Ortho Key Flashcards
1
Q
◙ 11-15 YO Boy
◙ Limping
◙ The affected leg is shorter than the other
◙ Externally rotated hip that ↑ with hip flexion
◙ Painful knee/ hip/ thigh/ groin
◙ Limited hip abduction.
A
Slipped Upper Femoral Epiphysis (SUFE
2
Q
On Foot bone Fractures:
◙ Falling “Vertically” on feet, the likely foot bone to fracture
A
Calcaneus.
(Also check for spinal Fracturs as they are also common in vertical falls)
3
Q
◙ Stress Fracture of Foot, the likely affected bones
A
Metatarsals.
4
Q
Bone pain (e.g. in a long bone such as a leg) especially in young people that is
unrelated to activity and responds quickly to NSAIDs (e.g. Aspirin
A
→ Osteoid Osteoma. “benign long bones tumour e.g. femur, tibia”
5
Q
Sensory Loss Responsible Nerve Roots
A
3 in the thigh ▐ 2 in the shin ▐ 1 in the foot
6
Q
• Groin and pelvic Girdle
A
→ L1
7
Q
• Anterior thigh
A
→ L2
8
Q
• Inner (Medial) thigh and distal anterior thigh
A
→ L3
9
Q
• Inner (medial) shin
A
→ L4
10
Q
• Outer (Lateral) shin and Dorsum of the foot
A
→ L5
11
Q
• Outer (Lateral) shin and Dorsum of the foot
A
→ L5
12
Q
Lateral Foot
A
→ S1
13
Q
→ Perianal/ groin numbness (Saddle Paraesthesia) ▐ Inability to initiate
voiding “urination” ▐ Back pain.
A
Cauda Equina Syndrome
14
Q
• Cauda equina = bundle of nerves and nerve roots at the lower end of spinal
• It resembles the horse’s tail, starts from (T12/L1 to Coccyx).
cord.
• Compression of the cauda equina is a surgical emergency!
A
The commonest cause → Central Disc Prolapse that compresses cauda equina.
15
Q
a patient with lower back pain, the presence of (Saddle Paraesthesia)
warrants urgent
A
urgent referral to neurosurgical/ orthopaedic team for MRI.
16
Q
Lumbosacral Disc Herniation/ Disc Prolapse
A
√ Lying down → relieves (↓) pain.
17
Q
↑ Pain in sciatica
A
√ Severe lower back pain that radiates to a leg (could be Acute sudden onset)
√ Lying supine with legs raised → ↑ pain (+ve straight leg raising test)
√ When getting up from a lying positing → ↑ Pain.
√ Walking/ Prolonged sitting → ↑ Pain
18
Q
Pain relief of sciatica?
A
♦ Next step → ♦ If any red-flags or this option is not given → Reassure and prescribe analgesics
19
Q
♦ If any red-flags or this option is not given → Reassure and prescribe analgesics
A
MRI spine
20
Q
Management of sciatica
A
◙ Management:
Amitriptyline ♦ If not severe, it usually resolves in 6 weeks to a few months.
♦ NSAIDs are preferred “for pain relief”. “Describe PPI with it”.
♦ If there is sciatica → “preferred”, is amitrytylline over Gabapentin, Pregabalin.
21
Q
(♣) Intervertebral disc:
√ Herniated disc is more common in people
A
people < 40 YO.
22
Q
(♣) Intervertebral disc:
√ Degenerative disc is more common in ?
A
more common in people > 40 YO.
23
Q
Ivdp
A
(♣) The commonest site is (L5/S1 )
followed by L4/L5).
24
Q
A 22 YO male presents complaining of a sudden onset severe lower back pain
which was elicited when trying to get up. The pain ↑ in intensity when lying
down with legs being raised. There is also a tense electric shock like pain
radiates down to his left leg.
A
The likely Dx → Lumbosacral disc herniation.
◙ Clinchers
→ +ve straight leg raising test (+) back pain with a lower limb radiation.
25
Example 2,
A 35 YO male presents complaining of back pain which started 2 days ago
when he was moving to a new house. The pain radiates to his left foot and
increases in severity when he coughs. O/E: +ve straight leg raising test, loss of
deep tendon reflexes of his left leg, Sensory loss over the anterior knee.
The likely Dx → Intervertebral Disc Prolapse.
◙ Clincher
→ +ve straight leg raising test (+) back pain with a lower limb radiation.
26
One of the commonest fractures 2ry to falling on “outstretched” hand
→ Scaphoid fracture
27
(Painful base of thumb▐ tender anatomic snuff-box▐ pronation followed by
ulnar deviation produces pain).
→ Scaphoid fracture
28
Scaphoid fracture
How to manage? “important √”
• If X-ray is +ve
→ Scaphoid Cast for 6 weeks.
• If X-ray is -ve “does not show the fracture”
→ Cast and Repeated X-ray in 2 weeks.
29
Developmental Dysplasia of the Hip (DDH)
A former name: Congenital Dislocation of the Hip (CDH)
Risk factors???
◙ Risk factors “Important √”
√ Female sex: 6 times greater risk (80%)
√ Breech presentation √
√ Positive family history √
√ Firstborn children
√ Oligohydramnios √
√ Birth weight > 5 kg
√ Congenital calcaneovalgus foot deformity
30
Investigation of cdh?
More common in which side?
DDH is slightly more common in the left hip. Around 20% of cases are
bilateral.
Ultrasound is used to confirm the diagnosis if clinically suspected.
31
◙ Clinical examination is made using the Barlow and Ortolani test
Barlow test: attempts to dislocate an articulated femoral head
Ortolani test: attempts to relocate a dislocated femoral head
32
Management of DDH
◙ Management
♠ Most unstable hips will spontaneously stabilise by 3-6 weeks of age.
♠ Pavlik harness (dynamic flexion-abduction orthosis) in children younger
than 4-5 months
♠ Older children may require surgery
33
◙ A child “Boy” with limping▐ shortened leg▐ externally rotated leg ▐ Painful LL
→ Slipped upper femoral epiphysis.
