Ortho unit 1

Question 1

what does orthopaedics mean

Answer 1

straight children

Question 2

define acute illness

Answer 2

sudden
polymorphonuclear leucocyte (polymorph)

Question 3

define chronic illness

Answer 3

long time to develop and may last long time

lymphocytes are produced by BM and spleen

Question 4

…otomy

Answer 4

open something up

Question 5

…ectomy

Answer 5

remove something

Question 6

overall treatment objectives

Answer 6

relieve patients complaints eg pain and stiffness

Question 7

cause of primary and secondary OA

Answer 7

primary - cause unknown

secondary - obvious causative factor

Question 8

most common type of OA

Answer 8

primary

Question 9

overview of treatment of OA

Answer 9

gp - simple analgesia
ortho/rheumatologist when pain is affecting sleep
non operative options or/and then operative

Question 10

non operative options for OA

Answer 10

non operative options to postpone surgery include

• weight loss (reduce load and improves well being),
• walking stick (normally when walking when weight is on right leg the right glutes contract to tilt left side of pelvis up so left leg can swing forward so efficient walking needs abductor muscles. stick on opposite side means shoulder girdle helps to tilt pelvis to help with wt bearing - stick decreases the work required of the weight bearing abductor muscles so there are decreased muscle induced loads on the hip),
• physio (relieve stiffness and muscle spasm and therefore reduce pain)

young sufferers should avoid excessive exercise but don’t totally rest wither as muscles work most effectively when in regular use. stretching maintains tone. excessive rest causes spasm which is painful and inhibiting

Question 11

name the operative treatment available for OA

Answer 11

nothing
arthrodesis
osteotomy
arthroplasty

Question 12

describe arthrodesis and describe times it is useful

Answer 12

surgical stiffening of a joint in a position of function (fusion). painful joint is cut out and raw bone ends are held together with external splint/screws until bony bridge is formed.
good in young patients who have painful range of motion.

Question 13

disadvantages of athrodesis

Answer 13

• long recovery - 6 months in plaster
• stress on adjacent joints eg in hip fusion extra forces on spine, knee and opposite hip - anticipate the problem by replacing the joint after 5th decade - gives good return of function
• hip fusion affects female sexual activity
• hard to fuse big joints - difficult to keep together (ankle and wrist are good joints to fuse - you also dont replace these joints) -

Question 14

angle to fuse the hip joint at

Answer 14

30 degrees flexion, some adduction gives functional gait and permits sitting

Question 15

describe osteotomy
when would you do this and what are the suitable joints
what is the disadvantage

Answer 15

surgical realignment of joint. redirects forces across a joint do the load is evenly distributed.
perform when a joint is deformed - eg in the knee where is they become bow legged all the forces go down the medial side rather than the middle
valuable in arthritis of young who have maintained good ROM despite pain. hip and knee are suitable
- disadvantage is its just a temporary measure (1-10years) as the underlying problem hasn’t been tackled

(bone is cut and angle of joint is changed (eg cut femur or tibia to change joint angle of knee and use a plate to hold the cut at the angle wanted)- useful when arthritic joint damage is confined to one side of the joint eg when bow legged all the pressure goes through the medial side of the knee joint so OA occurs as the bones touch as cartilage is worn away. favourable to knee replacement as you preserve the joint)

Question 16

what would you do in osteotomy of the hip

Answer 16

performed on the pelvic side by forming a shelf or by total acetabulum realignment
it can be performed on the femoral side by altering the angle of the fem neck to change the attitude of the fem head relative to the acetabulum.

Question 17

describe arthroplasty

Answer 17

creates a new joint/changes the shape of the joint

Question 18

how successful is athroplasty and what is teh main aim

Answer 18

> 90% will be in situ after 10 years but remember most of these will be old people whoa rent active. replacement should provide a joint which outlives the likely lifespan of the patient. it must be capable of functional and pain free ROM but also be able to withstand forces without undue wear and working loose, as well as having the same stability as the normal joint.

Question 19

reasons why goals differ for upper limb and lower limb joint replacement

Answer 19

relationship between pain relief and function id different.
arthroplasty improves pain related loss of function but not intrinsic stiffness as soft tissue distortion of the capsule and ligaments tend to remain the same after replacing articular surfaces. so this poses a problem in the upper limb if you are wanting to do arthroplasty as upper limb as it improved pain related loss of function but not intrinsic stiffness. eg elbow must flex to 90 degrees to eat and must full extend to wipe bum.

Question 20

most successful joint replacement

Answer 20

hip

Question 21

describe hip arthroplasty - forces and angles needed for daily life

Answer 21

huge forces but ball and socket is stable and functional ROM of hip is limited. only need 10-15 extension, 30-40 flexion and few degrees of abduction and rotation partic in extension for daily living
it is the 1st successful replacement

Question 22

arthroplasty in the knee describe

Answer 22

ROM is small but 90 flex needed to get up and down stairs and stability in extension id essential to take body weight especially when on one leg. surgery then must achieve an accurate soft tissue balance through dissection of the capsule and the ligaments.
modern knee replacements consist of 2 new smooth surfaces and the surgeon must balance the collateral ligaments by cutting tight parts of the ligaments and then putting in artificial surface replacements of sufficient thickness to retighten ligaments so that medial an lateral colateral ligaments are under equal tension

