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Y6 Senior Surgery > Ortho rest > Flashcards

Ortho rest Flashcards

1
Q

what is subacromial impingement syndrome

A

irritation and inflammation of rotator cuff tendons (esp supraspitnatus) as they pass through the subacromal space

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2
Q

what are causes of subacromial impingement syndrome

A

Intrinsic:

  • muscle weakness (rotator cuff weakness > imbalanced forces > humerus rotates)
  • hounder overuse (inflammation > reduced space)
  • degenerative tendinopathy (acromium degeneration > cuff tear)

Extrinsic

  • glenohumeral instabiklity
  • anatomical variation
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3
Q

what are signs and symptoms of subacromial impingement syndrome

A

painful arc (esp overhead activities)
decreased range of movement
weakness
hawkins +ve

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4
Q

list differentials for a painful arc

A
  • subacromial
  • frozen shoulder
  • rotator cuff tear
  • OA
  • septic arthritis
  • gout/pseudogout
  • RhA
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5
Q

How do you investigate subacromial impingement

A

XR (true AP, caudal tilt, supraspinatus outlet)
CT arthrography /USS
MRI (RCM and tendons)

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6
Q

How do you manage subacromial impingement

A

conservative: rest, physio
medcal: NSAID, steroid into subacromial bursa
Surgical: arthroscopic acromioplasty

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7
Q

what is calcific tendonitis

A

calcification of tendons

unknown aetiology

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8
Q

stages of calcific tendonitis

A
  1. pre-calcific (pain free)
  2. calcific (pain gradually increases)
  3. post calcific
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9
Q

S/S calcific tendonitis

A

loss of ROM
Pain (catching / locking with crepitus)
supraspinatus atrophy
Hawkins positive

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10
Q

Ix calcific tendonitis

A

XR (calcific deposiits)&raquo_space; US

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11
Q

Management of calcific tendonitis

A

non-operative: analgesia, phyiso, ECST, USS guided injection

Operative: surgical decompression

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12
Q

what are the four muscles in the rotator cuff

A

supraspinatus
infraspinatus
subscapularis
teres minor

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13
Q

what is the function of the rotator cuff muscles

A

to STABILISE the shoulder jount

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14
Q

what are RF for rotator cuff tears

A

age, smoking, FH, hypercholesteraemia

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15
Q

what are symotoms of rotator cuff tear

A

painful arc (if partial tear)

if complete tear:

  • shouldertip pain, full range of passve movement
  • inability to abduct arm
  • lowering the arm beneath 90 degrees causes a SUDDEN DROP (as this is supraspinatus role, which is torn)
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16
Q

management of rotator cuff tear

A

non-operatve: analgesia, physio, steroid injection

operative: shoulder arthroscopy, rotator cuff repair

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17
Q

how does rotator cuff arthropathy occur

A

rotator cuff tear > loss of joint congruence > abnormal glenohumeral joint > degeneration

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18
Q

What anatomical changes occur in rotator cuff arthropathy ?

A

rotator cuff insufficiency
glenohumeral joint dsestructon
subchondral osteoporosus
humeral head collapse

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19
Q

What are S/S of rotator cuff arthropathy

A

Night pain with weakness / stiffness

Limited range of movement, crepitus, inability to abduct

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20
Q

management of rotator cuff arthropathy

A

non-operative (analgesia, physio, subacromial steroid injection)
operative (arthroscopic debridement, hemiarthroèlasty ( reverse shoulder arthroplasty=

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21
Q

what is the medical term for frozen shoulder

A

Adhesive capsulitis

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22
Q

what is frozen shoulder – sx

A

FUNCTIONAL loss of ACTIVE and PASSIVE movement of shoulder with no clear cause (occasionally post-traumatic / post surgical)

external rotation most affected

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23
Q

who does frozen shoulder typically occur in

A

F>M, middle ages

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24
Q

pathophysiology of frozen shoulder

A

inflammatory process causing fibroblastic proliferation of the joint capsule
leads to mechanical block of motion

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25
Q

what are the three stages of FROZEN shoulder

A
  1. Freezing (gradual onset of pain, lasts up to 6 months)
  2. Frosen (stiff, decreased range of movement)
  3. Thawing (gradual return of range of motion, may last 5 months to 2 years)
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26
Q

What is the shoulder pain like in froaen shoulder

A

worse at night

cannot lie on affected side

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27
Q

How do you manage frozen shoulder?