34
◙ A child “girl” ▐ Breech presentation ▐ FHx ▐ Limping▐ Painless leg that is
shorter than the other ▐ Unequal skin fold
→ Developmental Dysplasia of the Hip (DDH).
35
an audible ‘pop’ in the ankle,
sudden onset of significant pain in the calf or ankle or the inability to walk or
continue the sport.
→ An acute referral (same-day) to orthopaedics should be made following a
suspected Achilles tendon rupture.
The affected muscle → Gastrocnemius.
36
Achilles tendon rupture
◙ Diagnosis → Mainly clinically by Simmond’s triad
Ask the patient to lie prone with their feet over the edge of the bed.
○ Look for an abnormal angle of declination.
○ Feel for a gap in the tendon.
○ Gently squeeze the calf muscles (Thompson Test) → No Plantar flexion
(Negative Plantar Flexion), (affected leg remains in a more dorsiflexed
position).
37
Dupuytren’s contracture
• a condition in which there is a fixed forward curvature of one or more
fingers, caused by the development of a fibrous connection
between the finger tendons and the skin of the palm.
• Dupuytren’s contracture has a prevalence of about 5%.
• It is more common in older male patients.
38
Dupuytryne contracture
• Specific causes include→
Manual labour
▐ phenytoin treatment
▐alcoholic liver disease
▐ trauma to the hand
▐ DM
▐ Smoking
39
• Mechanism
• Mechanism
→ Formation of thickened fibrous tissue within the palmar fascia.
• Rx → Fasciotomy
40
A 38-year old man is unable to extend and straighten his 4th and 5th fingers
(ring and little fingers). A firm nodule was found on the distal palmar crease in
the same line with the ring finger. His father has a Hx of a similar condition.
The likely diagnosis → The likely mechanism
Dupuytren’s contracture.
→ Formation of thickened fibrous tissue within the palmar fascia.
41
More common in the thumb, middle, or ring finger.
◙ Stiffness of a finger, and snapping (click) sound when extending a flexed
digit.
◙ A nodule may be felt at the base of the affected finger.
Trigger Finger = (Stenosing Tenosynovitis)
42
♠ Loss of joint space
♠ Juxta-articular osteoporosis
♠ Periarticular erosions
♠ Subluxation
Rheumatoid Arthritis
43
LOSS
♠ Loss of joint space
♠ Osteophytes forming at joint margins
♠ Subchondral sclerosis
♠ Subchondral cysts
Osteoarthritis
44
OA
√ Remember that osteoarthritis is triggered and worsen by joint use and
relieved by rest “less pain in the morning, more pain at night”
45
RA
√ On the other hand, RA improves by using the joints as the day goes.
46
Nodules due to osteophyte formation in OA
√ Note, associated “Nodules” = “swellings” due to “Osteophytes formation”
can be seen on fingers. These nodules are called:
(Heberden: affecting Distal IP joints) (Bouchard: affecting Proximal IP joints).
and HD: BP
47
“Paracetamol” is often the valid answer in an osteoarthritis scenario.
Osteoarthritis Management in Short
• First line → Paracetamol and Topical NSAIDs.
• Second line (if failed) → Add Oral NSAIDs or COX-2 inhibitor (give PPI as well).
• If still in pain → Opioids. E.g., Codeine.
→ Switch from codeine to tramadol If codeine is not effective or have side effects eg, constipation:
100 mg twice a day.
48
MUGGER
MU
And
GR
√ Monteggia Fracture (Radial Nerve is affected) (MU: Ulna fractured)
→ Dislocation of the head of radius + Fracture of the proximal 1/3 of the
Ulna.
Galeazzi’s Fracture. (GR: Radius fractured)
→ Distal Radio-ulnar joint Dislocation + Fractured Distal 1/3 of Radius Shaft.
49
→ injury to ulnar collateral ligament → painful swelling/ bruises + weakness
and pain when grasping things with the thumb + Tenderness over MCP joint
√ Gamekeeper thumb (Skier’s thumb): as it often occurs while skiing
50
→ Avulsion of extensor digitorum tendon at the “distal” IP joints → flexed -
bent-finger.
√ Mallet finger “especially if hit by a ball into his finger → finger bends”
51
(Painful base of thumb▐ tender anatomic snuff-box▐ Ulnar Deviation produces
Pain).
√ Scaphoid bone fracture.
52
Dinner fork deformity)
Median Nerve injury)
especially
if there is associated osteoporosis”
→ Distal radius is Dorsally “posteriorly” displaced “fractured”, Dorsally
angulated.
√ Colle’s Fracture (Dinner fork deformity) (Median Nerve injury
53
→ Distal radius is Anteriorly displaced “fractured”, Anteriorly angulated.
√ Reverse Colle’s Fracture = Smith’s Fracture (Garden Spade
Deformity)
54
Repetitive “overhead” “above the shoulder” activities. Examples:
♠ Volleyball – Tennis – Badminton player, Swimmer.
♠ Carrying heavy objects (e.g. a recent move to a new house).
(+)
Shoulder weakness, Pain especially on raising arm above shoulder (e.g.
inability to comb hair) and also pain ↑ at night
Think of → Supraspinatus Tendinitis.
55
Bone pain + ↑ Alkaline Phosphatase (ALP) + Multifocal Sclerotic patches on
X-Ray ± HF (e.g. shortness of breath on exertion
→ Paget’s disease. (the other name is “Osteitis Deformans”
56
Note that Paget’s disease may rarely present with hypercalcemia in case of??
Immobilisation
The presence of hearing loss + heart failure with bone manifestations (e.g.
Bone pain, fracture) favours the Dx of Paget’s disease even if calcium is high.
57
X-ray in Paget’s disease
(Cortical Sclerosis, Coarse trabecular pattern)
◘ The blade of grass lesion (V-shape pattern between healthy and diseased
long bone).
