Ortho 2 Flashcards
1
Q
What is osteomyelitis?
A
Infection of the bone
- In neonates - metaphysis or epiphysis commonly affected
- in children - metaphysis
- in adults - epiphysis and subchondral regions
2
Q
What increases incidence of osteomyelitis?
A
Incidence increases as living conditions drop
3
Q
How can osteomyelitis start?
A
Can be acute primary or can spread from local infection eg. boils, abscesses, pneumonia or GU instrumentation
4
Q
Pathology of osteomyelitis
A
Cancellous bone is typically affected in adults. Infection leads to cortex erosion with holes (cloacae). Exudation of pus lifts up periosteum interrupting blood supply to underlying bone - necrotic bone fragments form (sequestrum)
5
Q
What areas of bone are most commonly affected by osteomyelitis in IV drug users, diabetics and children
A
Vertebrae in IV drug users, feet in diabetics, children is most commonly vascular bone (eg long bone metaphyses, distal femur, upper tibia etc)
6
Q
What is typically present in the bone in chronic osteomyelitis?
A
Sequestrum (piece of dead of bone separated from the normal bone by necrosis)
7
Q
What is involucrum in osteomyelitis
A
New bone formation created by the elevated periosteum
8
Q
What can happen visually in osteomyelitis?
A
Pus may discharge into the joint spaces or via sinuses to the skin
9
Q
Typical hx and symptoms of osteomyelitis
A
Pain gradual onset over the course of a few days - tenderness, warmth and erythema at affected part
Unwillingness to move
May have slight joint effusion in neighbouring joints and signs of systemic infection
10
Q
In whom are osteomyelitis signs less marked
A
In adults - acute invariably happens in children, in adults it is normally IV drug users or immunosuppressed patients or those with other disease/infection elsewhere
11
Q
Common organisms for osteomyelitis x4
A
Staph aureus!!!, Pseudomonas, E.coli, Streptococci (sickle cell may be salmonella)
12
Q
Tests in osteomyelitis
A
Bone biopsy and culture is gold standard
Inflammatory markers will be raised
13
Q
Radiograph in osteomyelitis
A
Changes won’t show for 10-14 days, then slow haziness and loss of density - later sequestrum and involucrum
MRI is specific and sensitive for earlier osteomyelitis
14
Q
Treatment of osteomyelitis
A
Drain abscesses and remove sequestra by open surgery (if very severe)
Vancomycin and cefotaxime IVI for 6 weeks (change if specificity known)
15
Q
Treatment of pseudomonas osteomyelitis
A
Ciprofloxacin
16
Q
What is chronic osteomyelitis?
A
Any acute osteomyelitis can become chronic with poor treatment
Generally considered chronic if longer than a month
17
Q
Symptoms of chronic osteomyelitis
A
Pain, fever and sinus suppuration
18
Q
Xray in chronic osteomyelitis
A
Only if advanced infection, acutely - will see soft tissue swelling and may see joint effusion in local joint, then periosteal thickening and regional osteopenia with cortical loss
19
Q
What is Pott’s disease
A
Bone TB in vertebra
20
Q
Risk factors for osteomyelitis x6
A
Diabetes Vascular disease Sickle cell Impaired immunity Surgical prostheses Open fractures
21
Q
What cancers commonly metastasise to the bone x4
A
Breast, bronchus, prostate and kidney
22
Q
What time of bone cancer is rare
A
Primary (mostly children apart from chondrosarcoma)
23
Q
Radiological features of bone cancer x4
A
Bone destruction, new bone formation, soft tissue swelling, periosteal elevation
24
Q
What is the most common malignant primary tumour of bone
A
Osteosarcoma
25
Who is typically affected by primary osteosarcoma and where do they get it?
Adolescents
Arises in the metaphyses of long bones especially around the knee
Typically in sites of bone growth (metaphysis) presumably because proliferation makes osteoblastic cells more prone to mutation
26
Treatment of osteosarcoma
Resection + chemotherapy - 90% have limb sparing surgery
27
Cure rate for primary osteosarcoma
60-70%
28
What is Ewings Sarcoma?
Round-cell tumour of long bones and limb girdles - usually presents in younger adolescents
Typically occurs in femur, tibia and pelvic bones
29
What do you see on radiograph with Ewings Sarcoma?
Concentric layers of new bone formation = "onion-ring sign"
| and a soft tissue mass
30
Genetic association of Ewings Sarcoma?
