Ortho Flashcards
Tx cascade for OA
1st line = topical analgesia i.e. topical NSAID (diclofenac)
2nd line = paracetamol + local analgesia
3rd line = NSAID + paracetamol + local analgesia (+PPI)
4th line = Opioid (e.g. oxycodone) + paracetamol + NSAID + local analgesia
Adjunct = IA Corticosteroid injection
Surgical options = arthrodesis, THR/TKR
what is mnemonic for OA on x-ray
L – loss of joint space
O – osteophytes
S – sclerosis
S - subchondral cysts
what are the Ix results for RA (antibodies)
Auto-Ab – Rheumatoid factor, Anti-CCP
Bloods – CRP raised
how does RA present
swelling, morning stiffness, pain, deformity, loss of function, nodules
affects small joints and c-spine
what might be seen in hands in RA
Boutonniere deformity
Ulnar deviation
Swan-Neck deformity
Mx of RA
DMARD monotherapy +/-bridging prednisolone
= Methotrexate
TNF inhibitors
- infliximab
side effects of methotrexate
myelosuppression – monitor FBC + LFTs
pneumonitis
what are the seronegative/HLA B27 arthritis
AS
Psoriatic arthritis
Reactive arthritis
Inflammatory Bowel Disease arthritis
how does AS present
Chronic inflammation – spine and sacroiliac joints fusion of joints
Young males
Symptoms – pain, stiffness, hip/knee arthritis
Ix of AS
X-Ray
Key Buzzwords = ‘sacroiliitis’ ‘bamboo spine’, ’squaring of lumbar vertebrae’
Mx of AS
- important
1st line = NSAIDs, physio, EXERCISE [gets much better w/ exercise]
2nd line = Anti-TNF therapy = etanercept/adalumumab
DMARDS only useful if peripheral joint disease
Adjunct = IA corticosteroids
how does psoriatic arthritis present
30% skin psoriasis
Asymmetrical, oligoarthritis, sacroiliitis, spondylitis, dactylitis and enthesitis
nail changes: pitting, onycholysis, arthritis DIP joints
Ix of psoriatic arthritis
x-ray
- pencil-in-cup appearance
what are common causative organisms for reactive arthritis
GI - campylobacter, shigella, salmonella, yersinia
GU - chlamydia, gonorrhoea
Sx of reactive arthritis
urethritis, uveitis, arthritis
“can’t see, can’t pee, can’t climb a tree”
Mx of reactive arthritis
Rx underlying infection, symptomatic relief, +/- DMARDS
what is gout and what causes it
Urate crystals in joints – hyperuricaemia
Renal underexcretion or excessive intake of alcohol, red meat, seafood
how does gout present
Classic site – 1st MTP joint, ‘podagra’
CF – intensely painful, hot, swollen joint, tophi
Ix for gout
1st line = joint aspiration
- Synovial fluid with needle shaped, negative birefringence
Mx of gout
Acute = NSAIDS, colchicine, intra-articular corticosteroid
Long term = allopurinol
what can allopurinol interact with and what can it cause
Azathioprine
- can cause pancytopenia
what is pseudogout
1 - Calcium pyrophosphate crystals – causing acute arthritis
2 - Chondrocalcinosis - deposits in cartilage/soft tissue, but no inflammation
Ix of pseudogout
joint aspirate
= Synovial fluid w/ positively birefringent crystals
Mx of pseudogout
NSAIDS, corticosteroids, +/- colchicine
hydroxychloroquinine
causes of septic arthritis by age = adults/ivdu, children, young adult
Staphylococcus aureus – adults/IVDU
Haemophilus influenza – children
Neisseria gonorrhea – young adults
Mx of septic arthritis
Ix – urgent joint aspirate BEFORE giving Abx
Tx – Abx, surgical washout
SLE antibodies
anti-dsDNA.