◘ Multifocal Sclerotic Patches (Cotton wool pattern in the skull)
58
Treatment of pagets
Rx → Bisphosphonates
59
♠ Sclerotic lesions on X-ray → ______
♠ Lytic (Punched-out) lesions on X-ray → ______
♠ Sclerotic lesions on X-ray → Paget’s disease.
♠ Lytic (Punched-out) lesions on X-ray → Multiple Myeloma.
60
Whenever you see High Alkaline Phosphatase, think of 2 Bs + P
1) Bone: Osteomalacia, Paget’s disease, Hyperparathyroidism, Bone
metastases.
2) Biliary tract: Cholestasis (Obstructive Jaundice).
3) Pregnancy (Physiological).
61
62
√ It is a cancer of Plasma Cells.
√ “Overgrowth of plasma cells replacing the bone marrow tissues” +
Overproduction of Non-functioning Igs (Immunoglobulins).
Multiple Myeloma
63
The main presenting Symptoms of MM
√ The main presenting Symptoms:
• Bone pain “Particularly in the back and ribs”
• Hypercalcemia → Polyuria, Polydipsia, Low mood, Confusion.
• Anemia → Fatigue, Weakness, Pallor, Dyspnea on exertion.
√ Others:
• Recurrent Infections → As the immunoglobulins are functionless.
• Renal Failure.
64
√ Important Notes on Investigation of MM
♦ Bone Marrow Biopsy → Abundant Plasma cells
♦ Serum Protein Electrophoresis (Diagnostic √).
→ ↑↑↑ Monoclonal Immunoglobulin
Spike.
♦ Urine Protein Electrophoresis → Bence Jone’s Protein. √
♦ Blood Film → Rouleaux Formation.
♦ X-Ray Skeleton → Lytic Lesions “plasma cells → Osteoclasts → Bone Lysis”.
65
Electrolyte findings in MM
♦ ↑ Ca++ (>2.6 mmol/L) but with Normal Alkaline Phosphatase (30-150 U/L).
♦ Anemia (Normocytic Normochromic).
♦ Renal functions could be impaired (Low GFR, High Urea and Creatinine).
♦ High ESR
66
Example (1),
60 YO ♂ presents with Hx of Back and Ribs pain + being Thirsty + Tiredness.
Hb is 90 g/L (low)▐ Ca++ is 4 (high)▐ ALP is 115 (normal)▐ ESR is 88▐ eGFR is
45 (low).
The likely Dx → ________
The cell type to be found in BM → _____
The Diagnostic Test → _____
The likely finding on blood film → _____
Multiple Myeloma.
Plasma Cells.
Bone Marrow Biopsy.
Rouleaux Formation.
67
√_______ is the commonest laboratory finding in MM.
√ _______ presents in 50% of MM cases.
√ In MM, _____Calcium but ____ ALP.
√ Anemia is the commonest laboratory finding in MM.
√ Renal Impairment presents in 50% of MM cases.
√ In MM, High Calcium but normal ALP.
68
In a femur fracture, if the patient is hemodynamically stable (SBP >100
First step?
→ Thomas Splint first “Before IV fluid and before ABCDE”
This is to align the fracture; thus, reducing the blood loss as the femur
fracture bleeds significantly).
69
In any fracture (e.g. leg), if there is one of the following:
◘ Absence of Pulses “Neurovascular compromise”
.
◘ Obvious Deformity.
Next step??
The immediate “Next” action after ABCD to be done is
→ Urgent Reduction under Sedation or Analgesia
After that, A referral to neurovascular/ orthopaedics should be made.
“We aim at restoring the blood supply “the pulses” by an immediate
reduction “usually under IV Midazolam” even before X-ray.
The time is key in such cases.
70
A child presenting with Painful Hip (+)
◙ Mild fever▐ WBCs and ESR are normal or mildly elevated▐
No local signs
(no redness, tenderness, swelling)
Happy and systemically well child
→ Transient Synovitis.
71
A child presenting with Painful Hip (+)
◙ Fever > 38.5▐ WBCs > 12000, ESR > 40▐
There are tenderness, redness,
swelling of hip/leg▐
Systemically unwell
→ Septic Arthritis.
72
A child presenting with Painful Hip (+)
◙ A child “Boy” with limping
shortened leg
externally rotated leg
Slipped upper femoral epiphysis.
73
A child presenting with Painful Hip (+)
◙ A child “girl” ▐
Breech presentation ▐
FHx ▐
Limping▐
Painless leg that is
shorter than the other ▐
Unequal skin fold
Developmental Dysplasia of the Hip (DDH).
74
An elderly man fell at home 2 days ago and presents with hip pain and inability
to bear weight on his right leg.
X-ray shows a fracture of acetabulum.
The most likely affected nerve ?
→ Sciatic nerve.
75
76
Femur Neck Fracture → _____
- Acetabular Fracture → ____
- Posterior dislocation of the hip → ____
Femur Neck Fracture → Sciatic Nerve.
- Acetabular Fracture → Sciatic Nerve.
- Posterior dislocation of the hip → Sciatic Nerve.
77
- Humeral Shaft Fracture →
- Humeral Shaft Fracture → radial nerve
78
Wrist Drop →
Wrist Drop → Radial Nerve.
79
Paraesthesia and impaired sensation in both hands (Glove distribution) →
→
Peripheral Neuropathy.
80
- Colle’s fracture “dinner fork deformity” → nerve??
- Colle’s fracture “dinner fork deformity” → Median Nerve (Hand
numbness).
81
- Monteggia Fracture → nerve involved?
Radial nerve
82
Humeral Neck Fracture → nerve involved?
Humeral Neck Fracture → Axillary Nerve.
83
Humeral shaft fracture- nerve involved?
- Humeral Shaft Fracture → Radial Nerve.
84
A 47 YO ♀ with a Hx of breast cancer presents with painful,
dull-
aching pain over her right shoulder and thoracic spine.
The pain is
worse on lying down.
She goes to gym frequently as well.
X-ray shows
some degenerative changes.
This is likely a case of breast metastasis to bone
85
Investigation for mets bone?
