ortho Flashcards
patient is lying on back with knees flexed and unable to move due to pain –> ?
psoas abscess - keeping knees flexed reduces the pain
psoas abscess -
presentation:
most common causative organism:
RFs:
Ix:
Mx:
presentation: fever, back/flank pain, limp, unable to weight bear
most common causative organism: staph aureus
RFs: IVDU, Crohn’s, cancers, UTIs, endocarditis
Ix: CT
Mx: abx, may need surgical drainage
A 49 -year-old male presents with discomfort in the fingers of his left hand. On examination the ring and little fingers of his left hand are flexed and unable to extend completely. He is able to make a fist with the hand. Palpation reveals thickened nodules on the medial half of the palm.
Dx?
Dupuytrens contracture
difference between Dupuytrens contracture and ulnar claw?
ulnar claw: fingers can be passively extended + Duputreyen’s has thick nodules on palm
A 62-year-old man presents after his wife commented on the unusual shape of his fingers. On examination he has a hard swelling adjacent to the distal interphalangeal joint of his right hand with lateral deviation of the finger tip. There is no sensory disturbance and the swelling is not tender
Heberden’s nodes
A 57 year - old lady presents with a three month history of pins and needles in the fingers of the right hand, particularly at night. On examination, there is some loss of the sensation over the palmar aspect of the lateral three fingers and wasting of the thenar eminence.
Carpal tunnel syndrome83%
_______ score is useful to assess hypermobility
Beighton score
________ ‘cover’ should be used when starting allopurinol
NSAID/colchicine cover
__________: pain is exacerbated by walking on tip toes
plantar fasciitis
_________ excludes rupture of the Achilles tendon
Thompson’s test
______________ present with a shortened and internally rotated leg
Posterior hip dislocation
osteomalacia:
______ gait and bone pain
____ calcium, ____ phosphate
____ ALP, _____ PTH
waddling gait and bone pain
decreased calcium, decreased phosphate
increased ALP, increased PTH
Ankylosing spondylitis - x-ray findings:
subchondral erosions, sclerosis
and squaring of lumbar vertebrae
S1 lesion features =
- Sensory loss of posterolateral aspect of leg and lateral aspect of foot
- weakness in plantar flexion of foot, reduced ankle reflex
- positive sciatic nerve stretch test
prolapsed disc: ____ pain worse than ______ pain, pain worse when ______
leg pain worse than back pain
pain worse when sitting
1st line tx for reactive arthritis
NSAIDs
________ is a complication of discitis, cardinal features of which are fever and back pain
Epidural abscess
Pt with GCA is started on high dose pred and is concerned about bone health - what do you do?
prescribe alendronic acid, vitamin D and calcium supplements
If the patient was under 65 years old, then a bone density scan would be required to determine her need for bone protection medication.
EARLY xray findings for RA
L: loss of joint space
E: erosions (late finding)
S: soft tissue swelling
S: soft bones (osteopenia) (early finding)
miultiple fractures, widespread dental caries, deafness and blue sclera is associated _________
with osteogenesis imperfecta
The most common site of metatarsal stress fractures is the
2nd metatarsal shaft
pain reproduced on axial load through thumb –>
positive scaphoid compression test
________ typically present with hip/groin pain and a snapping sensation, , in a patient able to weight bear with pain on external rotation
Acetabular labral tears
_________ presents with isolated lateral hip/thigh pain with tenderness over the greater trochanter, particularly when rolling around, pain on internal AND external rotation of hip
trochantrtic bursitis
________ is a significant risk factor for avascular necrosis
Previous chemotherapy
note: Anterior = Avascular
_________ are the preferred surgical management for intertrochanteric (extracapsular) proximal femoral fracture
Dynamic hip screws
NoF
thenar wasting =
hypothenar wasting =
thenar wasting = carpal tunnel
hypothenar wasting = cubital tunnel (ulnar)
Fever/back pain with pain on extension of the hip → ?
iliopsoas abscess
severe pain after tibial fracture surgery =
compartment syndrome
what does DEXA score include?
age, gender, ethnicity
Following a fragility fracture in women ≥ 75 years _________
a DEXA scan is not necessary to diagnose osteoporosis and hence commence a bisphosphonate
osteoporosis: if it likely that the patient will have to take steroids for at least 3 months then we should
start bone protection straight away
vitamin D + Ca + bisphosphanata
eg. PR
Weber A fractures – Mx?
patients with minimally displaced, stable fractures may weight bear as tolerated in a CAM boot
It is important to _______ an ankle fracture as soon as possible due to risk of damage to the skin
reduce
A 68-year-old man presents to the plastics team with severe burns to his hands. He is not distressed by the burns. He has bilateral charcot joints. On examination; there is loss of pain and temperature sensation of the upper limbs.
