Ortho Flashcards
Carpal Tunnel
Compression of the median nerve (palmar digital branch) as it travels between carpals and flexor retinaculum
RF - repetitive strain, pregnancy, perimenopause, obesity, RA, DM, acromegaly, hypothyroid
= sensory symptoms from thumb to lateral ring finger, reduced thumb abduction, wasting of thenar eminence, Tinel’s (tapping), Phalen’s (pray)
Carpal Tunnel: Management
Inv - nerve conduction (prolonged AP in motor and sensory fibres)
-> 6wks conservative management (steroid injection, wrist splint), surgical decompression if severe
Hip Dislocation
Posterior (90%) = shortened, adducted, internally rotated
Anterior: abducted, externally rotated, no shortening
-> reduce under GA <4hrs, physio
Comp - sciatic nerve injury (foot drop), femoral nerve injury (anterior thigh sensation), avascular necrosis, OA, recurrent dislocation
Bisphosphonate Holiday
MOA - inhibit osteoclasts
SE: oesophagitis, oes ulcers, osteonecrosis of the jaw, atypical stress fractures, APR, v Ca
After 5 years PO or 3 years IV, re-assess with FRAX score and DEXA scan
Continue if; >75yrs, prev hip/ vertebral fracture, high risk FRAX, new fractures whilst on drugs, T score <2.5
Can stop for 2 years and reassess again
Paget’s Disease
Increased uncontrolled bone turnover, mostly affects skull, spine, pelvis and leg long bones
RF - age, M
= bone pain
Inv - isolated rise in ALP, normal Ca/ PO4, XR (osteolysis and sclerosis), skull XR (thick vault, OP circumscripta,cotton wool), bone scintigraphy (^uptake)
-> bisphosphonates if symptomatic
Comp - skull bossing, deaf, fractures, high-output HF, tibial bowing, sarcoma
Colles’ Fracture
Fracture of distal radius with dorsal displacement
Cause - FOOSH
= dinner fork deformity
Comp - median nerve palsy, compartment syndrome, vascular compromise, malunion, EPL rupture
Smith’s Fracture
Reverse Colles’, volar angulation of distal radius fragment
Cause - fall backwards onto palm
= garden spade deformity
Monteggia Fracture
Dislocation of proximal radioulnar joint and ulnar fracture
Cause - FOOSH (forced pronation)
Bennett’s Fracture
Intra articular fracture of 1st CMC (thumb)
Cause - impact on flexed metacarpal (fist fight)
Comp - abductor pollicis longus makes it hard to maintain reduction (unopposed pull)
Other Fractures
Galeazzi
= radial shaft fracture + dislocation of distal radioulnar joint
Bartons
= distal radial fracture (C/S) + radiocarpal dislocation
Radial Head Fracture
= tender head of radius, impaired elbow movement
Pott’s
= bimalleolar ankle fracture
OP Vertebral Fracture
Fragility fracture: mechanical force causes a fracture where in a normal person it would not, common in spine
= acute back pain, breathing issues, GI compressive symptoms, v height, kyphosis, local tenderness
Inv - XR spine (wedging, old sclerotic fractures), CT, MRI
? Future risk - DEXA, FRAX/ Qfracture tools (10yr)
Psoas Abscess
Cause - primary (blood, staph aureus) or secondary (Crohn’s, CRC, IVDU, UTI, osteomyelitis, IE)
= fever, back/ flank pain, limp, weight loss, pain on hyperextension and resisted flexion of the hip, may lie in mild external rotation (knee flexed)
Inv - CT abdo
-> Abx and PC drainage
Acetabular Labral Tear
Cause - 2nd to trauma or degenerative change
= hip/ groin pain, snapping/ locking sensation
Achilles Tendon Rupture
RF - ^age, FHx, quinolones (-floxacin), steroids, high cholesterol, inflammatory conditions, DM
= audible pop, sudden pain, loss of function, Simmond’s (angle of declination/ dorsiflexion, palpable gap, calf squeeze)
Inv - US
-> referral to ortho
Tendinitis: gradual onset posterior heel pain, try analgesia and eccentric calf exercises
AC joint injury
1-2: very common, rest in sling
3: depends on the individual
4-6: rare, surgery
Adhesive Capsulitis
Frozen shoulder, inflammation and fibrosis of the joint capsule leads to adhesions which restrict movement
RF - middle-age F, DM
= external rotation worst, active and passive effected, painful freezing, adhesive and recovery phase, 20% bilateral
-> NSAIDs, physio, steroids (PO/ IA)
Weber Classification
Describes level of fibula fracture in ankle injuries
