ortho on passmed year 5 Flashcards
long term steriod use risk for what
avascular necrosis of fem head
sx of avn fem head
vdevelopment of anterior hip pain and stiffness
relevant rf such as steriods, chemo, obesity, trauma and alcohol
ix of choice for avn
MRI
findings on hip XR of avn
This X-ray shows avascular necrosis of the femoral head (AVNFH), visible as flattening and a decrease in volume of the right femoral head. Additionally, a small but pathognomonic ‘crescent’ sign is visible in the lateral articular surface of the femoral head - this describes a curvilinear lucent line below the articular surface, caused by a subchondral fracture typical of AVNFH.
what is the crescent sign
The crescent sign refers to a linear cleft due to a subchondral fracture in the setting of osteonecrosis.
obvious ankle injury with neuro compromise what do you do
X-rays should not be taken of obvious ankle injuries if neurovascular compromise is present - immediate reduction / stabilisation instead
A DEXA scan should be offered without calculating the fragilty risk score in the following situations:
> 50 years of age with a history of fragility fracture
< 40 years of age who have a major risk factor for fragility fracture - these patients should be referred to a specialist depending on the T-score
before starting treatments that may have a rapid adverse effect on bone density (for example, sex hormone deprivation for treatment for breast or prostate cancer)
Greater trochanteric pain syndrome is also referred to as trochanteric bursitis
due to what seen in who
It is due to repeated movement of the fibroelastic iliotibial band and is most common in women aged 50-70 years.
what node is this
A 42-year-old lady who has systemic lupus erythematosus presents to the clinic with a 5 day history of a painful purple lesion on her index finger. On examination she has a tender red lesion on the index finger.
osler
A 62-year-old lady presents with an non tender lump overlying the distal interphalangeal joint of the index finger. On examination she has a hard, non tender lump overlying the joint and deviation of the tip of the finger.
what node is this
herbedens
most common type of fracture in the foot which is a stress fracture
2nd metatarsal
what is lumbar spinal stenosis and sx
Lumbar spinal stenosis is a condition in which the central canal is narrowed by tumour, disk prolapse or other similar degenerative changes.
Patients may present with a combination of back pain, neuropathic pain and symptoms mimicking claudication.
how do you differentiate lumbar spinal stenosis from true claudication
One of the main features that may help to differentiate it from true claudication in the history is the positional element to the pain. Sitting is better than standing and patients may find it easier to walk uphill rather than downhill.
simmonds triad for achilles tendon rupture
Calf squeeze test, observation of the angle of declination, palpation of the tendon
what is an ORIF
Open reduction internal fixation (ORIF) is a surgical procedure commonly done to repair bone fractures, especially those in which the broken bone fragments are not properly aligned or displaced. This procedure involves making an incision (an ‘open’ approach) to access the fracture site, realigning the fractured bones, and using internal fixation devices such as screws, plates, rods, or pins to stabilise and hold the bone fragments in their correct positions
what is charcots joint
Also termed neuropathic arthropathy, is characterised by the destruction of joints secondary to nerve damage. It frequently occurs in individuals with peripheral neuropathy. Alcoholic neuropathy may result in a loss of sensation and proprioception, rendering the joint vulnerable to unrecognised injuries and subsequent deformities.
Weber A fractures -
patients with minimally displaced, stable fractures may weight bear as tolerated in a CAM boot
Children and young people with unexplained bone swelling or pain: even if dont remember injury from gymnastics or something like that
consider very urgent direct access X-ray to assess for bone sarcoma
causes of carpal tunnel syndrome
pregnancy
oedema e.g. heart failure
lunate fracture
rheumatoid arthritis
Positive examination findings are that direct pressure on the coracoid elicits pain and there is impairment of active and passive external rotation.
adhesive capsulitis
psoas abcess source of infection
pyelonephritis or inflammatory bowel disease
psoas irritation indicated by what movements
Psoas irritation is evidenced when the position of comfort is the patient lying on their back with slightly flexed knees. Inability to weight bear or pain when moving the hip is usually evident.