What does he have?
syringomyelia which selectively affects the spinotholamic tracts
A 34-year-old man presents to the Emergency Department with a two-day history of left wrist pain following a fall onto his outstretched hand while ice-skating. On examination, he has a weakened left-sided grip and experiences pain upon longitudinal compression of the thumb. There is ulnar deviation of the wrist. X-ray imaging reveals no abnormalities.
What does he have?
Scaphoid fracture (diminished grip strength + pain elicited through longitudinal compression of thumb + ulnar deviation).
Mx for scaphoid fracture?
the wrist should be immobilised in a Futuro splint or below-elbow backslab, and the patient referred for orthopaedic review.
A 34-year-old medical secretary reports pain on the thumb side of her right wrist, ongoing for the past week. She also reports that right wrist appears more swollen than her left. On examination, she has pain over her radial styloid on forced flexion of the thumb
What is the most likely diagnosis?
De Quervain’s tenosynovitis as she is Finkelstein test positive ie. she has pain over her radial styloid on forced abduction/flexion of the thumb
_____________ is the most common mechanism of ankle sprain
Inversion of the foot
Z score vs T score
The T score compares the patient’s bone density with that of a healthy, young reference population.
The Z-score compares the individual’s bone density to an age-matched population, taking into account gender and ethnic background.
golfers elbow vs tennis elbow
- where is the pain?
- which actions worsen symptoms?
golfer’s: medial epicondylitis
pain worse on wrist flexion and pronation
tennis: lateral epicondulitis
worse on wrist extension and supination
__________ should be corrected before giving bisphosphonates
Hypocalcemia/vitamin D deficiency
1st line Tx for Paget’s?
bisphosphanate
Low serum calcium, low serum phosphate, raised ALP and raised PTH -
osteomalacia
in CKD, the phosphate will be raised rather than low
____________ are associated with an increased risk of atypical stress fractures
Bisphosphonates
A patient sustains an injury to one of the nerves of his upper limb. He complains of weak finger abduction and adduction with reduced sensation over the ulnar border of his hand. On examination you note clawing of the 4th and 5th digits. During recovery, the patient notices worsening of this deformity before eventually resolving.
What is the most likely diagnosis?
ulnar nerve damage at elbow
The ulnar paradox: proximal lesions of the ulnar nerve produce a less prominent deformity than distal lesions
presents with the insidious development of anterior hip pain and stiffness
avascular necrosis (AVN) of the hip
Ix for AVN of the hip?
XRAY
MRI**
Start alendronate in patients__________________, without waiting for a DEXA scan
> = 75 years following a fragility fracture
The most common site of metatarsal stress fractures
2nd metatarsal shaft
shoulder problems
1. Common in middle-age and diabetics
Characterised by painful, stiff movement
Limited movement in all directions, with loss of external rotation and abduction in about 50% of patients
- Rotator cuff injury
Painful arc of abduction between 60 and 120 degrees
Tenderness over anterior acromion
- adhesive capsulitis
- supraspinatus tendonitis
Osteomyelitis: ________is the imaging modality of choice
MRI
A 40-year-old woman complains of a permanent ‘funny-bone’ sensation in her right elbow. This is accompanied by tingling in the little and ring finger. Her symptoms are worse when the elbow is bent for prolonged periods. What is the most likely diagnosis?
The most likely diagnosis, in this case, is Cubital tunnel syndrome. This condition occurs when the ulnar nerve, which passes through the cubital tunnel at the elbow, becomes compressed or irritated. The symptoms described by the patient, such as tingling in the little and ring finger and worsening of symptoms when the elbow is bent for prolonged periods, are classic presentations of cubital tunnel syndrome.
Sudden popping sound during athletic activity → knee pain. swelling and instability ?
