Ortho Flashcards
What structure is divided in CTS surgery to decompress the median nerve?
Flexor retinaculum
What is Tinel’s sign?
In CTS when tapping causes parasthesia
What is Phalen’s sign?
IN CTS when flexion of the wrist exacerbates symptoms
What are the causes of CTS?
Idiopathic
Pregnancy
Oedema
RA
What is the management of CTS?
Corticosteroid injection
Wrist splints at night
Flexor retinaculum surgery
What nerve is affected in meralgia parasthetica, and what are the symptoms?
Lateral cutaneous nerve
Altered sensation over upper lateral aspect of the thigh
How might a tibial fracture cause an AKI?
Tibial fractures commonly cause compartment syndrome, which results in in muscle breakdown and myoglobin release which deposits in the renal tubules causing a dark brown urine.
What are the Ottawa ankle rules?
Ankle X ray is only needed if there is malleolar pain and any of:
Inability to weight bear for 4 steps
Tenderness over distal tibia
Tenderness over distal fibula
What is the Weber classification system?
Used to describe ankle fractures:
A - # below syndemosis
B - # starts at level of tibial plafond and may extend proximally to syndemosis
C - # is above the syndemosis
What is the management of a Weber A fracture?
Provided minimal displacement, stable fractures may be weight born in a CAM boot
What is the prognosis of axillary neuropraxis following glenohumeral dislocation?
Likely to regain full movement and sensation without surgical intervention in 6-12 months
What is the preferred management of intertrochanteric extracapsular proximal femoral fractures?
Dynamic hip screw
What is the Garden classification system?
Used to classify hip #
- Stable # with impaction in valgus
- Complete undisplaced #
- Displaced # rotated and angulated but still with bony contact
- Complete bony disruption
Rx of undisplaced intracapsular #?
YOung: Internal fixation
Old: Hemiarthroplasty
Rx of displaced intracapsular #?
<70: IF/hemiarthroplasty
>70: Total hip arthroplasty/hemi if poor mobility
Rx extracapsular #?
DHS or intramedullary device if specific type of #
When should patients start mobilising after extracapsular subtrochanteric hip # with intermedullary nail repair?
Immediately start weight bearing as tolerated
What does a stress fracture with callus formation indicate about recovery?
That immobilsation is likely to prove beneficial
What test is highly sensitive for detecting achilles tendon rupture?
Simmonds test - whereby squeezing the patients calf ellicits reduced or absent ankle dorsiflexion
What is the best treatment for young patients with intracapsular hip fracture?
Reduction and internal fixation with cannulated screws
What are the presenting featuers of an anterior shoulder dislocation?
Flattened shoulder contour
External rotation and abduction of the upper limb
Regimental badge sensory loss
What should be done in a patient with signs of compartment syndrome but normal peripheral pulses?
Fasciotomy - loss of arterial pulsation occurs late
What is the appropriate management?
A 28-year-old man falls onto an outstretched hand. On examination there is tenderness of the anatomical snuffbox. However, forearm and hand x-rays are normal.
Discharge with futura splint anf fracture clinic appointment
When would you use an intramedullary device?
For extramedullary fractures - specifically reverse oblique, transverse or subtrochanteric fractures
What is the management of a displaced intracapsular hip fracture in an elderly patient with reduced mobility?
Hemiarthroplasty non cemented prosthesis
What findings are pathognomic of an acute Charcot joint/
X ray findings of joint dislocation and osteolysis
Clinical findings of non-tender, swollen, erythematous, hot foot
What are the different Salter Harris Fracture types?
SALT CRUSH
Straight across Above Lower Through Crush
What structure is likely to be damaged in a supracondylar fracture of the distal humerus, which may be life threatening and therefore compromise requires surgery?
Brachial artery
True or false; acromegaly is a common cause of CTS in patients of all age?
False - Common cause in the over 50s
What is the classical presentation of chondromalacia patellae?