A - below the syndesmosis
B - fractures start at tibial plafond, may extend proximally to involve the syndesmosis
C - above the syndesmosis
-> all ankle fractues should be promptly reduced, surgery if young and unstable/ high velocity/ proximal injuries
Ottawa Rules for Ankle XR
Required only if pain in the malleolar zone + one of;
Bony tenderness at lateral malleolar zone
Bony tenderness at the medial malleolar zone
Inability to walk four weight-bearing steps immediately after the injury and in ED
Ankle Sprains
Low: involving lateral collateral ligaments, most common, ^ATFL
Cause - inversion
Grade 1-3 based on ligament disruption, bruising, pain
High: involving syndesmosis
Cause - external rotation
= more painful, Hopkins squeeze +ve
Inv - XR (widening), MRI if suspect syndesmotic or persistent pain
-> fixation if widening, cast or orthosis if not
Avascular Necrosis of the Hip
Death of bone tissue 2nd to loss of blood supply, leads to bone destruction and v joint function
Causes - steroids, chemo, alcohol, trauma
Inv - MRI best, XR (osteopenia, microfractures)
-> may need joint replacement
Baker’s Cyst
Distension of bursa
= swelling in popliteal fossa, rupture leads to pain, redness, calf swelling
Biceps Rupture
Long tendon to glenoid and short tendon to coracoid process
RF - heavy overhead activity, shoulder overuse, smoking, steroids
Proximal Rupture (90%, long)
= >60yrs, load applied when bicep is lengthened and contracted (descent of pull up)
Distal Rupture (short)
= 40yrs, flexed elbow suddenly extended when biceps are already contracted
= pop, pain, bruising, swelling, popeye in proximal, -ve squeeze (no supination)
Inv - US, urgent MRI for distal
Cervical Spondylosis
Extremely common, 2nd to OA (narrowing of IV spaces)
= neck pain, may refer (headaches)
Comp - radiculopathy, myelopathy
Charcot Joint
Neuropathic joint, disrupted and damaged 2nd to loss of sensation
Cause - DM, syphilis
= extensive bone remodeling / fragmentation involving the midfoot, may be painful, red, hot
Cubital Tunnel Syndrome
Compression of ulnar nerve in the cubital tunnel
= tingling and numbness in fingers 4/5, weakness and wasting with time, worse when leaning on elbow
-> physio, steroids
De Quervain’s Tenosynovitis
Inflammation of sheath containing EPB and AbPL
RF - F, 30-50yrs
= radial wrist pain, tender radial styloid, pain on resisted thumb abduction, Finkelstein’s (pull thumb in ulnar deviation and longitudinal traction)
-> analgesia, steroid injection, immobilise thumb
Discitis
Infection of the intervertebral disc space
Cause - bacterial (staph aureus), viral, TB, aseptic
= back pain, fever, rigors, neuro features (suggests epidural abscess)
Inv - MRI, CT-guided biopsy (for Abx), need TT ECHO or TOE to assess for IE
-> 6-8wks IV Abx
Comp - sepsis, epidural abscess
Dupuytren’s
Fascia of the hand becomes thickened and tight
RF - ^age, FHx, M, manual labour (vibrating tools), DM, smoking, alcohol, phenytoin
Cause - inflammatory process related to microtrauma
= cords of dense connective tissue extend into fingers, pulled into flexion, ring/ little finger (rarely Index)
-> consider surgery when MCP can’t be straightened
Fat Embolism
= ^HR, ^RR, v sats, fever, red/ brown flat petechial rash, oral bleeds, confusion, agitation, retinal bleeds
Inv - lipuria
-> fixation of fracture, supportive, DVT prophylaxis
Greater Trochanteric Pain Syndrome
Trochanteric bursitis
Cause - repeated movement of IT band causing inflammation of the bursa
= 50-70yr F, pain over lateral side of hip/ thigh, tender over greater trochanter
Hip Fracture
= hip pain, shortened, externally rotated, may weight bear if non-displaced, blood supply risk if displaced
Garden system
1 - stable fracture
2 - complete fracture, not displaced
3 - displaced but still boney contact
4 - complete boney disruption
Intracapsular
-> Undisplaced: internal fixation, hemiarthroplasty if unfit
-> Displaced: THR/ hemiarthroplasty
Extracapsular
-> Stable intertrochanteric: dynamic hip screw
-> Reverse oblique, transverse or subtrochanteric: intramedullary device
Surgery <48hrs, weight bear asap after
IT Band syndrome
