wounds)
- Burn edema
- Reperfusion syndrome with ischemia-reperfusion edema
- Edema from venomous animal bites (especially snake bites)
Non-traumatic:
- Increased capillary permeability (e.g., shock)
- Coagulopathy
51
What are some early presentations of acute compartment syndrome?
Pain - out of proportion - excessive use of breakthrough analgesia should raise suspicion
- worse with passive stretching or extension of muscles
- Very tight, wood-like muscles that are extremely tender to touch
Paraesthesia
Soft tissue swelling
6 P's of acute limb ischemia: Pain, Pallor, Paresthesias, Poikilothermia, Pulselessness, and Paralysis
52
What are some late presentations of acute compartment syndrome?
- Worsened pain and swelling
- Muscle weakness to paralysis
- cold peripheries
- pallor or cyanosis
- absent distal pulse
53
How is the diagnosis of compartment syndrome made?
Measurement of tissue pressure with a manometer and calculation of delta pressures
delta pressure = diastolic – (compartment) tissue pressure
Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic
54
How is compartment syndrome treated?
- essentially prompt and extensive fasciotomies
- In the lower limb the deep muscles may be inadequately decompressed by the inexperienced operator when smaller incisions are performed
- Myoglobinuria may occur following fasciotomy and result in renal failure and for this reason these patients require aggressive IV fluids
55
What is a late sign of cauda equina?
Incontinence
56
A 65-year-old lady presents to her GP complaining of sudden onset of pain and paraesthesia in her left leg. On further questioning, she reports that the pain radiates along the posterior thigh and the posterolateral aspect of the leg, to the dorsum of her foot and her large toe. On examination, you identify sensory loss in the dorsum of her left foot and reduced power upon performing dorsiflexion of her left ankle. Her reflexes remain intact and she has a positive left sided straight leg raise test.
Which of the following causes is most likely to be responsible for this presentation?
L5 radiculopathy: Weakness of hip abduction and foot drop, no specific reflex lost
57
What is the typical presentation of spinal stenosis?
Patients may present with a combination of back pain, neuropathic pain and symptoms mimicking claudication
Difference from claudication - history of positional element to the pain
Sitting is better than standing and patients may find it easier to walk uphill rather than downhill
58
A 73-year-old woman who has previously had a total hip replacement (THR) presents for review due to pain on the side of her prosthesis. What is the most common reason that a revision operation would need to be performed in a patient who has had a THR?
Aseptic loosening of the implant
2. pain
3. dislocation
4. infection
59
How do you differentiate between posterior hip dislocation and hip fracture?
posterior dislocation - shortened and internally rotated
hip fracture - shortened and externally rotated
60
What is the management of undisplaced intracapsular hip fracture?
internal fixation, or hemiarthroplasty if unfit.
61
What is the management of displaced intracapsular hip fracture?
NICE recommend replacement arthroplasty (total hip replacement or hemiarthroplasty) to all patients with a displaced intracapsular hip fracture
total hip replacement is favoured to hemiarthroplasty if patients:
- were able to walk independently out of doors with no more than the use of a stick and
- are not cognitively impaired and
- are medically fit for anaesthesia and the procedure.
62
What is the management of extracapsular hip fracture?
stable intertrochanteric fractures: dynamic hip screw
63
What are the features of galaezzi fracture?
Radial shaft fracture with associated dislocation of the distal radioulnar joint
64
What are the features of monteggia fracture?
proximal (or middle) ulnar fracture with concomitant dislocation of the radial head
65
What is the typical presentation of carpal tunnel?
- pain/pins and needles in thumb, index, middle finger
- unusually the symptoms may 'ascend' proximally
- patient shakes his hand to obtain relief, classically at night
- weakness of thumb abduction (abductor pollicis brevis)
- wasting of thenar eminence (NOT hypothenar)
66
What are the findings of the special tests in carpal tunnels?
Tinel's sign: tapping causes paraesthesia
| Phalen's sign: flexion of wrist causes symptoms
67
What is the treatment for carpal tunnel?