♦ The most test → INITIAL Serum Calcium
APPROPRIATE test → MRI, if not in the options
→ Bone scintigraphy.
√ The gold standard for bone metastasis is (MRI), followed by (Bone
Scintigraphy)
86
87
X-ray- deg changes
◙ This is NOT a case of osteoarthritis. Why?
√ The X-ray findings specific for osteoarthritis are not present here which are
LOSS: Loss of joint space, Osteophytes, Subchondral cysts, Subchondral
sclerosis)
√ The pain in osteoarthritis is worse on use “activity”. Here, it is worse on lying.
88
Note,
DEXA Scan Skeletal Survey → measures bone density → in _____\
→ in Multiple Myeloma ________ lesions on X-ray).
Note,
DEXA Scan Skeletal Survey → measures bone density → in Osteoporosis.
→ in Multiple Myeloma “lytic – punched out lesions on X-ray).
89
◙ A young boy + Painful knee + Gait abnormality + Tender, smooth, fixed mass
over a knee side + Other systemic (Fever, Weight loss, Tiredness)
the 2nd commonest bone tumor in children”.
→ Ewing Sarcoma
90
26
Fracture of the Head of the radius
Fracture of the Neck of the radius
Both have similar features:
√ Lateral elbow swelling.
√ Limited range of elbow movement.
√ Passive rotation of elbow → ↑ Pain
91
◙ However,
Radius HeaD Fracture → More common in _____
Radius Neck Fracture → More common in ____
◙ However,
Radius HeaD Fracture → More common in Adults (HeADult)
Radius Neck Fracture → More common in childreN.
92
The commonest Origins of Bone Metastasis
(commonly Spine, then pelvis, then ribs, then skull and long bones)
In Males ♂ → PROSTATE then Lung.
In Females ♀ → BREAST then Lung.
93
Femur fracture → the patient’s level of consciousness and O2 saturation
deteriorate after surgery (24-72 hours)
???
→ Suspect Fat Embolism “common in long bone fractures especially femur”.
94
Polytrauma -Multiple fractures- esp. of the long bones, particularly femur and
pelvis followed by open reduction surgery, followed by deterioration:
(hypoxemia + neurologic e.g.↓ consciousness-)
→ Fat Embolism is likely the cause.
95
◙ Fracture of distal radius + Dorsal Angulation (Dorsally displaced
fragments)
→ Colle’s fracture (Dinner Fork Deformity)
◙ The likely injured nerve → Median Nerve. (Numbness of hand).
♠ Rx in elderly
→ Closed reduction followed by POP “Plaster of Paris” cast below elbow.
♠ Rx in Young
→ Above elbow Backslab cast.
♠ If there are intra-articular fractures/ incongruity
→ Open reduction and internal fixation.
96
Low Ca + Low Phosphate + High ALP
Low Ca + Low Phosphate + High ALP ➔ Osteomalacia.
97
◙ Numbness and Tingling of the thumb, index and middle fingers
→ Think of Carpal Tunnel Syndrome
◙ The Transverse Carpal Ligament compresses the MEDIAN nerve.
Treatment?
◙ Thus, the treatment would be → Cut the Transverse Carpal Ligament =
Release Flexor Retinaculum
to release the pressure on the median nerve.
♠ Note: Transverse Carpal Ligament is also called = Flexor Retinaculum =
Anterior Annular Ligament.
98
Risk factor of CTS
√ Pregnancy is an important RF for Carpal Tunnel Syndrome (due to fluid
retention).
√ Tinel Test is not always positive in Carpal Tunnel Syndrome “very low
sensitivity”.
√ After applying cast for scaphoid bone fracture, tension may develop resulting in
Carpal Tunnel Syndrome. Release the flexor retinaculum to alleviate the tingling,
pain of thumb, index and middle fingers due to the compressed median nerve
might be indicated.
99
Rx of CTS in pregnancy?
√ If pregnant with Carpal Tunnel Syndrome
→ wear Wrist Splints until delivery (usually resolves after delivery).
√ If it did not resolve and long-standing → cut the transverse carpal ligament
100
◙ A ____, also known as a torn ligament, is damage to one or more
ligaments in a joint, often caused by trauma or the joint being taken beyond
its functional range of motion (overstretched).
◙ ____ can occur in any joint but are most common in the ankle and wrist.
Sprain injury
101
Signs and symptoms of sprain injury
Severe Pain
Rapid Swelling
Bruising
Decreased ability to move the limb
Difficulty using the affected extremity
102
◙ Management → P.R.I.C.E
Protect
Rest
Ice
Compress
Elevate (eg, high arm sling for a few days).
103
♠ Example,
A factory worker has his hand stuck in a machine. He presents with extremely
painful wrist, rapidly increasing swelling, limited range of hand movement.
X-ray shows no fractures.
♦ The likely Ds → Sprains injury.
♦ Management → PRICE → High arm sling for 3 days (elevation). √
104
Septic Arthritis
Monoarthritis = Single joint involvement (commonly Knee)
Fever/ Pain/ Swelling/ Limited movement
Risk factors?
+ A Risk factor (e.g. DM, Steroid,
HIV, Rheumatoid Arthritis) “
important √”
Think of → Septic Arthritis
105
♦ The commonest causative organism → Staphylococcus Aureus.
♦ A common organism in young SEXUALLY active → N. Gonorrhea.
Investigation?
♦ Dx
√ Aspiration of Synovial Fluid → send for staining, microscopy, WBC count
and Culture.
√ Blood Culture.
106
♦ Management
√_____ (for 4-6 weeks) “first-line” “like cellulitis”
√ If penicillin allergic → _____
♦ Management
√ Flucloxacillin (for 4-6 weeks) “first-line” “like cellulitis”
√ If penicillin allergic → Clindamycin.
107
√ If the causative organism is N. Gonorrhea nor Staph → ______
√ If still not responding →_____
√ If the causative organism is N. Gonorrhea nor Staph → Cefotaxime or
Ceftriaxone.