A

NONE

it is self limiting

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28
Q

what is the difference between a dislocation and a sublaxation

A

dislocation = TOTAL non-articulation of the bone head in the joint

sublaxation: PARTIAL non-articulation of the bone head in the joint

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29
Q

how does shoulder dislocation present

A

shoulder contour lost (square shoulder)
bulging infraclavicular fossa
arm supported by hand + severe pain

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30
Q

How do you investigate shoulder dislocation

A

Assess NV status (axillary nerve in Chevron area) before manipulating
also do XR before and after manipulation

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31
Q

how do you manage shoulder dislocation

A
  1. Reduction (with sedation - traction method or stimson mthod)
  2. Rest in sling for 3/4 weeks
  3. Physio
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32
Q

complication of shoulder dislocation

A
  • Axillary nerve palsy (at time of presentation due to trauma OR iatrogenic due to manipulation OR delayed onset due to hematoma)
  • rotator cuff tear
  • recurrent dislocation (<20yo)
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33
Q

where are bicep tendon ruptures most likely to occur

A

most in the LONG TENDON of the biceps

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34
Q

what are risk factors for bicep tendon ruptures

A

heavy overhead activities
shoulder overuse
smoking, steroids

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35
Q

what are S/S of biceps tendon rupture

A

POP sound
followed by pain, bruising, swe,ling
Popeye deformity (muscle bulk results in bulge in middle of upper arm)
Weakness in shoulder and elbow

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36
Q

what are ix for biceps tendon ruprure

A

biceps squeeze test
MSK USS
Urgent MRI if suspecged distal tendon rupture

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37
Q

what is the difference in presentation between lateral (tennis) epicondylitis and medial (golfer) epicondylitisa?

A

lateral (tennis) epicondylitis - pain is around LATERAL epicondyle, worse on wrist EXTENSION

medial (golfer) epicondylitis - pain is around medial epicondyle, worse on wrist FLEXION

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38
Q

How do you investgate epicondylitis

A

USS

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39
Q

How do you investgate epicondylitis

A

conservative (rest, NSAID gel, physio)

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40
Q

how does olecranon bursitis present

A

swelling over posterior elbow
associated pain, warmth, erythema
typically affects middle aged pts

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41
Q

what are conditions associated to carpal tunnel syndrome

A

Conditions causing tissue swelling:

  • Pregnancy
  • Acromwegaly
  • AMyloidosis

Conditions causing tendon / nerve inflammation:

  • DM (glycosilates the tendon=
  • hypothyroidism=
  • RA (esp bilateral)
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42
Q

what is carpal tunnel

A

compression of the median nerve within the carpal tunnel

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43
Q

how does CTS present

A

parasthesia in 3.5 fingers (palmar aspect)
shaking of hand relieves parasthesia
occasionally pain

weakness of hand when grasping objects

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44
Q

what does the median nerve innervate in the hand

A

sensory to 3.5 fingers (thumb, index, middle, 0.5 ring finger) palmar aspect

motor to flexors to hand

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45
Q

How do you assess for carpal tunnel syndrome

A

CLINICAL EXAM

EMG may be necessary

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46
Q

What does CTS clinical exam reveal

A
  • weak thumb abduction
  • wasting in theminar eminence
  • Tinel’s sign: pressing the carpal tunnel causes parasthesia
  • Phalen’s sign: flexion of wrist causes parasthesia
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47
Q

How do you manage CTS

A

conservative: rest the hand, wrist splints at night
surgical: corticosteroid injections > surgical decompression

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48
Q

what are EMG findings for CTS

A

AP prolongation in sensory and motor axons > allows to grade severity

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49
Q

what is de quervain’s tenosynovitis

A

the sheath (proximal to thumb) contaning extensor pollicis brevis and abductor pollicis longus become infected

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50
Q

symptoms of de quervain’s tenosynovitis

A

tenderness on radial side of wrist

Adbuction of thumb against resistance is painful

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51
Q

How does de quervain’s tenosynovitis present on examination

A

Finkestein test: pull thumb in ulnar deviation and longitudinal tractrion > pain over radial styloid and radial side of wrist