- corticosteroid injection
- wrist splints at night
- surgical decompression (flexor retinaculum division)
68
How do you differentiate tronchanteric bursitis from iliotibital band syndrome?
trochanteric buristis:
- pain over the lateral side of hip/thigh
- tenderness on palpation of the greater trochanter
Iliotibial band syndrome usually presents with lateral knee pain, usually after running.
69
What are the red flags of back pain?
- age < 20 years or > 50 years
- history of previous malignancy
- night pain
- history of trauma
- systemically unwell e.g. weight loss, fever
70
What are the drugs that can cause osteoporosis?
Long term use of:
- systemic corticosteroids
- Anticonvulsants
- L-thyroxine
- Anticoagulants (heparin)
- PPI
- Aromatase inhibitors (anastrozole, letrozole)
- Immunosuppressants (cyclosporine, tacrolimus)
71
What is the typical presentation of vertebral fractures?
- Asymptomatic: an osteoporotic vertebral fracture may be diagnosed through an incidental finding on X-ray
- Acute back pain
- Breathing difficulties: changes in the shape and length of vertebrae lead to the compression of organs such as the lungs, heart and intestine
- Gastrointestinal problems: due to compression of abdominal organs
- Only a minority of patients will have a history of fall/trauma
72
What is the test used to look for bone mineral density?
Dual-energy X-ray absorptiometry (DEXA) scan
73
What tool is used for assess 10-year risk of fracture?
FRAX tool
74
What is the primary cause of iliopsoas abscess?
- Haematogenous spread of bacteria
| - Staphylococcus aureus: most common
75
What is the secondary cause of iliopsoas abscess?
- Crohn's (commonest cause in this category)
- Diverticulitis, colorectal cancer
- UTI, GU cancers
- Vertebral osteomyelitis
- Femoral catheter, lithotripsy
- Endocarditis
- intravenous drug use
76
What are the clinical features of iliopsoas abscess?
- Fever
- Back/flank pain
- Limp
- Weight loss
77
What is the investigation of choice for iliopsoas abscess?
CT abdomen
78
What is the management of iliopsoas abscess?
Antibiotics
- Percutaenous drainage is the initial approach
- Surgery is indicated:
1. Failure of percutaneous drainage
2. Presence of an another intra-abdominal pathology which requires surgery
79
How do you differentiate iliotibila band syndrome from osgood schlatter disease?
Osgood-Schlatter disease, also known as tibial apophysitis, would typically cause pain and swelling over the tibial tubercle.
iliotibail band - lateral knee pain in runners - tenderness 2-3 cm above the laterla joint line
80
A 23-year-old-woman attends her GP with a history of right-sided knee pain. She is a keen runner, and notices the pain most after exercise. There has been no redness or swelling of the joint, and the knee has not been locking.
On examination, there is a full range of movement of the knee. There is sharp pain on palpation over the lateral epicondyle of the femur, particularly with the knee at 30 degrees of flexion.
Which of the following is the most likely diagnosis
Iliotibilal band syndrome
81
What test in positive in de quervain's tenosynovitis?
Finkelstein's test can be performed to help diagnose this condition. In a patient with De Quervain's tenosynovitis, pulling the thumb of the patient in ulnar deviation and longitudinal traction causes pain over the radial styloid process.
82
What are the causes of dupuytren's contracture?
- Manual labour
- Phenytoin treatment
- alcoholic liver disease
- diabetes mellitus
- Trauma to the hand
83
What is the highest risk factor for adhesive capsulitis/ frozen shoudler?
Diabetes mellitus
84
What are the features of adhesive capsulitis?
- external rotation is affected more than internal rotation or abduction
- both active and passive movement are affected
A painful freezing phase, an adhesive phase and a recovery phase
85
When do you refer to specialits for sciatica?
Try neuropathic analgesia first along with physiotherapy
If unresolved after 4-6 wks - referral for MRI
86
What are the risk factors for achilles tendon disorder?
- quinolone use (e.g. ciprofloxacin) is associated with tendon disorders
- hypercholesterolaemia (predisposes to tendon xanthomata)
87
What is the management of achilles tendinopathy?