√ If still not responding → Repeated percutaneous aspiration.
108
“IV antibiotics for _____until blood cultures become -ve and swelling resolves
Then, Oral antibiotics for ___weeks”
◙ Note, do not forget ________as risk factors for Septic Arthritis.
“IV antibiotics for 1 week until blood cultures become -ve and swelling resolves
Then, Oral antibiotics for 4 weeks”
◙ Note, do not forget (DM, RA) as risk factors for Septic Arthritis.
109
Migratory Oligoarthritis of lower limbs + Back pain + Extraarticular features)
• Typically, there is no fever.
• Typically, seen in young adults.
• Typically follows Urogenital infection “STI” or GI infection “dysenteric
illness”.
• Asymmetric, Migratory Oligoarthritis of LL (Knees and Ankles
Reactive arthritis: Seronegative Spondyloarthritis
110
√ Cannot see → Conjunctivitis, Uveitis.
√ Cannot pee → Urethritis.
√ Cannot climb a tree → Arthritis.
+ Skin manifestations
• Extraarticular features: (Reiter’s Triad)
111
Skin manifestations of reiters syndrome
+ Skin manifestations
circinate balanitis (painless vesicles on the coronal margin of the prepuce),
keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)
Erythema nodosum (Tender, red nodules over shins).
112
Management of reiters syndrome
♦ Symptomatic: analgesia, NSAIDS, intra-articular steroids
♦ Sulfasalazine and methotrexate are sometimes used for persistent disease
♦ Symptoms rarely last more than 12 months
113
A child (4-10 YO) fell on his outstretched “arm”
+
Absent radial/ brachial pulse
Think → Angulated Supracondylar Fracture of Humerus.
The most likely structure to be damaged → Brachial artery. √ imp.
114
If Supracondylar fracture of humerus is not in the options, and the falling
victim on an outstretched “arm” is a child, look for → ______
As the bones in young children are still soft, they tend not to break
completely, forming what’s called
“Greenstick Fracture”.
It is tender, but no visible deformity.
115
◙ Fracture of distal radius with anterior displacement
→_______ Fracture = _____ fracture
→ ______ Deformity.
◙ Fracture of distal radius with ANTERIOR displacement
→ Reverse Colle’s Fracture = Smith’s fracture
→ Garden Spade Deformity.
116
Fracture of distal radius with DORSAL “posterior” displacement
→______ fracture → _____Deformity
Fracture of distal radius with DORSAL “posterior” displacement
→ Colle’s fracture → Dinner Fork Deformity
117
Locked leg seen in _____ and popping?
Investigation of choice in meniscus tear??
♦ Locking (Locked leg) → Meniscal tear.
♦ +ve Apley and McMurray tests → Meniscal tear.
Imp √, meniscal tears are best seen by → MRI scan
♦ Popping → Anterior Cruciate Ligament injury.
♠ Note, Meniscal tears are often associated with Anterior Cruciate Ligament injury
118
Direct impact to the lateral side (Valgus stress test is +ve. Ie, there is pain
on valgus stress test):
→ Medial Collateral Ligament injury. Important √
119
♣ Direct impact to the medial side (Varus stress test is +ve. Ie, there is pain
on valgus stress test)
→ Lateral Collateral Ligament injury. Important √
120
g. a player fell on his knee and presents with valgus stress test being +ve
→ Medial collateral ligament injury.
121
e.g. a player fell on his knee and presents with Varus stress test being +ve
→ Lateral collateral ligament injury.
122
√ Anterior drawer test (Lachman tes
→ Anterior Cruciate Ligament.
123
√ ______ drawer test → Posterior Cruciate Ligament.
√ +ve Apley and McMurray tests, _____sensations
→ Meniscal tear → do____Knee. √
√ Posterior drawer test → Posterior Cruciate Ligament.
√ +ve Apley and McMurray tests, locking sensations
→ Meniscal tear → do MRI Knee. √
124
Fracture of middle to distal third of humerus (shaft of humerus)
Fracture of middle to distal third of humerus (shaft of humerus)
→ Radial nerve injury
→ Wrist Drop (unable to dorsiflex wrist).
125
√ After applying cast for scaphoid bone fracture, tension may develop
resulting in Carpal Tunnel Syndrome. Management?
→ Release of flexor retinaculum to alleviate the tingling, pain and the limited
movements of thumb, index and middle fingers due to the compressed
median nerve.
♦ Remember,
Flexor retinaculum = Transverse carpal ligament = Anterior annular ligament
126
A young boy + Painful knee + Gait abnormality + Tender, smooth, fixed mass
over a knee side.
→ Osteosarcoma “the commonest bone tumor in children”
127
.
◙ A young boy + Painful knee + Gait abnormality + Tender, smooth, fixed mass
over a knee side + Other systemic (Fever, Weight loss, Tiredness)
“the 2nd commonest bone tumor in children”.
→ Ewing Sarcoma
128
X-ray and clinical difference between Ewing sarcoma and osteosarcoma?
So, if no fever → Osteosarcoma ▐ If with fever → Ewing Sarcoma.
Another differentiation point is X-ray
√ X-ray → Sunburst lytic bone lesions → Osteosarcoma
√ X-ray → Lytic lesion + Onion-Skin layers → Ewing Sarcoma.
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√ Severe lower back pain that radiates to a leg (could be Acute sudden
onset)
√ Lying supine with legs raised → ↑ pain. (+ve straight leg raising test)
√ Lying down → relieves (↓) pain
♦ The likely Dx → ♦ Next step → ♦ If any red-flags or this option is not given → Reassure and prescribe analgesics.
MRI Spine.
130
The best modality for bone metastasis →____, followed by Bone
Scintigraphy.
MRI should be done within 7 days if there is bone pain only.
MRI should be done within 24 hours if pain + Neurological signs
131
Muscle bunches up in the distal arm, Popeye
appearance
Proximal Biceps Tendon Rupture: Muscle bunches up in the distal arm, Popeye
appearance.
132
A football player was kicked to his left calf and presented with severe pain.