Typically have a t11:22 chromosomal translocation
31
Treamtent of Ewings Sarcoma?
Chemo, surgery and radiotherapy - chemo first to shrink the tumour
32
5 year recurrence free survival for Ewings Sarcome?
22% if mets at diagnosis, 55% if no mets - 30% overtly metastatic at presentation
33
What is Chondrosarcoma and who does it affect?
Carcinoma of cartilage producing cells which affects the axial skeleton as well as long bones
In middle-aged people typically (unlike other bone tumours which are more common in children)
34
Treatment of chondrosarcoma
Doesn't respond to chemo or radio
| Therefore treat with excision
35
What is the most common benign bone tumour - where does it occur
Osteochondroma
Occurs about the knee, proximal femur or proximal humerus
Usually around growth plates
Grows with the bone and then will usually stop growing when bone stops growing
36
Presentation of osteochondroma
Painless lump or local mass effects
Pain with exercise - tendon snapping over the growth
Neurological symptoms - tingling or numbness
Decreased blood flow from vascular compression
37
Osteochondroma on x ray
Bony spur pointing away from the joint
38
Treatment of osteochondroma
Remove if causing symptoms from pressure on local structures
| Or if continuing to grow after skeletal maturity because risk of malignancy
39
What do you suspect if boney pain responding to aspirin within 15mins in young adult?
Osteoid Osteoma - nocturnal pain is a significant feature
40
Details of osteoid osteoma
Painful benign bone lesion occurring in long bones of young males 10-25 years old
responds to aspirin (produces prostaglandins which lead to pain unrelated to activity)
41
Treatment of osteoid osteoma
CT guided biopsy and radiofrequency ablation - treatment is dependant on symptoms, if can be managed with anti-inflammatories then it will be
42
Features which lead to suspecting mass as being soft tissue sarcoma x4
Bigger than 5cm, increasing in size, deep to deep fascia, painful
43
Treatment of soft tissue sarcoma
Excision by wide margins - followed by radiotherapy
44
What is osteogenesis imperfecta?
An inherited disorder of type I collagen that results in fragile, low density bones = brittle bone disease/ Lobstein syndrome
45
Incidence of osteogenesis imperfecta?
1 in 20,000 affected
46
Details of type 1 osteogenesis imperfecta? x8
```
Mildest and most common
Autosomal dominant
Blue sclerae (increased corneal translucency)
50% have hearing loss
Fractures typically before puberty
Loose joints and poor muscle tone
Normal life expectancy
Normal collagen produced but not enough of it
```
47
Details of type 2 osteogenesis imperfecta? x3
Lethal perinatal form with many fractures and dwarfism
Recessive
Most die within first year of life from respiratory failure or intracerebral haemorrhage
48
Details of type 3 osteogenesis imperfecta? x8
```
Severe form
Occurs in 20%
Recessive
Fractures at birth and progressive (key feature of type 3) limb and spinal deformity with resultant short stature
Blue or white sclera
Dentinogenesis imperfecta is common
Life expectancy decreased
Enough collagen is produced but it's defective
```
49
Details of type 4 osteogenesis imperfecta? x6
```
Moderate form
Autosomal dominant
Fragile bones
White sclera after infancy
Has been expanded into types 4-7
Not high enough quality collagen is produced but enough is produced
```
50
Radiographs in osteogenesis imperfecta? x3
Many fractures
Osteoporotic bones with thin cortex
Bowing deformity of long bones
51
Treatment of osteogenesis imperfecta? x4
Prevent injury
Physio, rehab and occupational therapy
Intramedullary rods sometimes used in long bones
Bisphosphonates
52
What is Achondroplasia?
Most common form of dwarfism due to reduced growth of cartilaginous bone
53
Inheritance of achondroplasia
Autosomal dominant but 80% are from spontaneous mutations - if inherit two forms of gene (one from each parent) likely to die in first few months of life
54
Gene mutation causing achondroplasia
95% are caused by mutation in the gene encoding fibroblast growth factor receptor type 3 (FGFR3)
55
Effects of achondroplasia x5
```
Large heads with ventriculomegaly and frontal bossing
Normal trunk length
Short limbs
Fingers all the same length
Delayed gross motor skills development
```
56
Appearance of adults with achondroplasia x4
Short, increased lumbar lordosis, bowed legs and short proximal arms and legs
57
What is the affect of achondroplasia on lifespan?