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52
Q

how do you manage de quervain’s tenosynovitis

A

activity modification
analgesia
steroid injection, thumb splint, surgery

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53
Q

what is a duptyren’s contracture

A

progressive, painkless, fibrotic thickening of palmar fascia

fibroblasts are replaced by myofibroblasts which cause contraction

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54
Q

how do you manage duptyren’s contracture

A

splinting
fasciotomy
collagenase injection
fasciecotomy

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55
Q

conditions associated with duptyren’s contracture

A 
AIDS 
DM 
FH 
Booze 
Epilepsy and epilepsy meds e.g. phenytoin
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56
Q

how can you split causes of EFFUSION in the kneee

A

BLOOD

  • immediate: ACL, intra-articular fracture,
  • delayed: menisceal tear (delayed)
  • can also be spontaneous: coagulopathy

SYNOVIAL FLUID:

  • synovitis
  • gout, pseudogout

PUS
- septic arthritis

57
Q

what causes joint tenderness along the joint line?

A

mensceal tear

58
Q

What investigation myst you always do if suspecting cruciate ligament rupture

A

XR (exclude fracture) > MRI (visualise cruciates)

59
Q

what is classical history of ACL injury

A

Rotational / deceleration injury (skiing, football)
heard a pop > knee gave way > unable to continue walking
HAEMARTHROSIS: massive swelling immedately, as ligament contains an artery (becomes clear within 4-6 hours)

60
Q

how do you manage ACL injury

A

isolated: conservative mx (quads physio)

instability/ paediatric / young and sporty: reconstruction (autologous graft from hamstring or patellar tendon)

61
Q

what is PCL history

A 
tibia forced backwards with knee flexed 
often multiligamented (rarely occurs in isolation)
62
Q

how do you manage PCL injury

A

isolated: conservative:

instability/concurrent injury/paediatrc: reconstruction

63
Q

MCL/LCL injury history

A

extreme valgus / varus injury

64
Q

MCL/LCL management

A

usually conservative

65
Q

what is the purpose of ACL

A

limit anterior translation of tiba relative to femur

provide stability in internal rotation

66
Q

which two tests are positive for ACL injury

A

Lachman

Anterior draw

67
Q

Explain Lachman test

A

knee at 30 degrees

pull knee forward to see how anterior tibia moves compared to femur

68
Q

Explain Anterior Draw test

A

knee at 90 degrees

Thumbs along joint line, index along hamstrings posteriorly . Apply force to demonstrate tibial excursion

69
Q

what is the function of menisci

A

joint surface contact and weightbearing

70
Q

when is maximum loadbearing on the knee achieved

A

with a flexed knee at 90 degrees

71
Q

what is hhyistory of menisci injury aand presentation

A 
twisting injury (medial meniscus most common) 
pain worse when loading knee in flexion (going downstairs) 
pain across joint line, locking or catching of the knee
overnight effusion
72
Q

how do you mange menisceal tear

A 
arthroscopic debridement (risk of OA) 
arthroscopic repair
73
Q

how does osgood shattler present

A

knee pain after exercise (gradual onset), relieved by rest

localised tenderness and swelling over tibial tuberosity

74
Q

osgood shattle management

A

analgesia, ice packs, protective knee pads, stretching
reassure
advise stopping / reducing all sporting acrivities

75
Q

what is a baker’s cyst

A

BAKERS CYST: popliteal extension of gastrocnemius-semimebranosus bursa (NOT a real cyst)

essentially there is knee effusion from intra-articular pathology > fluid escapes from the joint membrane into the popliteal fossa region (between head of gastrocnemius and semimembranosum)

76
Q

how does a baker’s cyst present

A

swelling in popliteal fossa

77
Q

what are the three important joint parts holding the ankle togeter

A

syndesmosis
lateral collateral ligament
medial collateral ligament

78
Q

how does an achilles rupture injury occur and present

A

S/S: pop in ankle, sudden onset pain in calf or ankle

inabability to walk or continue with ssport

79
Q

How do you investigate achilles tendon rupture

A

SIMMONDS TRIAD:
put patient prone, feet over edge of bed:
1. Calf sqeeze (thomas’ test: injury means you cannot elicit plantarflexion)
2. Angle of declination (injury means greater dorsiflexion in injured foot)
3. Gap (injury =gap in tendop path