He was given morphine but still in pain.
His calf is bruised and swollen.
Passive movements of his toes aggravate the pain.
He has weak pulse on his
dorsalis pedis and posterior tibial arteries but still felt. X-ray is normal
.
The likely Dx → compartment syndrome
The most appropriate action → If fasciotomy is not among the given options,
and there is an option for
→ Measuring the intracompartmental pressure, pick it.
133
Compartment syndrome clinical features?
This is a case of Compartment Syndrome
History of trauma/ compression of a limb. Very painful and very tense muscles
bundle.
Passive movement of fingers/ toes of the affected limb leads to a
significant pain.
Morphine is NOT so helpful in relieving pain.
Distal pulses can
be felt and their presence does NOT exclude the diagnosis of compartment
134
A 60 YO man has had a distal radial fracture 2 years ago. He does not smoke,
and drinks 4 units of alcohol a week
. His BMI is 22 kg/m2.
He would like to
decrease his risk of fractures in the future. What is the appropriate action?
→ DEXA scan.
√ Anyone who is > 50 YO with a Hx of fragility fracture should be assessed for
osteoporosis by DEXA scan.
√ If the result of the DEXA scan shows a bone mineral density T-score is -2.5 or
less, he would be given bisphosphonate.
135
Fragility fracture
√ Fragility fracture is a fracture that results from a low-level trauma that
usually does not cause a fracture (commonly seen is vertebrae, proximal
femur, distal radius).
136
What If he has risk factors for osteoporosis (e.g., smoking, DM,
prolonged use of corticosteroids, low BMI, heavy alcohol) but has
not had fragility fracture??
In this case, we would initially do a (fracture risk assessment) e.g., (calculate
the patient’s 10-year major osteoporotic fracture risk using a fracture risk
assessment tool).
If the result is ≥ 10% → go for DEXA
scan
. If T-score ≤ 2.5 → bisphosphonates
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A 60 YO man wants advice to decrease his risk of osteoporotic fracture. He is
a smoker. His BMI is 17.5. He has DM. He has no Hx of fractures but his
father had hip fracture
→ Calculate the patient’s 10-year major osteoporotic fracture risk using a
fracture risk assessment tool.
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62 YO man has had a proximal femur fracture 6 months ago. He does not
smoke, and drinks 4 units of alcohol a week.
His BMI is 22 kg/m2.
His
estimated calcium intake is 400 mg a day.
He has done DEXA scan and his T-
score is -2.2.
What is the most appropriate action
→ Start calcium and vitamin D tablets.
√ Anyone who is > 50 YO with a Hx of fragility fracture should be assessed for
osteoporosis by DEXA scan. He has a fragility fracture (proximal femur).
√ His t score is still above -2.5, thus, he would not be given bisphosphonate.
√ For adults, the recommended intake of calcium is 700 mg/day.
√ For people at risk of fragility fracture, the recommended intake of calcium is
at least 1000 mg/day.
√ NICE suggest using both calcium + vit. D if calcium intake is insufficient.
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A 72 YO man fell down and presents with severe right hip pain. X-ray shows a
right femoral neck fracture. ECG shows atrial fibrillation. He was given IV
morphine as a bolus but still in severe pain. His pulse rate is 88 and respiratory
rate is 11 breaths per minute. The plan is to take him to the theatre for an
open reduction and internal fixation. What should be done now?
→ Fascia iliaca compartment block.
√ He has femur neck fracture.
√ He is still in severe pain.
√ He has no contraindications for fascia iliaca compartment block (even
though he has AF, he is not on anticoagulation therapy. AF is not a
contraindication for fascia iliaca nerve block or general anaesthesia.
√ It is dangerous to add more morphine as it can cause respiratory depression
and his RR is already 11.
√ young pt-rta -fear of avascular necrosis of the femoral head.
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Example (2):
A 72 YO man fell down and presents with severe right hip pain. X-ray shows a
right femoral neck fracture. ECG shows atrial fibrillation. He was given IV
paracetamol but is still in severe pain. His pulse rate is 88 and respiratory rate
is 18 breaths per minute. He is on rivaroxaban and his INR is 2. What should
be done now?
→ IV morphine
√ Firstly, he has not been given morphine (he was given paracetamol). He is
still in severe pain.
√ Secondly, it is dangerous to do fascia iliaca compartment block as he has a
contraindication which is (he is on anticoagulation; rivaroxaban) for risk of
bleeding.
141
Distal radius fractures (even if minimal displacement) RX
Rx → Then → Closed Reduction
Below elbow backslap “for immobilisation”.
142
After moving to a new house and lifting heavy objects, a 30 YO
man presents with back pain around the level of L3. There are no
other complaints. Examinations are normal.
→ Take over the counter analgesics and continue to mobilize.
Do not advise to rest for mild musculoskeletal pain or myofascial pain.
Rest
would cause spasm and prolonged pain while keep mobilising would help
muscles to return to normal sooner.
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A 60 YO woman fell down and had a neck of femur fracture. She is
due for surgery the next day. He Hb is 76 g/L. What should be
done?
→ Transfuse Blood and Proceed with the surgery.
Hip surgery is NOT elective. The sooner the surgery, the better the results.
Her Hb is 76 g/L (ie, 7.6 mg/dl)
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◙ Elective Surgery: HB less than 8 & Hb 10
♠ If Hb is < 10 → Delay “defer” “Postpone” the surgery and Investigate for the
anemia reasons first.
♠ If Hb is < 8 → Transfuse Blood and also Defer the surgery.
145
Hb 8 and 10 or less
Emergency surgery
◙ Emergency Surgery:
♠ If Hb is < 10 → Proceed with the surgery.
♠ If Hb is < 8 → Transfuse Blood and Proceed with the surgery
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√ The supraspinatus muscle is a part of the rotator cuff muscles.
√ It initiates arm abduction.
√ Classic sign is → painful arc in resisted abduction between 60-90 degree.
√ Passive abduction is normal “no pain”.