Remember C3/C4 low in active disease
sjogrens antibodies
anti RO/anti LA
systemic sclerosis antibodies
limited = anti-centromere
diffuse = anti-scl-70
polymyositis antibodies
anti-Jo-1
mixed connective antibodies
anti-RNP
Sx of Anti-Phospholipid Syndrome
CLOT
Coagulation defect Levido reticularis Obstetric problems (miscarriages) Thrombocytopenia
what is surgery reserved for in back pain
nerve root compression
single level disc degeneration/prolapse
?Sudden shooting pain while performing heavy lifting
prolapsed disc
?Lowgrade fever, local tenderness at L3
discitis
?Lorry driver, stiff, tender
mechanical back pain
?Person with sciatica and back pain and wants something to be done . They are also obese
weight loss programme + physiotherapy 1st line
what causes radiculopathy and how does it present
Gelatinous nucleus pulposis can ‘herniate’ or ‘prolapse’ = impinge on nerve
Neuralgic burn, severe tingling
what does an L3/4 prolapse cause and what are the Sx
L4 root entrapment
- pain to medial ankle, loss of quad power, reduced knee jerk
what does an L4/5 prolapse cause and what are the Sx
L5 root entrapment
- pain to dorsum of foot, reduced power on dorsiflexion
what does an L5/S1 prolapse cause and what are the Sx
S1 root entrapment
- pain to sole of foot, reduced foot plantar flexion, reduced ankle jerks
what are Sx of Cauda Equina
Bilateral leg pain
Paraesthesia
Saddle anaesthesia
Urinary retention / faecal incontinence
Ix and Tx for Cauda Equina
Ix – PR mandatory, urgent MRI
Mx – surgical intervention
generally, what are the issues in shoulders related to young, middle age, and eldery
Young adult – instability
Middle aged – rotator cuff tears, frozen shoulder
Elderly – glenohumeral joint OA
how does frozen shoulder present, who is likely to get it, and what is buzzword clinical sign
Progressive pain and stiffness.
Pain subsides, stiffness increased and then ‘thaws’
Affects aged 40-60. Diabetics.
Loss of external rotation
how does RC tear present, who is likely to get it
Shoulder dislocation, degenerative changes in tendons
”Sudden jerk” = pain and weakness
what tendon is affected in painful arc syndrome
supraspinatus
broadly, what are the two classifications of hip fractures
intracapsular
extracapsular
summary of intracapsular hip fractures
Affect arterial supply of femoral head
Risk of avascular necrosis and non-union
Replace femoral head – hemi-arthroplasty or THR
summary of extracapsular hip fractures
Not at risk of AVN and high union rate
Fixed with Dynamic Hip Screw
how is a clavicle fracture managed
broad arm sling/ORIF
how is a proximal humerus fracture managed
collar + cuff/ORIF
how is an olecranon fracture managed
tension band wiring
how is an colles fracture managed
splintage/plaster cast
how is a femoral shaft fracture managed
IM nail
A 40-year-old man is investigated for back pain. For the past few months he has been troubled with pain in his lower back which is typically worse in the morning and better by the end of the day. There is some radiation of pain to the right buttock but no leg pains. What is the likely diagnosis?
Ankylosing Spondylitis
59-year-old man with a history of gout presents with a swollen and painful first metatarsophalangeal joint. He currently takes allopurinol 400mg od as gout prophylaxis. What should happen to his allopurinol therapy?
Continue at reduced dose
45-year-old lady presents with a 6 month history of pain in the joints of her right hand. On examination she has tenderness in the right distal interphalangeal joints. An X-ray shows erosions in the centre of the right distal interphalangeal joints, which are described as having a pencil in cup appearance.
Psoriatic arthritis
75-year-old woman presented to her GP with shoulder pain and discomfort. She had a full shoulder examination performed, during which she was unable to abduct her shoulder when it was flat against her body while standing. She was, however, able to fully abduct the shoulder after the doctor passively abducted it during the first 20 degrees. Which muscle is most likely to have been affected?