= lateral knee pain in runners, tender 2-3cm above joint line
-> modify activity, stretches, physio
Knee Ligament injuries
Unhappy triad: ACL, MCL and meniscus
ACL
Cause - twisting with bent knee
= loud crack, pain, rapid joint swelling, +ve lachman and anterior drawer
PCL
Cause - dashboard injuries (hyperextension)
MCL
Cause - leg forced into valgus e.g., skiing
= abnormal passive abduction of the knee
Meniscus
Cause - twisting
= locking and giving way, delayed swelling, Thessaly’s test (weight bear at 20° knee flexion, twisting causes pain)
Chondromalacia Patellae
Common in teenage girls, following an injury
= pain going downstairs or at rest, tender, quad wasting
Osteochondritis Dissecans
Mainly affects subchondral bone
= kid/ young adults, subacute knee pain and swelling, locking of the knee, painful clunk
Inv - XR (subchondral crescent, loose bodies), MRI
Tibial Plateau Fractures
Knee forced into varus or valgus, knee fractures before ligaments rupture
RF - elderly, sig trauma in young
Schatzker Classification
1) vertical split of lateral condyle
2) lateral condyle + load bearing part
3) depression of articular surface
4) medial tibial condyle
5) both condyles
6) condylar and subcondylar fractures
Le Riche Syndrome
Atheromatous disease of iliac vessels, comprises blood flow to pelvic viscera
= buttock claudication, impotence
Inv - angiography
-> endovascular angioplasty, stent
Lower Back Pain: Red Flags
<20yrs or >50yrs
Hx cancer
Night pain
Hx trauma
Weight loss, fever
Lower Back Pain: Management
Inv - MRI only if likely to change management.
-> NSAIDs 1st line (w/ PPI if >45), exercise programme, manual therapy with this
Prolapsed Disc
= dermatomal leg pain, associated neuro defects
L3: sensory loss of anterior thigh, weak hip flexion/ hip adduction/ knee extension, v knee reflex, +ve femoral stretch
L4: sensory loss of anterior knee and medial leg, weak knee extension/ hip adduction, v knee reflex, +ve femoral stretch
L5: sensory loss of dorsum of foot, weak hip abduction/ foot dorsiflexion, normal reflexes, +ve sciatic
S1 - sensory loss of posterolateral leg and lateral foot, weak plantar flexion, v ankle reflex, +ve sciatic
Inv - consider MRI if persist 4-6wks
Femoral, Obturator and LCN
Femoral
Motor: knee extension, hip flexion
Sensory: anterior and medial thigh, lower leg
Cause - hip/ pelvis fracture
Obturator
Motor: thigh adduction
Sensory: medial thigh
Cause - anterior hip dislocation
LCN of the Thigh (L2/L3)
Sensory: lateral and posterior thigh
Cause - compression near ASIS (meralgia paresthetica, RF incl. obesity, pregnancy, trauma)
Gluteal, Tibial, Common Peroneal Nerves
Superior Gluteal
Motor: hip abduction
Cause - posterior hip dislocation, IM injection, hip surgery, pelvic fracture (= Trendelenburg)
Inferior Gluteal
Motor: hip extension, external rotation
Cause - with sciatic nerve (= can’t stand from seat or jump)
Tibial
Motor: plantarflexion, inversion
Sensory: sole of foot
Cause - uncommon, popliteal laceration
Common Peroneal
Motor: dorsiflexion, eversion, EHL
Sensory: dorsum of foot, lateral lower leg
Cause - neck of fibula, tight cast
Spinal Stenosis
Narrowing of the central lumbar canal
Cause - tumour, prolapse/ herniated disc, degenerative changes, fractures
= back pain, claudication-like symptoms, better when sitting/ bending/ walking uphill (canal widens)
Inv - MRI
-> laminectomy
Metatarsal Fracture
Proximal 5th is most common, 1st is least likely
Types
Proximal avulsion (pseudo-Jones): ^common, proximal tuberosity fracture 2nd to lateral ankle sprain/ inversion
Jones: transverse fracture at meta-diaphyseal junction
Stress: athletes, ^2nd shaft
Inv - XR (non/displaced, periosteal change at 2-3wks), MRI
Froment’s Sign
Test for ulnar nerve palsy
= pull piece of paper out from between thumb and index finger, can’t hold and try to compensate with FPL
Management of Open Fractures
-> image the area, check NV status distally, cover with dressing, Abx, early debridement, 6L saline to irrigate, stabilise the fracture
OA
RF - FHx, F, >55yrs, prev. trauma, obesity, hypermobility, occupation, DDH, (OP is protective)
Hand