what is the most common reason total hip replacements need to be revised
Aseptic loosening is the most common reason total hip replacements need to be revised
long term steriod use rf for
avascular necrosis of hip
hip replacement complications
perioperative
venous thromboembolism
intraoperative fracture
nerve injury
surgical site infection
leg length discrepancy
posterior dislocation
may occur during extremes of hip flexion
typically presents acutely with a ‘clunk’, pain and inability to weight bear
on examination there is internal rotation and shortening of the affected leg
- aseptic loosening (most common reason for revision )
prosthetic joint infection
Axillary nerve palsy can also occur due to shoulder dislocation.
anterior
what does imaging of lateral epicondylitis look like
imaging typically shows calcification or microtears at the origin of the extensor tendons.
mixed features of SLE, systemic sclerosis and myositis.
sharp syndrome
Fever
Joint pain - especially the knees, wrists and ankles
Maculopapular salmon rash
Other - lymphadenopathy, sore throat, hepatosplenomegaly, myalgia, pericarditis.
ferritin and ESR raised
adult onset still disease
unexplained lump increasing in size of forearm for exmaple what is the diff between adults and children in examination time
adults - urgent USS 2ww
children USS in 48hr
when do you do an LP in CT head
NICE : If CT head done within 6 hours of symptom onset shows no evidence of SAH, do not routinely offer an LP and consider alternative causes
If CT head is done > 6 hours and is negative, consider LP
LP should be performed at least 12 hours after injury to identify xanthochromia
acute gout treated with what
NSAIDs such as naproxen are generally used first-line, if there are no contraindications.
colchine
coeliac disease can lead to osteomalacia - describe how OM can lead to results of high alp low ca and low phosphate
In osteomalacia, calcium absorption decreases, leading to low serum calcium. In response, parathyroid hormone (PTH) is released to raise serum calcium. PTH increases bone resorption and the conversion of vitamin D to its active form, while also increasing phosphate excretion by the kidneys. ALP, a marker of osteoblast activity, is elevated due to increased bone turnover. Therefore, the expected results are high ALP, low calcium, and low phosphate.
hydroxychloroquine main side effect
retinopathy
pseduogout is associated with what other conditons and electorlyte abnormalities
haemochromatosis
hyperparathyroidism
low magnesium, low phosphate
acromegaly, Wilson’s disease
specific test for SLE
Anti-dsDNA - specific as has the s in it
dermatomyositis what autoantiboides
ANA
jo-1
post hip op when should you weight bear
Full weight bearing immediately post-op
On examination, there is some bruising to the lateral aspect of his right forearm, with no obvious deformities and good tone, power and range of movement and in the fingers, wrist and elbow joints. Sensation is in-tact throughout the limb, although he reports pins and needles in his fingers. When assessing tone, the patient is in visible discomfort, which is not reproduced to the same extent as when assessing power.
what is this describing
compartment syndrome
what do late presenting stress fractures look like on XR and when might you need further surgical input
case callus formation may be identified on radiographs. Such cases may not require formal immobilisation, injuries associated with severe pain and presenting at an earlier stage may benefit from immobilisation tailored to the site of injury.
Freibergs disease the x-ray changes - condition whereby the head of the metatarsal becomes misshapen and loses its nice round smooth contour turnign into square
joint space widening
formation of bony spurs
sclerosis
flattening of the metatarsal head.
most common cause OM
staph a
what movement classically impaired in adhesive capsulitis
external rotation
Squaring of the thumbs is a characteristic feature of hand
osteoarthritis
commonly used analgesia method for hip fractures
An iliofascial nerve block is an effective and commonly used method of analgesia for patients with a neck of femur fracture
spinal anaesthesia used during surgery
In children the most common site where osteomyelitis occurs in a long bone is the
metaphysis
Meralgia paraesthetica affects what nerve
Meralgia paraesthetica comes from the Greek words meros for thigh and algos for pain and is often described as a syndrome of paraesthesia or anaesthesia in the distribution of the lateral femoral cutaneous nerve (LFCN)
sx of meralgia peaesthetica
Patients typically present with the following symptoms in the upper lateral aspect of the thigh:
Burning, tingling, coldness, or shooting pain
Numbness
Deep muscle ache
Symptoms are usually aggravated by standing, and relieved by sitting
They can be mild and resolve spontaneously or may severely restrict the patient for many years.
is the LFCN sensory or motor
sensory
RF for meralgia perasesthica
Obesity
Pregnancy
Tense ascites
Trauma
Iatrogenic, such as pelvic osteotomy, spinal surgeries, laparoscopic hernia repair and bariatric surgery. In some cases, may result from abduction splints used in the management of Perthe’s disease.