Supraspinatus
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 down to the dorsum of her foot. 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.
L5 radiculopathy
Treatment of necrotizing fasciitis
Surgical debridement
Iv Amox + clarithromycin + Gentamicin
? Rotator cuff – unable to initiate abduction
supraspinatus
hitting knee on dashboard
PCL injury
ankle jerk nerve roots
S1-S2
knee jerk nerve roots
L3-L4
Biceps jerk nerve roots
C5-C6
triceps jerk nerve roots
C7-8
brachioradialis/supinator jerk nerve roots
C5-C6
tx for Osteomyelitis - not pen allergic
Flucloxacillin IV 2g qds
2 weeks minimum IV followed by oral therapy
Total course 4-6 weeks
Tx for osteomyelitis - pen allergic
Clindamycin IV 600mg qds
Total Course 4-6 weeks
tx for Osteomyelitis - MRSA
Vancomycin IV
tx for septic arthritis
IV flucloxacillin 2g qds for 2 weeks
then oral therapy
Total course 4-6 weeks
1st line for mechanical back pain
NSAIDs
Mx of paget’s disease
Biphosphonates
best imaging for achilles tendon
USS
what are the Ottawa rules for ankle injury and deciding if an x-ray is needed
x-ray is required only if there is any pain in the malleolar zone and any one of the following findings:
- bony tenderness at the lateral malleolar zone
- bony tenderness at the medial malleolar zone
- inability to walk four weight bearing steps immediately after the injury and in the emergency department
tx for Intracapsular fracture, displaced, when person is mobile
THR
tx for Intracapsular fracture, displaced, when person is not mobile
Hemiarthroplasty
what fractures is compartment syndrome common in
supracondylar and tibial shaft fractures
what nerve roots make up the sciatic nerve
L4 to S3
left leg is shortened, adducted and internally rotated = ?
posterior hip dislocation
= risk of sciatic nerve damage
what are the muscles of the rotator cuff and their function
supraspinatus = 0-15 degrees of shoulder abduction [deltoid does 15-90]
teres minor = shoulder extension
subscapularis = shoulder internal rotation
infraspinatus = shoulder external rotation
what is spondylothesis
slippage of one vertebrae over another
what is spondylolysis
defect in pars interarticularis of a vertebra
what is spondylosis
degenerative disease of the spine
Tx for rotator cuff tear
if complete = arthroscopic repair
if not = physio + pain relief
brown sequard injury
ipsilateral loss of proprioception, vibration and motor function
contralateral loss of temp and pain
where is most likely fractured at humeral neck, what nerve is at risk and what is the management
Surgical neck = axially nerve
Mx
- if minimally displaced = sling and conservation
- if displaced = manipulation/ORIF
mx of anterior shoulder dislocation
closed reduction + pain relief
sling for 2-4 weeks
physio
mx of # = humeral shaft
splint + immobilise = 8-12 weeks
if polytrauma = I.F. w/ IM nail/plate
mx of # = olecranon
tension wire banding = ORIF to repair tricep function
mx of # = supracondylar
ORIF
mx of # = radial head/neck
Collar and cuff sling + physio
ORIF
mx of = pulled elbow
forced supination
mx of # = colles
if minimally displaced = splint
if displaced + old = closed reduction + cast
if displaced + young = ORIF
mx of # = scaphoid
XR lateral, AP and 2x oblique
if unsure = splint and further XR in 2 weeks
if sure = plaster for 6-12 weeks
if displaced = compression screw
mx of # = intracapsular hip
undisplaced + young = internal fixation
undisplaced + old = hemiarthroplasty
displaced + < 70y/o = internal fixation + hemiarthroplasty
displaced + > 70y/o and mobile = THR
displaced + > 70y/o and immobile = hemiarthroplasty
mx of # = extracapsular hip
dynamic hip screw
mx of # = proximal femoral
IM nail
mx of # = femoral shaft
thomas splint
IM nail