80
Q

what is diagnostic of achilles tendon rupture

A

USS

81
Q

how do patients describe a morton’s neuroms

A

like walking on a marble
shooting / stabbing / burning pain in ball of foot
numb toes

82
Q

WHAT Is a morton’s neuroma

A

NOT a true neuroma

is is a compression neuropathy of the common digital planntar nerve (aka benign fibrotic thickening of the nerve)

83
Q

what does morton’s neuroma commonly occur in response to

A

in responsse to irritation, trauma or pressure

84
Q

how do you manage morton’s neuroma

A 
orthotics 
change shoes (no tight / pointy shoes) > steroid injections > surgical resection
85
Q

where doe morton’s neuroma usually occur

A

3rd - 4th tarsal bone

86
Q

what is plantar fascitiis

A

inflammation of plantar aponeurosis

87
Q

S/S plantar fascitis

A

pain / tendernes of heel and sole of foot

worse after periods of inactivity, better with exercise

88
Q

what is osteoporosis

A

reduced bone mineral density (T score -2.5; BMD more than 2.5 st devs lower than general population)

89
Q

RF osteoporosis

A 
Age 
Female 
Steroid use 
Smoking, alcohol 
low BMI 
FH 
premature menopause 
caucasian, asian
sedentary 
endocrine dosorders 
CKD, MM
90
Q

What scores can you do for osteoporosis

A

QFracture or. FRAX (assess 10 year risk of developing fracture)

91
Q

what do you do wth Qfracture / FRAX results

A

if low risk: reassure
if medium risk: BMD test
high risk: offer bone protection

92
Q

T score meaning

A

BMD compared to young reference pop

93
Q

Z score meaning

A

BMD compared to age, gender and ethnic matched

94
Q

How do you manage osteoporosis

A

Vitamin D
Calciun suppleents
PO biphosphonates (alendronate)

95
Q

what do you give if biphosphonates are not tolerated (e.g. eGFR<30, severe GORD)

A

give SC biologics (denosumab)

96
Q

what is most common cause of OA

A

wear and tear

97
Q

what are S/S of OA

A

pain in large, weight bearing joints and hands
crepitus, joint locking, pain after exercise
better with rest

98
Q

what signs do you see on the hands in OA

A 
Herbenden's nodes (DIPJ) 
Bouchard nodes (PIPJ)
99
Q

investigtions for OA

A

XR (loss of joint space, osteophytes, subchondral cysts, subchondral sclerosis)
CT, MRI

100
Q

conservative management of OA

A

CONSERVATIVE MX OF OA:

  • WL
  • Physio/occupational therapy
  • TENS (transcutaneous electricaal stimulation)
101
Q

medical management of OA

A

Medical mx of OA:

  1. Paracetamol PO, topical NSAID
  2. PO NSAID + PPO or weak opioid
  3. intraarticular corticosteroid or
102
Q

what is surgical management of OA

A

arthroscopy (trim the cartilage, remove ostephytes, lavage)

arthroplasty (joint replamenent)

103
Q

what are red flag sx for back pain

A 
age <20/ >50
malignancy hx 
night pain 
hx trauma 
FLAWS
104
Q

general mx of open fractures

A

they need URGENT washout (max 6h) and debridement in theatre
Use EXTERNAL FIXATION until soft tissues have healedd

105
Q

what is CUBITAL TUNNEL SYNDROME

A

compression of the ulnar nerve

106
Q

how does cubital tunnel syndrome present

A

parasthesia in 4th and 5th digit (worse on elbow flexion)

with weakness AND ulnar claw

107
Q

what is RADIAL TUNNEL syndrome

A

compresson of posterior interosseus branch of radial Nerve

108
Q

how does RADIAL TUNNEL SYNDROME present

A

similar to lateral epicondylitis

4-5cm distal to the lateral epicondyle

109
Q

most common organism to cause osteomyelitis

A

S aureus

110
Q

how do you treat osteomyelitis?