None - lifespan normal
58
What is the affect of achondroplasia on mental and sexual development?
None - both normal
59
Complications of achondroplasia x6
```
Tibial bowing
Joint hypermobility
Hydrocephalus, foramen magnum compression
Recurrent otitis media and hearing loss
Sleep apnoea
Increased BMI
```
60
Radiographs in achondroplasia
Short proximal long bones and wide ephiphyses
61
What is hereditary multiple exostoses?
Autosomal dominant disorder in which certain proteins accumulate in the Golgi apparatus leading to cartilage-capped tumours developing from affected cartilage at the end of long bones (point away from joint)- many osteochondromas/extoses
62
Effects of hereditary multiple exostoses
If severe, bones are broad and badly modelled
Causing short stature as well as forearm, knee and ankle deformity
Boney spurs may have local effects, nerve/vascular compression
63
What can occur in hereditary multiple exostoses
Malignant transformation from exostoses/osteochondromata to chondrosarcomas or osteosarcomas
64
Treatment of hereditary multiple exostoses
Removal of symptom producing exostoses, pain management and physiotherapy
65
What is osteopetrosis
Lack of differentiation between cortex and medulla of bone following from underlying failure of osteoclastic bone resorption - Marble bone disease/Albers-schonberg disease
66
What are bones like in osteopetrosis?
Very hard, dense 'marble' bones that are brittle
67
What can you get with osteopetrosis
Anaemia and thrombocytopenia from decreased marrow space
Deafness and optic atrophy from CN compression
Despite being hard the bones are still very brittle therefore multiple fractures
68
Radiograph in osteopetrosis
Lack of remodelling therefore ossific density with bone within a bone appearance
69
What are osteochondroses? What are they also called?
Group of conditions characterised by abnormal endochondral ossification of epiphyseal growth during childhood
Also called osteochondritis
Bone grows and then stops and then starts again
70
Underlying of cause of osteochondroses?
Unknown
| Inheritance, overuse/trauma, rapid growth and anatomic configuration may be predisposing factors
71
Pathology of all osteochondroses?
Interruption of blood supply to epiphysis, followed by bone and cartilage necrosis, revascularisation and regrowth of bone
72
What is Scheuermann's disease?
Osteochondrosis - Most common cause of kyphosis in 13-16 year olds
Problem with thoracic vertebrae - deforming forces are greatest anteriorly therefore vertebrae narrower here causing kyphosis
73
Presentation of Scheuermann's disease?
Usually present for deformity rather than pain
74
Radiographing features of Scheuermann's disease? x4
Irregular vertebral end plates
Schmorls nodes (protrusion of IVD through vertebral body end plate and into adjacent vertebra)
Decreased disc space
Anterior wedging
75
Treatment of Scheuermann's disease?
Posture control and exercise
Physiotherapy + spinal braces
Surgery if severe
76
What is Calve's vertebra
Not true osteochondroses as due to eosinophilic granulomata but produces similar picture to scheuermann's disease but in younger child 2-10years
77
Symptoms of Calves vertebra
Pain and tenderness over affected vertebra with slight kyphosis
78
Radiograph in Calves vertebra
Flattened vertebral body with disc space preserved
79
What is Kienbocks disease?
Osteochondroses affecting lunate bone in males 20-40 years
80
Symptoms of Kienbocks disease
Pain over lunate especially during active wrist movement
| Grip impaired due to pain
81
Radiograph in Kienbocks disease
Dense lunate with a depth reduction - leads to OA
82
Treatment of Kienbocks disease
Splinting and analgesics
| Can do surgery if needs be to restore blood flow to lunate (or to realign bones or remove lunate if severe)
83
What are Panner's disease and osteochondritis dissecans of the elbow?
Spectrum of conditions affecting the capitellum (radial attachment on humerus)
84
Who does Panner's disease affect and what does it cause?
Affects boys under 10
| Lateral elbow pain and swelling
85
Management of panner's disease
Usually just conservative management
86
What does osteochondritis dissecans of the elbow cause?
Loose body from cartilage becoming avascular and separating from bone
Causes early aching and effusion after use in adolescents
Sudden painful locking if loose bodies
87
Treatment of OCD?
Stable lesions managed conservatively in a hinged brace
| Unstable lesions may need fixation +/- removal of loose bodies
88
What is Kohlers disease?