Teenage girl with knee pain on walking downstairs with locking
Cause?
A tall 18-year-old male athlete is admitted to the emergency room after being hit in the knee by a hockey stick. On examination his knee is tense and swollen. X-ray shows no fractures.
Patellar dislocation - a common cause of traumatic haemarthosis which will spontaneously reduce when the leg is straightened
What are Kanavel’s signs and what do they indicate?
Kanevels signs of flexor tendon sheath infection include: Fixed flexion Fusiform swelling Tenderness Pain on passive extension
What are the key featuers of an acromioclavicular dislocation?
Secondary to trauma
Loss of shoulder contour
Prominent clavicle
What is a Hill-Sachs lesion?
When the cartilage surface of the humerus is in contact with the rim of the glenoid following glenohumeral dislocation.
Which rotator cuff is most commonly injured?
Supraspinatus
What does the Lachman test assess?
ACL (Anterior draw)
What medication is first line for back pain?
NSAIDs
What is the difference between a Barton’s fracture and a Colle’s fracture?
Barton’s is an intraarticular fracture of the distal radius, whereas Colles is extraarticular
What is a FRAX score, and what is indicated in patients with a score > 10%?
FRAX score estimates the 10 year risk of fractuer fragility assessing things like age, weight, height, gender, # history, PMH, EtOH, smoking etc.
Patients with a score of 10%>= should receive a DEXA scan
Describe a positive Finkelstein test
Pain over the radial styloid process on forced abduction or flexion of the thumb
What is De Quervain’s tenosynovitis?
Pain over radial styloid process on thumb abduction due to inflammation of the sheath containing extensor pollicis brevis and abductor pollicis longus tendons
What are the red flags for lower back pain?
Age <20 or >50 Thoracic back pain History of previous malignancy Night pain History of trauma Systemically unwell e.g. weight loss, fever
What are the clinical features and imaging modality of choice to detect Morton’s neuroma?
Forefoot pain commonly in third IMP space, worse on walking and +- loss of sensation distally.
Diagnosis is usually clinical but an USS may be helpful
What is a Galeazzi fracture?
A distal radial fracture with associated dislocation of the distal radioulnar joint
What is the management of a subcapital #nof?
Internal fixation if fit, hemiarthroplasty if not
What are the features of talipes equinovarus?
Inverted, plantarflexed foot which is not passively correctable
What is the presentation of an L5 lesion?
Loss of foot dorsiflexion and sensory loss at the dorsum of the foot with reflexes in tact
What is the rpesentation of an L4 lesion?
Sensory loss over anterior knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
What are the features of S1 lesion?
Sensory loss over posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test
What is the most concerning/common complication following a posterior hip dislocation?
Sciatic nerve injury
What is the most common type of hip dislocation and how does it present?
Posterior (90%)
Affected leg is shortened, adducted and internally rotated
What is a Pott’s fracture?
Bimalleolar ankle fracture
What is a Bennet’s fracture?
Intra articular fracture of the first carpometacarpal joint (Fist fights)
What is a Monteggia’s fracture?
Dislocation of the proximal radioulnar joint with associated ulnar fracture
What might morning stiffness >2hours indicate?
Inflammatory arthritis
WHat is a Buckle fracture?
Seen in children, there is buckling of the cortex of the distal radius without a distinct fracture line after FOOSH
What is the role of corticosteroid injections in the management of Dupuytrens contracture?
None - operate if severe (cannot place hand on table)
What is the management of subluxation of the radial head?
Passive supination at 90deg elbow flexion
What does McMurray’s test test for?
Menisceal tear
How do you perform McMurray’s test?
To perform McMurrays test, the knee is held in one hand, which is placed along the joint line, and flexed while the sole of the foot is held with the other hand. One hand is placed on the medial side of the knee to pull the knee towards a varus position. The other hand is used to rotate the leg internally whilst extending the knee. If pain or a ‘click’ is felt, this constitutes a ‘positive McMurray test’.