A 
IMMEDIATE ABX (e.g. vanc + cef) 
AND RADICAL DEBRIDEMENT INTO LIVING BONE
111
Q

how do you treat septic arthritis

A

JOINT WASH OUT FIRST (COLLECT SAMPLE FOR MCS()

THEN ABX

112
Q

when do you need to do a partial fasciectomy in duptyrens contractures

A

when the hand cannot be placed flat on the table

113
Q

what is trigger finger

A

a tendon nodule which catches on the tendon sheath&raquo_space; triggers on forced extension, leads to FIXED FLEXION deformity (uually of 3rd and fouth digits)

114
Q

commonest method of analgesia for pts wth NOF fracture

A

iliofascial nerve block

this reduces opioid analgesia required

115
Q

sx of lumbar spinal stenosis

A 
back pain (standing  > sitting, walking uphill > downhill=) 
leaning forwards relieces pain 
neuropathic pain 
neurogenic claudication 
preserved distal pulses
116
Q

what shoud you change alendronate to in osteoporottic lady with UGI sx

A

change to risedribate, etudrinate first (before biologics)

117
Q

first line OA analgesia

A

Oral Paracetamol + TOPICAL NSAID

only after trying topical you can chhange to oral

118
Q

what test can you do to identify sciatic nerve pain

A

straight leg raise

119
Q

which malignant neoplasm has onion skin appearance

A

EWING SARCOMA

120
Q

who does Ewing occur in

A

in young people

121
Q

what is a ganglion

A

‘cyst’ arising from a joint or tendon sheath

122
Q

where and in whom are ganglions commonly seen

A

back of the wrist

3 times more common in women

123
Q

how do you treat ganglion

A

reassure > will self resoslve

124
Q

what is osteogenesis imperfects

A

a collagen disorder aka brittle bone disease

autosomal dominant

125
Q

presenting sx of osteogenesis imperfecta

A

fractures following minor trauma
dental caries
blue tinge of sclera
deafness (otosclerosis)

126
Q

how do you manage lateral malleolus fractures that are A, B or C

A

A: below syndesmosis > boot weight-bearingg as able for 6 weels

B: through syndesmosis > boot NON weightbearing 6w

C: above syndesmosis = ORIF + syndesmotic repair

127
Q

how does ulnar nerve injury differ based on whether it is damaged at elbow or at wrist?

A

LESS SX if DAMAGED AT ELBOW

Damage at elbow: ulnar half of flexor digitorum profundus is also affected > less marked clawing due to reduced unopposed flexion at the IPJ. Sx will get worse as nerve regenerates, once FDB starts working

Damage at wrist: FDP not damaged >claw like appearancew

128
Q

what bacterium causes osteomyelitiss in sickle cell disease

A

SALMONELLA

129
Q

what is FIRST LINE MEDICATION for back pain

A

NSAID (+PPI if over 45)

paracetamol was found to be ineffective

130
Q

how do you manage sciatica with no red flags

A
  1. anto-neuropathic pain agent (gabapentin / pregab/ amyltriptiline) + physio
  2. wait 4-6 weeks > if no response, routine referral to spinal surgery
131
Q

what location of scaphoid fracture must you ALWAYS operate (ORIF) on

A

the proximal scaphoid pole

132
Q

what does a CHARCOT JOINT look like

A

HOT and SWOLLEN
NOT or MILDLY TENDER (due to peripheral neuropathy)
bone remodelling with osteolysis

133
Q

first line ix to rule out osteoporotic vertebral fracture

A

X ray spine

134
Q

which rheymatoid condition is associated to carpal tunnel and why

A

rheumatoid arthritis

because it causes synovitis > joint swelling> bilat carpal tunnel

135
Q

first line meds for back pain

A

NSAID

NOT paracetamol alone

136
Q

which structure is most likely compromised in a scaphoid fracture

A

dorsal carpal arch of radial artery

137
Q

what does a positive straight leg raise indicate

A

L5 root pain (herniated disc)

138
Q

what is the key movement impaired in adhesive capsulitis

A

EXTERNAL ROTATION(both active and passovre)

Y6 Senior Surgery (10 decks)

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