Navicular osteochondroses in children 3-5 years old
89
What does Kohlers disease cause?
Pain in mid-tarsal region
Limp
Navicular tenderness
Dense deformed bone on radiograph
90
Treatment of Kohlers disease
Rest the foot or wear walking plaster - symptomatic treatment
Prognosis good
91
What is Freibergs disease?
Osteochondritis dissecans of the metatarsal heads - most commonly 2nd
92
Freibergs disease symptoms
Forefoot pain, worsens with pressure, usually starting around the time of puberty
93
What is Freidrich disease?
Clavicle osteochondroses
94
What is Froelich disease?
Humeral condyles osteochondroses
95
What is Perthes disease?
Osteochondroses of hip
96
What is Blount disease?
Osteochondroses of proximal tibial epiphysis
97
What is Osgood-Schlatter's syndrome?
Osteochondroses - Tibial tuberosity apophysitis (secondary ossification centre) that affects children 10-15 years old - association with overuse
98
Signs and symptoms of Osgood-Schlatters syndrome?
Pain below the knee, worse on strenuous activity and quadriceps contraction
Tuberosity looks enlarged and is tender
99
Prognosis of Osgood-schlatters syndrome?
Self-limiting in >90% of cases
100
Radiograph of Osgood-schlatters syndrome?
Tibial tuberosity enlargement with possible fragmentation (as opposed to normal immature tuberosity appearance)
101
Treatment of Osgood-Schlatters syndrome
Limitation of activity with ice, oral anti-inflamm's, knee padding and physiotherapy
Tibial tubercle excision may be recommended if above fail
102
What is Sinding Larsens disease?
Also called jumpers knee - traction tendinopathy with calcification of proximal attachment of patella tendon - may be partially avulsed
Symptoms similar to OSS but earlier presentation 8-13 years
103
Structure of hip prostheses
Metal femoral component with intramedullary stem sometimes held in place by bone cement
and a plastic acetabular component
104
Sign of later loosening or infection with hip replacement
Return of pain
105
Risk factor BMI for osteoporosis
Low BMI
106
Osteoporosis risk factors
```
Menopause
RA
Low BMI
Steroids
FHx
Immobility
```
107
Common cause of tibial nerve injury
Posterior hip dislocation
108
Signs of tibial nerve damage
Loss of inversion of foot and ability to tiptoe
| Sensation of plantar aspect lost (S1)
109
Signs of femoral nerve injury
Unable to extend knee
Absent knee jerk
Loss of sensation over front and medial thigh
110
Symptoms of osteosarcoma
Pain, may be worse at night and can be intermittent
Typically just below the knee, worse on exercise
Can be present as sudden fracture due to weakened bone
111
Symptoms of Ewing's sarcoma
Pain at site, gets worse and can be extremely painful
| Can also get intermittent high fevers, weight loss and severe fatigue (anaemia)
112
Presentation/symptoms of chondrosarcoma
Pain most common feature but may be swelling therefore palpable lump or local mass effect
113
Chondrosarcoma on x ray
"popcorn calcification" on x-ray with lysis as well
114
Osteoid osteoma on imaging
Nidus - Xray is a thickened oval area which is a well-circumscribed lucent area with a sclerotic dot in the centre (black with white in middle)
on CT nidus is seen as well
115
Pathological steps behind septic arthritis
Bacteria get into joint, inflammatory response causes damage to articular cartilage. Increased permeability and fluid secretion causes joint effusion.
116
What can happen during healing of septic arthritis?
Raw articular surfaces may result in fibrosis and bony ankylosis
117
Most common organisms causing septic arthritis in under 3 yr olds x3
Staph Aureus, haem influenza and coliforms
118
Most common organisms causing septic arthritis in adults x2
S.aureus and neisseria gonorrhoea
119
Risk factors for septic arthritis
Diabetes, IV drug use, immunocompromised, chronic joint disease (rheumatoid)
120
What can be seen in gonococcal septic arthritis
Skin pustules near the joint
121
Radiograph in septic arthritis
Increased joint space, soft tissue swelling
| In late cases subchondral bone destruction
122
Surgical management of septic arthritis
Surgical washout of the joint to remove pus and infected material - either arthroscopy or open (arthrotomy)
123
Medical management of septic arthritis
Antibiotics given IV 1-2 weeks then oral 4-6 weeks
Splint joint for pain reduction
Physio to prevent fibrosis and maintain joint mobility