√ External rotation of the arm is normal “no pain”.
√ It commonly affects athlete
Supraspinatus Tendinitis
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Example:
A 30 YO female presents complaining of painful left shoulder for a few
months. Her pain started after joining a gym and lifting heavyweights. She
cannot lift her left arm over her shoulder due to pain. There is no muscle
wasting. O/E, pain is present when she abducts her left arm to 80 degrees.
There is no pain when she externally rotates her left arm. There is no
reduction in passive movements of glenohumeral joint.
The most likely Dx → Supraspinatus tendinitis.
148
• Compression of spinal cord → Spinal Claudication (leg pain that is worse when
standing or walking, and improves with sitting or bending forwards -flex-)
Causes??
• Causes:
- Degenerative “the commonest cause”
- Wear and tear in the vertebrae due osteoarthritis
- Herniated disc.
- Spondylolisthesis (slipping of vertebrae
149
• Spinal claudication description?
IOC?
√ Leg pain that is worse on long-standing or walking (eg, starts 10 minutes
after standing) and improves by sitting or bending forwards.
√ Radical radiated pain the dermatome distribution.
√ The leg pain can be unilateral or bilateral. It can involve back, buttocks,
thighs, and spread to feet.
• Investigation of choice → Magnetic Resonance Imaging (MRI). √ imp.
150
√ Painful, tender and swollen elbow (inability to move elbow due to pain).
√ Inability to supinate forearm or fully extend elbow.
√ Cubitus varus is common.
√ Hand numbness (due to compression on ulnar, radial or median nerves).
√ Hand coldness/ cyanosis (due to compression on brachial artery).
Supracondylar Fracture of the Humerus
• One of the most common fractures in children.
151
Notes on Managing Back Pain:?
Notes on Managing Back Pain:
NSAIDs Naproxen) especially if mild-moderate back pain.
• Paracetamol alone is not recommended by NICE CKS to manage back pain
as it does very little to manage back pain (ineffective).
• Start with a (eg, • Another valid option for back pain is codeine (given after trying NSADs, and
if the pain is more severe
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• Infection of bone, often caused by bacteria, mainly staphylococcus Aureus.
• Risk factors:?
Diabetes, immunocompromised, open fracture, recent trauma.
• Clinical features:
√ Acute onset of pain in the affected bone.
√ Swelling, erythema and warmth overlying the affected bone.
√ Fever.
153
• What is the best modality to diagnose vertebral osteomyelitis?
Mng?
• What is the best modality to diagnose vertebral osteomyelitis?
→ MRI of the spine. Others → blood cultures.
• Note that one of the complications of staphylococcus aureus bacteremia is
distant spread via haematogenous route causing infections like vertebral
osteomyelitis.
• Management → IV antibiotics (Flucloxacillin).
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What is the most common muscle involved in rotator cuff tears?
→ Supraspinatus.
Supraspinatus muscle is the most involved muscle in rotator cuff tears,
especially in patients who present with pain on abduction and external
rotation of the arm.
There is usually tenderness over the anterior aspect of
the shoulder.
155
156
• Common in children due to the relative flexibility of their bones.
• Commonly seen in the distal radius after a fall on an outstretched hand.
• Tenderness, Pain and ± swelling over the distal radius.
Buckle Fracture (Torus Fracture)
157
Rx of buckle fracture?
this case, alignment is maintained, and therefore, no immediate
orthopaedic intervention is required other than immobilisation.
158
Clinical Scenario:
• Elderly patient with osteoporosis.
• Sudden onset of sharp thoracic pain following physical exertion (eg, lifting).
• Pain localized to thoracic region.
• History of medication for osteoporosis (e.g., alendronate
Exmn
Investigation- initial and follow up?
).
Examination Findings:
• Tenderness over thoracic vertebrae.
• No visible bruising or deformity
• Normal neurological examination.
Initial Investigation:
• Preferred Test → X-ray of the Thoracic Spine.
o Readily available and cost-effective.
o First-line imaging to evaluate new onset back pain.
o Useful in identifying vertebral fractures.
o Especially indicated in the context of trauma or physical exertion.
159
160
161
Follow up investigation
Follow-Up Considerations:
• If X-ray results are inconclusive or complex fractures are suspected, MRI
may be considered for detailed assessment.
• MRI can be used if complications develop or if further investigation is
necessary after initial X-ray.
162
• The patient’s presentation suggests a potential meniscal injury, which is
characterized by intermittent pain, catching or locking sensations, and positive
McMurray’s test findings.
Gold std?
• MRI of the knee is considered the gold standard for diagnosing soft tissue
injuries of the knee, including meniscal tears, ligament damage, and cartilage
abnormalities. It provides a detailed view of both soft tissue and bone, which
makes it ideal for this situation
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The image shows swelling over the elbow region, which is characteristic of
→ Olecranon Bursitis.
Definition?
◙ Definition:
Olecranon bursitis is the inflammation of the bursa located over the olecranon
process at the elbow. The bursa acts as a cushion between the bone and the
skin, reducing friction during movement. When it becomes irritated or inflamed,
it fills with fluid, causing swelling, pain, and limited movement of the elbow.
164
Olécrenon bursitis
First line mng?
Compression bandage and ice application.
1. Conservative Management: → o Rest: Avoid activities that exacerbate the symptoms.
o Ice application: Apply ice packs intermittently to reduce swelling and
inflammation.
o Compression: Using an elbow pad or compressive wrap can help reduce
swelling.
o Elevation: Elevate the arm to reduce swelling when possible.
2. NSAIDs: Non-steroidal anti-inflammatory drugs (such as ibuprofen or
naproxen) to reduce pain and inflammation
3. Aspiration (if necessary): If the swelling is significant or persistent, aspiration
of the fluid may be considered for relief and diagnostic purposes (to check for
infection).
4. Infection management (if suspected): If there is any concern for septic
bursitis (e.g., warmth, redness, systemic symptoms), antibiotics may be
required after aspiration and culture.