Various sports have been implicated, including gymnastics, football, bodybuilding and strenuous exercise.
Some cases are idiopathic.
most useful investigation for diagnosing ank spond and what are you looking for
Plain x-ray of the sacroiliac joints is the most useful investigation in establishing the diagnosis
hill sachs lesions assoicated with what dislocation
glenohumeral dislocation
suspected osteovertebral wedge fracture what is the first line investigation
XR
3 signs of osteovertebral frctures
Loss of height:
Kyphosis
Localised tenderness on palpation of spinous processes at the fracture site
when should you not follow the ottawa ankle rules and not get an XR
clear evidence of neurovascular compromise (paraesthesia, reduced sensation, and prolonged capillary refill)
thus needing closed reduction and stabaility
5th metatarsal fractures often happen following forced
inversion of the foot and ankle
what is a weber fracture fo the ankle
fracture of the fibula
weber a fracture involves the syndemosis ) joint between two bones) how should this be managaed
- patients with minimally displaced, stable fractures may weight bear as tolerated in a CAM boot 6week
Inverted + plantar flexed foot which is not passively correctable
what is this describing
clubfoot
1st line drug management of back pain
NSAID
Pain on the radial side of the wrist/tenderness over the radial styloid process
de quervains
hip/groin pain and a snapping sensation
acetabular labral tear
plantar fasitis mx
DM , heel pain and peyriones disease in a person
Management
rest the feet where possible
stretch exercises
wear shoes with good arch support and cushioned heels
insoles and heel pads may be helpful
Compartment syndrome is most commonly associated with what two fractures
supracondylar and tibial shaft fractures
pain and swelling over the tibial tubercle.
osgood schlatter
locking and swelling of the joint as well as tenderness.
osteochondiritis dissecans
pain located at the lower aspect of the patella
patellar tendonitis
anterior knee pain worse when going up or down stairs
Patellofemoral pain syndrome, previously known as chondromalacia patellae,
lateral knee pain with tenderness in the lateral joint line
illiotibial band syndrome
Management
activity modification and iliotibial band stretches
if not improving then physiotherapy referral
Lloyd- Davies stirrups can carry the risk of peroneal nerve neuropraxia if not done carefully.
true
hernia removal what nerve do you need to be careful of
ilioingunal nerve
someone with medial epicondylitis is typically aggravated by what movement or poistions
Medial epicondylitis is typically aggravated by wrist flexion and pronation
achilles tendonitis been on NSAID fro 7 days what else can you do
refer to physio
Kocher technique reduction
affected arm is bent at the elbow, pressed against the body, and rotated outwards until resistance is felt.
Then lift the affected arm that is externally rotated in the sagittal plane as far as possible forwards and finally turn inwards slowly.
why is early reduction importnant in a dislocation
early reduction will also lead to a lower risk of muscle spasms and damaging manipulation of the neurovascular structures within the shoulder
what is spondylarthrosis
a condition in which there is abnormal wear on the cartilage and bones of the neck (cervical vertebrae)
thinning of cartilage therefore leadign to compression sx and potential risk of fractures
which reduction is done without surgery open or closed
closed
what is the dare procedure
Debridement, antibiotics, and implant retention (DAIR) is a procedure to treat a periprosthetic joint infection (PJI) after total hip arthroplasty (THA) or total knee arthroplasty (TKA).
other differentials for septic joint
and what criteria do you need for prothetic join tinfections
nec fasc
cellulitis or erispileyas over the top
MSIS criteria
wound dehisicince look for sinus tracts
loosening of a joint thus septic on xr if wider joint space
why are bacteria harder to treat on prothetic
as bacteria form a biofilm
why do you check the full bone and joints above and below
incase of pathological fracture and something sinister
also helps with management ie dont want to put an IM nail through a cancer causing mets
Absolute bone healing is a type of bone healing that occurs when a fracture is fixed with absolute stability. This means that there is no movement at the fracture site.