Ruptured anterior cruciate ligament i
spina cord compression?
1. Ix?
2. How to differentiate between lesions above L1 and below L1?
3. Mx?
- urgent MRI
- . Lesions above L1 usually result in upper motor neuron signs in the legs and a sensory level. Lesions below L1 usually cause lower motor neuron signs in the legs and perianal numbness. Tendon reflexes tend to be increased below the level of the lesion and absent at the level of the lesion
- high-dose oral dexamethasone
positive Simmonds sign =
achiles tendom rupture
trauma + snapping sensation in hip + occasional locking –>
acetabular labral tear
if the person describes the following whilst playing a sport or running; an audible ‘pop’ in the ankle, sudden onset significant pain in the calf or ankle or the inability to walk or continue the sport –>
Achilles tendon rupture
Imaging for Achilles tendon rupture
US
adhesive capsulitis features + Tx
- external rotation most affected
- active and passive movement both affected
- NSAIDs, physio, oral/intra-articular corticosteroids
Mx of ankle fractures
- prompt reduction
- young pt: surgical repair + compression plate
- elderly pt: conservative Mx
Ix choice for ANOH
MRI
Colle’s fracture - Px
- median nerve injury: weakness/loss of thumb/index finger flexion
2 main fractures that carry risk of compartment syndrome
- supracondylar fractures
- tibial shaft fractures
Px of compartment syndrome
- excessive pain even on passivement + excessive use of breakthrough analgesia
- parasthesia
- pallor
- paralysis
- pulse can usually still be felt
Tx for compartment Sx
- prompt, extensive fasciotomies + aggressive IV fluids (as myoglobin released during fasciotomy)
assess all pts with discitis for ________
IE with TTE
Anterior shoulder dislocation is associated with _______; while posterior shoulder dislocation is more likely associated with_______
FOOSH
seizures and electric shock
shortened + internally rotated leg =
posterior hip dislocation (much more common)
Sickle cell patients are prone to ____________ osteomyelitis
Salmonella
_______________ typically presents with muscle wasting of the hands, numbness and tingling and possibly autonomic symptoms
Neurogenic thoracic outlet syndrome
In some cases, symptoms can be worsened by raising the arm above the head
a well-known osseous anomaly is the presence of cervical rib
painless muscle wasting of hand muscles, with patients complaining of hand weakness e.g. grasping
sensory symptoms such as numbness and tingling may be present
if autonomic nerves are involved, the patient may experience cold hands, blanching or swelling
Clinical presentation of vascular TOS:
subclavian vein compression leads to painful diffuse arm swelling with distended veins
subclavian artery compression leads to painful arm claudication and in severe cases, ulceration and gangrene
Klumpe’s palsy vs Ulnar nerve palsy
the pattern of sensory loss is different. In an ulnar nerve palsy, the sensory loss is limited to the hypothenar eminence, little finger, and half the ring finger. In Klumpke’s palsy, the sensory loss covers the entire C8 and T1 dermatomes.
Weber fractures management
Weber A fractures occur below the syndesmosis of the ankle and so are stable. As such they should be immobilised in a CAM boot for 6 weeks and the patient should be encouraged to weight bear as tolerated.
Weber A -> 99% of times CAM boots as ankle is fine.
Weber B -> need radiograph (mortis view) to assess syndesmosis + mortis for ankle stability. It there is instability as ligaments are affect -> surgery. If not, then CAM boot.
Weber C -> 99% of times fracture will involve syndesmosis -> ankle instability -> required surgery (ORIF)
Weber fractures classes
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
A subtype known as a Maisonneuve fracture may occur with spiral fibular fracture that leads to disruption of the syndesmosis with widening of the ankle joint, surgery is required.
Mx rules for open fractures
Definitive management of open fractures should be delayed until soft tissues have recovered
Do debridement + application of spanning external fixation device
What is a recognised complication of Colle’s fracture? How does it present?
Median nerve palsy
Weak thumb abduction and opposition, difficulty with daily tasks
how would Extensor pollicis longus rupture present?
EPL rupture would present with pain at the wrist, inability to extend the thumb and inability to raise the thumb when placed flat on a table
Mx of undisplaced, closed humeral shaft fracture?
simple sling