- Simple analgesia
- Reduction in precipitating activities
- Calf muscle eccentric exercises: this may be self-directed or under the guidance of physiotherapy
88
What is the imaging of choice for suspected achilles tendon rupture?
US is the initial imaging modality of choice
89
What should be done if an achilles tendon rupture is suspected?
An acute referral should be made to an orthopaedic specialist
90
What are the risk factors of bicep rupture?
- Heavy overhead activities
- Shoulder overuse or underlying shoulder injuries which may stress the biceps tendon
- Smoking
- Corticosteroids; these weaken tendons
91
What is the criteria for rotator cuff repair?
Tears greater than 2cm should generally be repaired surgically.
92
A 35-year-old lady has been experiencing intermittent pins and needles in her right hand for the past month. As part of your neurological examination, you attempt to elicit the triceps reflex by placing the lady's arm across her chest and striking the triceps tendon with a tendon hammer. Which nerve (and its nerve root) are you testing?
Radial nerve C7
93
What are the symptoms of cubital tunnel syndrome?
Cubital tunnel syndrome is caused by compression of the ulnar nerve and can present with tingling/numbness of the 4th and 5th finger
Overtime patients may develop weakness and muscle wasting
94
What are the typical features of fat emolism?
Fever, breathlessness, confusion and retinal haemorrhages are all features of a fat embolus and can occur up to 3 days after the trauma.
95
What is the typical features of osteochondritis dissecans?
- Knee pain and swelling, typically after exercise
- Knee catching, locking and/or giving way: more constant and severe symptoms are associated with the presence of loose bodies
- Feeling a painful 'clunk' when flexing or extending the knee - indicating the involvement of the lateral femoral condyle
96
how is open fracture managed?
1st step - Analgesia and abx along with debridement and lavge within 6hrs of injury
2nd step - external fixation
97
what is the salter harris classification?
SALTR
```
I = S = SLIPPED
II = A = Above
III = L = Lower
IV = T = Through (all) Three
V = R = Rammed
```
98
what are the classical features of a colles fracture?
1. Transverse fracture of the radius
2. 1 inch proximal to the radio-carpal joint
3. Dorsal displacement and angulation
Colles' - Dorsally Displaced Distal radius → Dinner fork Deformity
99
what are the signs of scaphoid fracture?
1. point of maximal tenderness over the anatomical snuffbox
2. wrist joint effusion
3. pain elicited by telescoping of the thumb - pain on longitudinal compression
4. tenderness of the scaphoid tubercle
5. pain on ulnar deviation of the wrist
100
what is foucher's sign?
increase in tension of the baker's cyst on extension of the knee
101
what are the features of a morton's neuroma and what is the sign that can be elicited?
forefoot pain - commonly in the third inter-metatarsophalangeal space
worse on walking - shooting or burning pain
mulder's click - one hand tried to hold the neuroma between the finger and the thumb. the other hand squeezes the metatarsal together.
102
what is the mx of morton's neuroma?
1. avoid high heels
2. metatarsal pad
3. referral if symptoms persist for >3 mths despite footwear modifiations
103
how do you diganose morton's neuroma?
US
104
what is a positive simmonds' test and what is it a sign of?
absence of plantar-flexion on squeezing the calf on the affected leg - achilles tendon rupture
105
what is the ulnar paradox?
The ulnar paradox: proximal lesions of the ulnar nerve produce a less prominent deformity than distal lesions
when ulnar nerve affected at the elbow, the ulnar half of flexor digitorum profundus is also affected resulting in a less marked clawing due to reduced unopposed flexion at the IPJ
106
what is the difference between monteggia fracture and galeazzi fracture?
Monteggia ulna (Manchester United), Galeazzi radius (Galaxy rangers)
107
what are the conditons, talipes equinovarus associated with?
1. spina bifida
2. cerebral palsy
3. Edward's syndrome (trisomy 18)
4. oligohydramnios
5. arthrogryposis
108
what is the tx for perthes disease in a kid that is 5 yrs old?
less than 6 yrs - observation