= bilateral, CMC and DIP, episodic ache, worse with movement, better with rest, short periods of stiffness
*Heberden’s DIP, Bouchard’s PIP, thumb squaring
Hip
2nd most common area (after knee)
-> THR (SE: VTE, posterior dislocation, aseptic loosening needs revision)
Gradual mobilisation over 6wks
Osteomyelitis
Infection of the bone
Haematogenous: kids (metaphysis), vertebral if adults
RF - sickle cell, IVDU, IS, HIV, IE
Non-haematogenous: adults, polymicrobial
RF - DM foot ulcers/ pressure sores, PAD
Cause - staph aureus, salmonella in sickle cell
Inv - MRI
-> flucloxacillin for 6wks (clindamycin if not)
Osteoporosis Risk Assessment
Assess if; F>65 or M>75 or younger with RF
FRAX: 10yr fracture risk, age 40-90
-> low risk (lifestyle), moderate (DEXA), high (treat)
With BMD
-> reassure, consider, strongly consider
Qfracture: 10yr fracture risk, age 30-99, uses more RF
BMD Assessment with DEXA
- when starting sex hormone deprivation
- <40yrs with major RF (Hx of multiple/ major fracture, high dose steroids >3m)
Recalculate risk after 2 years or change of RF
Risk factors for OP fractures
Age
Prev fragility fracture
Steroids
Falls
FHx of hip fracture
2nd OP (Cushing’s, hyperthyroid, renal disease)
Low BMI
Smoking
Over 14 units alcohol
Growth Plate Fractures
Salter Harris system
1) through physis only (XR may be normal)
2) physis and metaphysis
3) physis and epiphysis
4) all three
5) crush injury (XR may be normal)
Straight through
Above
Low
Through
Erasure
Common fractures in children
Complete - both sides of cortex breached
Toddlers - oblique tibial fracture
Plastic - deformity with no cortex disruption
Greenstick - unilateral cortical breach
Patella Fracture
Inv - XR (AP and lateral)
-> 6wk hinged knee brace if non-displaced, consider surgery if displaced (lose extensor mechanism) then brace
Plantar Fasciitis
Inflammation of the plantar fascia, connective tissue attaching calcaneus to flexor tendons
= most common heel pain in adults, worse at medial tuberosity
-> rest, supportive shoes, insoles
Rib Fractures
= severe sharp chest pain, tender chest wall, bruising
Inv - CT best
-> resolve on own, pain relief, deep breathing
Flail chest: 2+ fractures along 3+ consecutive ribs, paradoxical movement during respiration
Rotator Cuff Injury
Encompasses subacromnial impingement (60-120°), calcific tendonitis, cuff tears and arthropathy
= pain on abduction, tender anterior acromion
Sarcoma
Malignant tumours of mesenchyme, bone or soft tissue
= painful, growing mass, fractures, v function
Osteosarcoma - 20% of primary (most common), ^meta of long bones, kids, Rb, XR (Codman triangle, sunburst)
Ewing’s sarcoma - small round blue cell tumour, ^pelvis and long bones, kids, t(11:22), XR (onion skin)
Chondrosarcoma - tumour of cartilage, middle-age, ^axial skeleton
Scaphoid Injury
Most common carpal fracture, dorsal carpal branch of radial artery supplies 80% of blood (risk of AVN)
Cause - FOOSH, contact sport
= pain on radial side of wrist, v grip strength, tender snuffbox and scaphoid tubercle, effusion (4hrs-4d), pain on telescoping thumb and ulnar deviation of wrist
Inv - XR, CT, MRI definitive
-> Futero splint/ elbow backslab to immobilise, ortho review <7-10d if imaging inconclusive
Non-displaced: cast for 6-8wks
Displaced/ proximal scaphoid pole: surgical fixation
Shoulder Dislocation
Most common dislocation, 95% anterior
-> if recent then may reduce with no analgesia/ sedation
Subluxation of the Radial Head
Most common upper limb injury <6yrs, weak annular ligament covering radial head
= elbow pain, limited supination and extension
-> pain relief, passive supination of the elbow whilst flexed to 90 degree
Talipes Equinovarus
Club foot, inverted and plantarflexed
RF - 2M:1F, 50% bilateral
-> Ponsetti method, manipulation and casting from soon after birth, 85% need Achilles tenotomy
Trigger Finger
Thickening of tendon or tightening of the sheath, MCP joint A1 pulley
RF - F, RA, DM
= thumb, middle and ring finger, stiffness and snapping when extending, nodule at base of finger
-> steroid injection and splint, surgery
Msc, Axillary and Radial Nerve
Musculocutaneous (C5-C7)