heals with rigid can not heal - this is why sliding nails ae useful for that callus formation and thus healing
causes of delayed bone healing
poor blood supply to the fracture site, instability of the fracture, infection, smoking, advanced age, poor nutrition (low calcium and vitamin D), certain medications like anti-inflammatory drugs, diabetes, severe anemia, and complications from open fractures where the bone breaks through the skin
bisphosphaonate cause what common fracture
transverse fracture of femur- thick cortex then just snaps
what is a barton fracture
a smiths fracture with intraarticular involvement - goes further than the distal radius
dipunch fracture
lunate against the radius
bennent and rolando fracture
rolando is just intrarticularted and comminuted of first metacarpal. bennet is just split into two pieces
ortho feature of HSP
non arthritic joint pain
long term steriod usage what should pt be taking
Vitamin D + calcium supplementation + oral bisphosphonate
what is a buckle fracture
Buckle, or torus, fractures are incomplete fractures of the shaft of a long bone that is characterised by bulging of the cortex.
main neurovascular structure that is compromised in a scaphoid fracture
The dorsal carpal branch of the radial artery
psoas abcess what ix of choice
CT abdomen
postmenopausal women, men age ≥50, who are treated with oral glucocorticoids for ≥7.5 mg/day prednisolone or the next 3 months -do you wait for dexa
no start bisphospjonates
carpul tunnel conservative tx what should ou do
Carpal tunnel syndrome: a trial of conservative treatment (wrist splint +/- steroid injection)
common drug cause of ruinary retention
opiods
Froment’s sign
a hand test that assesses the function of the adductor pollicis muscle. It’s used to detect ulnar nerve palsy
how you grab paper
how many beats in clonus is abnormal
3
1st lumbrical controlled by and atrophies in what condition
median nerve - carpal tunnel syndrome
ulnar nerve sensation where to test
outside of pinky finger
median nerve sensation where to test
inside the index finger
radial nerve sensation where to test
base of the thumb
how to most test ulnar
push two pinky fingers together
motor test of radial
wrist ext and finger ext , wrist drop
median nerve test
thumb abd - not ext as that is radial
how are upper limb reflexes best tested
resting arm on upper leg - with supinator relfex little bit of rotation with hammer to allow branchioradalis to contract
observing for muscle twitching
when looking a lower limb xr how do you know what side is lateral
side of fibula
what is a pelvic insufficiency fracture
a break in the bone when the bone is already weakened
difference between subluxation and dislocation
subluxtion is a partial discloation - up to 100% then dislocation
collar and cuff
used for clvicle fracture
what do the dots on asia chart show
best places to test sensation
resp rate below 8 or less what should you do
bag valve mask them as below 8 too late so hypoxic
what is cystatin c used for
high level kidney function
All patients with peripheral arterial disease should take
Atorvastatin and clopidogrel
Symptomatic AAA have high rupture risk and should undergo even small
endovascular repair (EVAR)
Pain on the radial side of the wrist/tenderness over the radial styloid process ?
de queervains
do frinklestein test
in hand OA what joints are affected
Carpometacarpal and distal interphalangeal joint involvement is characteristic of hand osteoarthritis
1st line for OA of the spine ix
X-ray of the spine is the first-line investigation for a suspected osteoporotic vertebral fracture
carpal tunnel syndrome - what conservative tx should be offered first
Wrist splinting +/- steroid injection
Fever, facial spasms, dysphagia in an intravenous drug user → ?what infectious disease
tetanus (botulism would cause a flacid paralysis)
Men who have sex with men should be offered immunisation
hep a
A 44-year-old man presents with a 24-hour history of weakness and double vision. He has a history of intravenous drug abuse. On examination, you note a flaccid paralysis of all 4 limbs (MRC grade 3/5). He also has a complex ophthalmoplegia in both eyes. Observations are as follows: heart rate 80 beats per minute, respiratory rate 18 breaths per minute, blood pressure 145/90 mmHg, temperature 37.2ºC, and oxygen saturation 96% on air.
botulinum antitoxin
difference between botulinum and tetanus
Botulism:
symmetrical and descending flaccid paralysis rather than spasms.
( meaning it affects the muscles of the neck, shoulders, and upper extremities first, followed by the proximal and distal lower extremities)
Tetanus:
trismus (lockjaw)
facial spasms causing a grimace expression which looks like forced grinning (described as risus sardonicus).
back pain
increased tone
dysphagia
spasms
temperatures.
Injecting drug habits is a risk factor for tetanus infection. Therefore the presentation of this patient is most consistent with a diagnosis of tetanus.