What are the causes/RFs for Dupuytrens?
FHx CLD Phenytoin DM Trauma Manual labour
What is the presentation of a hip fracture?
Leg is shortened and externally rotated
Quinolone use increases risk of rupture of which tendon?
Achilles
What is true of the timing of managmeent of open fractures and why?
Definitive management should be delayed until soft tissues have ‘recovered’.
What infectious agent osteomyelitis are sickle cell patients at increased risk of?
Salmonella enteritidis
What type of fractures are the following classification systems used for?
i) Gartland
ii) Salter Harris
iii) Ottowa
iv) Garden
v) Weber
i) Supracondylar fractures in children
ii) Growth plate fractures in children
iii) Ankle fractures
iv) #nof
v) Ankle fractures about the syndemosis
What are the features and underlying pathology of Leriche syndrome?
- Impotence
- Butt/thigh claudications
- Atrophy of leg muscles
Atherosclerotic occlusive disease involving the abdominal aorta and or both of the iliac arteries. Management involves correcting underlying risk factors.
What part of the bone is commonly affected in osteomyelitis in children vs. adults?
Children - Metaphysis
Adults - Epiphysis
What does the Gustilo Anderson classification system measure?
Open fractures/
What is the highest grade of open fracture, and how should it be managed?
Gustilo Anderson Grade 3C, where there is a high energy wound with >1cm extensive soft tissue damage with inadequate soft tissue coverage AND assocaited vascular injury.
Management is by vascular shunting, temporary skeletal stabilisation and then vascular reconstruction - ideally within 3-4 hours of injury.
What is the imaging modality of choice to detect Achilles tendon rupture?
USS
What is Perthes’ disease?
Avascular necrosis of the femoral head seen predominantly in young boys
What are the Xray findings in Perthes disease?
Increased joint space with flattening of the femoral head
What is a typical presentation of pauciarticular JIA?
4-year-old girl with a three month history of a limp. Her parents report that she has ‘not been right’ for a few weeks now. She typically complains of pain in her left hip and right knee in the morning which gets better during the day.
Hows should a young patient with ?bone malignancy be investigated?
X ray of area within 48 hours
What is the best initial management of an open fracture with no complications?
IV Abx
Imaging
Sterile soaked gauze and impermeable film
What condition is risk factor for developing adhesive capsulitis?
Diabetes - up to 20% of pts experience symptoms
Which of the following pathologies does a positive straight leg raise suggest?
Spinal stenosis Ank Spon Vertebral compression fracture Sciatic nerve pain Intervertebral facet joint pain
Sciatic nerve pain
What are the presenting features of a fat embolism/
Resp - tachycardia+pnoea, hypoxia, pyrexia
Derm - NON BLANCHING PETECHIAL RASH
CNS - Confusion and agitation with retinal haemorrhages
What are the motor and sensory roles of the musculocutaneous nerve, as well as its nerve roots and typical mechanism of injury
Motor: Elbow flexion and supination
Sensory: Lateral forearm
Roots: C5-7
Injury: Usually part of brachial plexus injury
What are the motor and sensory roles of the axillary nerve, as well as its nerve roots and typical mechanism of injury
Motor: Deltoid
Sensory: Regimental badge
Roots: C5-6
Injury: Humeral head #/dislocation resulting in flattened deltoid
What are the motor and sensory roles of the radial nerve, as well as its nerve roots and typical mechanism of injury
Motor: Extension at forearm, wrist, fingers, thumb
Sensory: Between dorsal 1st and 2nd metacarpals
Roots: C5-8
Injury: Humeral midshaft fracture presenting as wrist drop
What are the motor and sensory roles of the median nerve, as well as its nerve roots and typical mechanism of injury
Motor: LLOAF muscles
Sensory: Palmar lateral 3.5 fingers
Roots: C6, C8, T1
Injury: Carpal tunnel syndrome
What are the motor and sensory roles of the ulnar nerve, as well as its nerve roots and typical mechanism of injury
Motor: Hand muscles - LLOAF
Sensory: Medial 1.5 fingers
Roots: C8, T1
Injury: Medial epicondyle fracture resulting in claw hand, remember ulnar paradox
What are the motor and sensory roles of the long thoracic nerve, as well as its nerve roots and typical mechanism of injury
Motor: Serratus anterior
Sensory: nil
Roots: C5-7
Injury: Complication of mastectomy resulting in winging of scapula
What is the most common reason why total hip replacements need revising?