Motor: elbow flexion, supination
Sensory: lateral forearm
Cause - part of brachial plexus injury
Axillary (C5-C6)
Motor: shoulder abduction
Sensory: inferior region of deltoid
Cause - humeral neck fracture (collar and cuff for non-displaced)
Radial (C5-C8)
Motor: elbow, wrist, finger extension
Sensory: small area between dorsal 1st and 2nd MC
Cause - humeral midshaft fracture (= wrist drop)
Median, Ulnar and Long Thoracic Nerve
Median (C6, C8, T1)
Motor: LOAF
Sensory: palmar aspect of lateral 3.5 fingers
Cause - carpal tunnel
= (at wrist) paralysis of thenar muscles and opponens pollicis, (at elbow) v pronation and wrist flexion
Ulnar (C8, T1)
Motor: intrinsic hand excl. LOAF, wrist flexion
Sensory: medial 1.5 fingers
Cause - medial epicondyle fracture (= claw hand)
Long Thoracic (C5-C7)
Motor: serratus anterior
Cause - blow to ribs, mastectomy (= winged scapula)
Benign Bone Tumours
Osteoma - overgrowth of bone, ^skull, link to FAP/ Gardner’s syndrome
Osteochondroma (exostosis) - most common benign, M <20yrs, cartilage-capped bony projection
Giant cell tumour - 20-40yrs, ^epiphysis of long bones, XR (double bubble, radiolucent)
Management of Ankle fractures
Weber A and B - cast / boot and weight bear as tolerated
Weber C or unstable - ORIF
Femoral Neck: Blood Supply
Medial and lateral circumflex femoral arteries join the femoral neck proximal to intertrochanteric line, and run along the surface of the femoral neck within the capsule
I.e., an intracapsular fracture can affect blood supply
Sciatica
L4-S3, travels down back of leg, divides at knee into tibial and common peroneal
Causes - spinal stenosis, herniated disc, spondylolisthesis (anterior displacement of a vertebra)
*if bilateral think cauda equina
= pain from buttock down back of thigh, to below knee or foot, paraesthesia, numbness, motor weakness
Cauda Equina Syndrome
Compression of lumbrosacral nerve roots that extend below the spinal cord (terminates at L2/ L3)
Causes - prolapsed disc (L4/5 or L5/S1), tumour, abscess, discitis, trauma, haematoma, spondylolisthesis
= low back pain, bilateral sciatica, v perianal sensation, v anal tone, incontinence
Inv - urgent MRI
-> surgical decompression
Metastatic SCC
Oncological emergency, 5% of cancer patients
RF - lung, breast, prostate cancer
= back pain, worse coughing/ lying down/ straining, lower limb weakness, sensory loss (UMN signs if above L1, LMN signs below L1), ^reflexes below the lesion
-> high dose PO dex, surgery or radiotherapy
Osgood-Schlatter
Inflammation of the tibial tuberosity
Cause - traction apophysitis due to repeated avulsion where patella tendon inserts
Fat Pad Atrophy
Wasting of the fat pad under heel of foot
= presents like plantar fasciitis
Morton’s Neuroma
Dysfunction of a nerve in the intermetatarsal space, ^between 3rd and 4th
= sensation of lump in shoe, pain at front of foot, p+n
Injuries with Ant. Shoulder Dislocation
Bankart lesions: tear to anterior portion of labrum
Hill-Sachs: compression fractures of the posterolateral head of humerus
Axillary nerve damage: C5/6, v sensation over lat deltoid, weak deltoid
Epicondylitis
Inflammation where tendons of forearm insert onto the epicondyles
Lateral (Tennis) - worse on wrist extension or supination
Medial (Golfer’s) - worse on wrist flexion and pronation
Ganglion
Sac of synovial fluid originating from tendon sheath or joint
= ^dorsal wrist, F, firm well-circumscribed mass, transilluminates
-> disappear over months, excise if severe symptoms
Nerve Supply to Hand
Rock - finger flexion - median
Paper - finger extension - radial
Scissors - abduction and adduction - ulnar
Volkmann’s Ischaemia
Cause - supracondylar fracture of the humerus leading to vascular compromise
= persistent pain first (worse on passive extension of fingers), pallor, poor CR, absent radial pulse, paraesthesia in median nerve area
Comp - contracture (claw), gangrene
Supracondylar Humeral Fracture
Common paeds elbow injury
-> urgent ortho review
Comp - nerve palsy (ant. interosseus nerve, ulnar post-op), posterior displacement of the distal fragment is common, varus deformity due to malunion, Volkmann’s