If conservative treatment fails or infection is suspected, referral to a specialist
may be necessary.
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A 30-year-old woman, 10 weeks postpartum, presents to the clinic complaining
of persistent pain and swelling on the radial side of her right wrist. She reports
that the pain worsens when she lifts her baby, particularly during feeding or
carrying. On examination, there is tenderness over the radial styloid, and the
pain is exacerbated by thumb movement. What is the most likely diagnosis?
De Quervain's tenosynovitis is common in women during the postpartum
period, likely due to the repetitive strain from lifting and holding the baby.
It
involves inflammation of the tendons at the base of the thumb near the radial
styloid. The key clinical feature is pain and tenderness over the radial side of the
wrist, often worsened by activities that involve gripping or lifting. This scenario is
typical for De Quervain's, as postpartum women frequently experience this due
to repeated hand use in caring for their newborn.
166
CTS vs de quervain tenosynovitis
Why not carpal tunnel syndrome?
Carpal tunnel syndrome presents with numbness, tingling, and pain in the
thumb, index, and middle fingers due to compression of the median nerve. It
typically affects the volar aspect of the wrist, not the radial styloid area, and the
symptoms are often worsened by activities like typing or during the night. Since
this patient’s pain is localised to the radial side of the wrist and exacerbated by
thumb movement rather than median nerve compression symptoms, carpal
tunnel syndrome is less likely.
167
Acute Flare of Osteoarthritis (Scenario-Based Key Points)
❖ Patient Presentation:
o 57-year-old woman, 12-month history of wrist pain (osteoarthritis).
o Recent worsening with pain, stiffness, swelling, particularly after movement
.
❖ Examination:
o Joint space narrowing, osteophyte formation on radiographs.
o Blood tests negative for rheumatoid factor and anti-CCP.
❖ Management:
o Corticosteroid injection is the most effective for rapid relief of acute flare
symptoms.
o Provides short-term relief (2-10 weeks) for pain and inflammation.
o Over-the-counter NSAIDs (e.g., ibuprofen) can be used initially but may not
always control severe flares.
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Long term mng OA
❖ Long-term Management:
o Physiotherapy can improve joint function and strength but is not the best
choice for acute flares. (Pick physiotherapy if the pain is mild, as it is more
useful for improving the range of motion. However, in significant pain and
tenderness acute flare of osteoarthritis, pick corticosteroid injection).
o Avoid glucosamine and acupuncture as they are not recommended for
symptom relief in osteoarthritis (according to NICE guidelines)
169
When should physiotherapy be chosen over
❖ Physiotherapy corticosteroid injections in osteoarthritis management
❖ Physiotherapy corticosteroid injections in osteoarthritis management?
is recommended for patients with mild to moderate
osteoarthritis who experience stiffness and reduced range of motion without
severe pain.
It helps improve joint function and mobility, and provides
long-
term benefits by strengthening muscles and stabilising joints.
170
Moderate to severe pain OA management?
❖ Corticosteroid injections are more appropriate for patients with moderate to
severe pain that significantly impacts daily activities, or when inflammation is
present. They offer faster pain relief, especially when conservative treatments
like physiotherapy and analgesia have not been effective. Injections are
particularly useful for focal pain and can provide short- to medium-term
relief.
171
❖ Patient Presentation:
o 54-year-old man, 3 weeks post minimally displaced distal radius fracture.
o Treated initially with a cast (3 weeks ago).
o Now presents with stiffness, mild discomfort, weakness, no significant pain.
❖ Examination:
o Warm, well-perfused fingers.
o No swelling or concerning symptoms like severe pain, swelling, or
discoloration.
❖ Management?
o → to address stiffness and promote recovery.
o Encourage finger movement for range of motion, joint health, and
circulation.
o Pain is likely due to immobilisation, not a serious complication.
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Red flags for immediate action in distal radial fracture post cast application?
❖ Red Flags for Immediate Action:
o Severe pain, significant swelling, discoloration, or loss of sensation would
suggest complications like compartment syndrome, requiring urgent cast
removal.
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Bone pain + ↑ Alkaline Phosphatase (ALP) + Multifocal Sclerotic patches on
X-Ray ± HF (e.g. shortness of breath on exertion
Paget’s disease. (the other name is “Osteitis Deformans”).
The diagnosis of Paget’s disease of the bone is a combination of
√ High alkaline phosphatase (↑ ALP), and:
√ X-ray findings usually reveal a mixture of:
Sclerotic lesions, Lytic lesions, Coarsened trabecular pattern.
174
A swelling behind the knee (in the popliteal fossa), usually asymptomatic,
round, smooth, non-tender?
→ Baker cyst (popliteal cyst)
175
◙ An osteoarthritis patient with a Hx of right popliteal mass (was present for 3
weeks then subsided) now presents with right calf pain, swelling, erythema
and tenderness.
Baker’s cyst rupture
→ “There is an association between osteoarthritis and baker cyst”.
176
Perthes disease definition?
◘ Perthes’ diseas’ is a degenerative ’ondition affecting the hip joints of
children, typically between the ages of 3-9 years.
◘ It is due to avascular necrosis of the femoral head, specifically the femoral
epiphysis. Impaired blood supply to the femoral head causes bone infarction.
◘ Perthes’ disease is 5 times more co’mon in boys. Around 10% of cases are
bilateral.
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◙ Features
√ Hip pain: develops progressively over weeks-months.
√ Limping.
√ Stiffness and reduced range of hip movement.
√ X-ray: early changes include widening of joint space, later changes include
decreased femoral head size/flattening, radiolucency of the proximal
metaphysis.
Diagnosis?
Perthes
178
179
• DDx according to age
Hip pain
• < 3 years DDx according to age:
→ Developmental dysplasia of the hip (usually girl, breech
presentation) ▐ toddler’s fracture e.g. spiral injury, may not be seen on X-ray.
3 to 9 years → Perthes disease (Chronic, stiffness, flattening on x-ray).
9 years → Slipped upper femoral epiphysis (boy, shorter leg, limping).
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