Ortho 3 Flashcards
What is the single most important part of the management of a bone tumour?
referral to MDT
- surgeons
- pathologist
- radiologist
When should you do a bone biopsy of a suspected tumour?
Only when guided by MDT
- otherwise may make it worse
What generalised investigations would you do into bone tumours? and which is gold standard
Full history & examination Blood Myeloma screen X-ray \+/- CT scan
*most will require a biopsy for definitive diagnosis but this must be done after MDT - require guidance
x-ray is gold standard
- huge amount of info regarding the lesion can be seen
What are the general broad rules regarding lytic and sclerotic lesions of bone?
If there is narrow lytic or sclerotic lesion its likely narrow
If there is a large area its likely aggressive
What is meant by the zone of transition on a bony tumour?
an area where new bone is forming around the lesion to try and protect it
Name some specific descriptions used to describe periosteal retraction that occurs with bone tumours:
Lamellated/ onion ring:
- new layers of bone forming over a tumour growing just to fast to keep up with it
Speculated/ sun-set burst
- where the tumour protrudes and breaks through the Sharpe’s fibres that then ossify in a perpendicular fashion to the bone
Codman’s
- where the Sharpe’s fibres do not even get a chance to ossify and only do so at the edges
What is a solitary tumour of multiple myeloma called?
Plasmacytoma
How would you inform a patient to take their bisphosphonate in the morning?
30mins before breakfast and sit up straight for 30mins after
What is the most common benign bony tumour? how many become malignant and when should their removal be thought of?
Osteochondroma
1% become malignant. removal if cartilaginous cap exceeds >2cm
If a patient has a pacemaker and has symptoms suggestive of cauda equina, what investigation should they have?
CT myelogram
What are the compications of cauda equina syndrome?
Bowel dysfunction
Bladder dysfunction
Sexual dysfunction
What are the anatomical differences of a surgical neck of humerus and anatomical neck?
Surgical is a weaker place under the head, more prone to fracture
Anatomical neck is the old epiphyseal plate. usually stronger and less likely to fracture.
Define a simple and complex elbow dislocation:
Simple
- only a dislocation.
- usually posterolateral
Complex
- associated fracture
- typically in form of terrible triad (dislocation, radial head fracture, coronoid tip fracture)
What is the position of safety when immobilising the hand?
30 degrees wrist extension
90 degrees of MCJ flexion
0 degrees PIP, DIP
What is a Bennet’s fracture?
Fracture at the base of the 1st which extends into the CMC joint.
- usually with subluxation due to the pull of the abductor pollicis longus
*note a Roland fracture is the same but Comminuted
Where is a boxer’s fracture?
Surgical neck of the 4th or 5th
When x-raying a shaft fracture of a metacarpal what x-rays do you get and why?
AP
Lateral
oblique
Oblique allows for visualisation of the 4th and 5th base
Name some deformities which can occur from phalanx fractures:
Mallet finger
Boutonniere deformity
Swan neck deformity
What is the name of a fracture that can occur on the distal phalanx causing an open fracture and nail damage, typically due to hyperflexion?
Seymore fracture
What determines whether a finger tip following injury can be preserved?
The amount of bone loss and nail loss
> 50% of nail loss it may be better to shorten nail
What are the key ideas of treatment following finger tip injuries?
Preserve as much length as possible
Try to preserve the FDP
Preserving nail bed
Anatomically where on a finger amputation may it be suitable for replantation?
Distal to the FDS and proximal to the FDP
- if the amputation occurs proximal to the FDS then it is unlikely to suitable for replantation
- typically only replanted if multiple digits involved
Following tendon and nerve injuries what should be checked?
Vascular assessment
- cap refill
- pulses
- if vascular compromise but potential for replant hten it is a medical Emergancy
Neurological assessment
Tendon assessment
- make sure on hand to differentiate between FDS and FDP
What is the management for a tendon/ nerve injury?
LA and irragation
- do not LA until neurological assessment is completed
Tetanus
Antibiotics
- maybe IV
Dressing
Back slab
Refer to ortho for washout if needed
In human bites or fist fights why should you always organise an x-ray, and which joint is particularly susceptible to damage?
x-rays to check not only for bone damage but also teeth
MCP joints are at high risk of damage and infection
What is the most common muscle to be affected by lateral epicondylitis/ tennis elbow?
Extensor Carpi Radials Brevis
What nerves innervate the flexor digitirum profundus?
Medial half - ulnar nerve
Lateral half - Anterior interosseous nerve of the median nerve
What two muscles in the forearm does the ulnar nerve innervate?
Flexor carpi ulnaris
Medial half of the flexor digitorum profundus
Which muscles does the ulnar nerve innvervate in the hand?
Hypothenar muscles
Medial 2 lumbricals
Adductor pollicis
interossei muscles
What are the interossei muscles?
There are two sets of interossei muscles.