Aseptic loosening of the implant
Also; pain, dislocation, infection
What is the classical presenting feature of a subacromial impingement?
Painful arc worst at 90-120deg
What population does IT band syndome typically afffect, and how does it present?
Runners
Presents with tenderness 2-3 cm above the lateral joint line with no reduction in ROM or swelling
What is the likely cause of this patients joint pain?
A 34-year-old man reports the sudden onset of back pain after bending over to tie his shoe laces. There is tenderness over the lumbar spine on examination and leaning back worsens the pain. Neurological examination and straight leg raising is normal
Facet joint pain
While there is often a Hx of bending prior to disc prolapse, the normal straight leg test makes this less likely
What are the risk factors for avascular necrosis of the hip?
Long term steroid use
Chemotherapy
EtOH excess
Trauma
How would you manage mild and severe acromioclavicular injuries/
Grade 1-2 - Conservative with rest and sling
3-6 - Surgery
Describe Osler’s nodes
Painful purple/red raised lesions with a pale centre
What conditions might cause Osler’s nodes?
Most strongly associated with endocarditis
Also SLE, gonorrhoea, typhoid, haemolytic anaemia
A 38-year-old man is playing football when he slips over during a tackle. His knee is painful immediately following the fall. Several hours later he notices that the knee has become swollen. Following a course of non steroidal anti inflammatory drugs and rest the situation improves. However, complains of recurrent pain. On assessment in clinic you notice that it is impossible to fully extend the knee, although the patient is able to do so when asked.
Menisceal tear
A 34-year-old woman is a passenger in a car during an accident. Her knee hits the dashboard. On examination the tibia looks posterior compared to the non injured knee.
PCL rupture
How would you differentiate clinically between plantar fasciitis and subcalcaneal bursitis/
Plantar fasciitis is exacerbated by walking on tip toes
Imaging modality for ?osteomyelilts?
~MRI
What is Thessaly’s test?
Thessaly’s test is used to assess meniscal tear. In this test, the patient is supported by a doctor and is asked to stand on the affected leg, flexed to 20 degrees. The test is positive if there is pain on twisting the knee.
From which nerve does the common peroneal nerve arise?
Sciatic
What is the best imaging modality for hip fractures?
MRI
How urgently should children with ?sarcoma be reviewed by a specialist?
48 hours
Iliofascial nerve block is an effective method of analgesia for which injury?
NoF
Best imaging modality for menisceal tear/
MRI
Old man with shoulder pain/weakness, impaired active abduction but normal passively
Rotator cuff tear
What is Parsonage Turner syndrome?
A rare form of post infective peripheral neuropathy
How should this be repaired/
A 74-year-old male is admitted to A&E with a fall. He is known to have rheumatoid arthritis and is on methotrexate and paracetamol. He lives alone in a bungalow and enjoys playing golf. He is independent with his ADLs. He complains of left groin pain, therefore has a hip x-ray which confirms a displaced intracapsular fracture.
Total hip replacement
Pre-existing joint disease, good level of activity and a relatively high life expectancy, therefore THR is preferable hemiarthroplasty.
How might a femoral nerve lesion present?
Weak knee extension
Loss of patellar reflex
Numbness of thigh
How might an obturator nerve lesion present?
Weak hip aDduction
Numbness over medial thigh