Dorsal - which abduct the digits
Plantar - which adduct the digits
also aids in flexion of the digits
What tendon can often be injured alongside a distal radius fracture?
Extensor Pollicis longus
Following a suspected scaphoid fracture - how should the patient be managed following a negative x-ray?
Placed into a cast to hold thumb in neutral position.
- re xray in 2 weeks
What are the clinical signs of a scaphoid fracture and What type of x-ray should be requested for suspected scaphoid fractures?
Anatomical snuff box tenderness
Pain on telescoping of the the thumb
Pain on ulnar deviation
Wrist joint effusion (>4 years old maybe delayed)
Scaphoid views x-ray:
- PA
- Lateral
- Oblique
- Ziter view (ulnar deviated whilst oblique)
Describe the 3 main types of pelvic fractures:
Type A: Stable fracture. usually includes: - avulsion - pubic fracture - iliac wing fracture
Type B: Unstable fracture: open book fracture - lateral internal rotation forces - stable in vertical motion - unstable in rotational forces
Type C:
Very unstable fracture. At least 2 points broken.
- unstable in vertical forces
- unstable in rotational forces
Other classification: Young Burges classification:
Lateral compression:
- internal rotational forces
AP compression:
- external rotational forces
- if the posterior sacro-iliac ligaments are damaged the pelvis is extremely unstable
Vertical sheer
- vertically moved.
- very unstable
What is the most common place for the ulnar nerve to become entrapped?
Between the two heads of the flexor carpi ulnaris
List signs and symptoms of cubital tunnel syndrome and Name two clinical tests to help diagnose cubital tunnel syndrome:
- pain at elbow
- paraesthesia in little and ring finger
- weakness in abduction of little finger
- interossei wasting
- claw hand
Tinnels test
Froment’s sign - unable to pincer grip
- weak adductor pollicis so the flexor pollicus longus flexes the IPJ instead
Finger grip strength
Give some differentials for elbow pain:
Medial/ lateral epicondylitis
Bicep tendon rupture
OA
Cubital tunnel syndrome
Medial collateral ligament injury
Olecranon bursitis
What conditions pre-dispose to quadriceps tendon rupture?
Diabetes RA Hyperparathyroidism Gout Steroid injection around the area
List the three main functions of the meniscus:
Shock absorber
Load Sharing
Joint stabiliser
What are the treatment options for a meniscus tear?
Small <4mm Red Zone Degenerative - physiotherapy - NSAIDs - Steroids injections
Surgical:
- Meniscectomy (usually for white zone)
- Mencius repair (usually red zone)
- Mencius transplant
What is a game keeper’s thumb and what complications can occur?
what is diagnostic?
Where there is damage to the ulnar collateral ligament of the MCJ
Stenner lesion may occur where they avulsed ligament gets trapped in the aponeurosis of the adductor pollicis
> 40 degree abduction when the thumb is fully extended.
What is the diagnostic test for iliopsoas abscess?
CT scan
What is the most important blood vessels to the neck of the femur:
Medial Femoral Circumflex Artery
If a patient presents due to NOF fracture and has been lying on the ground for a few days, what do you need to consider?
Dehydration
Ulcers
Rhabdomyolysis
What signs may be seen on an x-ray of a patient with osteoporosis?
there needs to be >30% bone mass loss to be seen, thus x-ray is unreliable. some signs though may include:
- wedge fractures
- kyphosis
What biochemical marker may be found in the urine of a patient with osteoporosis?
Telopeptides
- collagen degradation products
Outwith a DEXA scan name two other investigations that can be done to quantify bone density:
Quantitative CT scan
Quantitative US
- usually of the calcaneum
Highlight some side effects of bisphosphonates:
Peptic ulcers/ GORD
Osteonecrosis of jaw
Sub-trochanteric hip fractures
- more so in young affective people
Out with bisphosphonates, name some other therapies used in treating osteoporosis:
Calcium and Vitamin D
- doesn’t increase BMD but reduces reabsorption
Selective oestrogen receptors
Teriparatide -PTH
Oestrogen therapy (HRT)
Calcitonin
Increased physical activity
What are the phases of Paget’s disease?
“LAB”
- Lytic lesions - increased size and number of osteoclasts
- Active phase
- osteoblast activity 40x over, creating disorganised woven bone
- increased blood flow - Burn out stage
- little to no cellular activity
What are the most common areas affected by Paget’s disease:
Pelvis
Lumbar spine
Skull
Femur
Describe the phalens test and tinels test:
Phalens:
- flexing then extending the wrist will elicit symptoms in the median nerve distribution
Tinel’s test:
- taping over the volar aspect of the carpal tunnel elicits symptoms
In nerve conduction studies of carpal tunnel, what is being measured?
Velocity of conduction
What are the complications of carpel tunnel syndrome surgery?
Damage to blood vessels/ tendons of hand
Infection
Complex regional pain syndrome
Failure to resolve symptoms
What is the most serious bacteria infection to follow from an open fracture?
Clostridium perfringes