Question 23

describe complications of joint replacement

Answer 23

after any surgery - pressure sores, UTI, chest infection, DVT –> PE

early

• prosthesis not fully supported by soft tissue yet and muscles and propriocepters may be out of action due to surgical trauma and pain and scar tissue hasnt formed yet so risk of dissolacation (even as time goes on can still occur eg in hip in extreme flexion with adduction and internal rotation - so need advice about dressing and aids)
• DVT - give heparin as prophylaxis. stockings?
• infection - hosp bacteria eg staph aureus/commensals on skin eg staph albus . MUST GIVE PROPHYLACTIC ANTIBIOTICS AND ULTRA CLEAN AIR IN THEATRE. (if precautions taken the risk of infection shoudl be <0.1% - but in uk reality is about 1-3%)

late

• can occur as late as 10 years after
• infection - usually at time of insertion but could be blood borne from bacteraemias eg after tooth extraction –> heart valve
• loosening and wear - inevitable but delay as much as poss

Question 24

describe RA and the role of surgery in treatment

Answer 24

RA - cause unknown. small joints if hands and feet, symmetrical. more common in women and stiffness is worse in morning.
role of surgery - patient as comfortable as possible while retaining as much function as poss. control of RA with drugs must be adequate to get good results from surgery. surgeon must ensure its function rather than deformity the patient wants to improve
soft tissue surgery - disease can damage tendons and sheaths. remove damages synovial tissue by removing synovium (synovectomy). good in teh wrist for clearing damage around the extensor tendons. good in young people with retained ROM as it can reduce pain and stiffness. sometimes tendons about the wrist rupture and need repair
joint surgery - useful at elbow and wrist where it can be combined with a limited excision of the joint (excision arthroplasty). it relieves pain but never get full return of function as some of the joint has been removed.

Question 25

describe AVN

Answer 25

bone tissue death through loss of blood supply . can be due to trauma where blood supply is particularly vulnerable, can also occur spontaneously

Question 26

sites where AVN is common due to trauma

Answer 26

femoral head (due to damaged capsular vessels(
prox part of scaphoid and prox part of talus (distal blood supply is severed from the prox part of bone)

Question 27

sites where AVN can occur spontaneously

Answer 27

lunate, 
femoral head (can be due to chronic alcohol abuse, high dose steroids and deep sea divers (CAISSONS DISEASE)

Question 28

symptoms and signs of AVN

what to do

Answer 28

no x ray changes initially, later the bone appears dense due to lack of blood supply. can be reversed if blood supply restored but in the re-vasculating phase the bone is soft and can distort, with secondary arthritic changes. surgical restoration of the blood supply is not possible.

patients suffer acute severe pain, worse on movement. difficult to distinguish from OA especially as time goes on, but in young patient its usually AVN

joint should be rested

Question 29

why are crystals deposited in crystal arthropathies

Answer 29

by products of metabolism are deposited on articular surfaces within the synovial fluid. either due to excess production or kidneys not excreting it

Question 30

what happens in crystal arthropathies

Answer 30

cause chronic degenerative change in the joint and may be a cause of secondary arthritis. also causes acute inflammation which tends to settle spontaneously but we usually reduce pain with drugs

Question 31

describe gout, causes, symptoms, treatment

Answer 31

• urate crystals, waste product of metabolism
• deposited in dehydration (particularly after surgery) and following chemo, commonest cause is diuretics in the west
• exclude infection as it can mimic gout
• diagnose by urate crystals in blood. usually passed in urine. more accurate diagnosis by aspirating synovial fluid and detecting crystals
• treat with anti-inflam drugs which reduce inflammation and help kidneys excrete

Question 32

describe pseudogout, causes, symptoms, treatment

Answer 32

• pyrophosphate crystals, origin unknown
• causes calcification of joint surfaces and meniscus of knee
• less acute presentation than gout
• symptoms controlled with anti-inflams but long term degeneration is likely

Question 33

describe septic arthritis - in kids and adults

Answer 33

bacteria spread to joint via blood from a site such as a boil. rare in adults unless got a damaged joint already or have weak immune defence
in kids - acute illness, temp, affected joint is still, hot, tender
in adults - less acute. unwell for days. can die as delay in diagnosis. young adult with little constitutional upset = gonococcus (ass. with venerial disease)

Question 34

treatment of septic arthritis

Answer 34

surgery - open and wash joint
IV AB - best guess in kids is anti-staph agent. if treatment doesn’t work then the articular cartilage can disintegrate leading to fibrosis or bony fusion (and blood poisoning)

Question 35

define chronic septic arthritis, symptoms, diagnosis, management

Answer 35

joint TB. AIDS suffers are at risk. spreads via blood. kidney and joint TB often found together
chronic ill health, wt loss, muscle wasting around the joint
x rays show bone thinning
management - drugs and AB eg streptomycin, ethambutol, rifampicin are given for months

Question 36

describe meniscal lesions, when they happen, who they happen to, symtoms

Answer 36

rare in women
can occur in teens but not common, and occasionally kids are born with abnormal lateral meniscus
due to twisting usually - femur twists over stationary tibia causing wrench to meniscus which may be torn or pulled off the bone
pain, excess fluid around joint (effusion), locking/giving way, poorly localised pain but general discomfort when you forcibly extend the knee

Question 37

types of meniscal tears

Answer 37

medial is most common. can be torn at peripheral attachment to the joint capsule or within the substance.
can split horizontally (cleavage lesion) which is common in old and can act like a flap trapping fluid in the meniscus causing a cyst
vertical split - bucket handle tear
split off one end of lateral meniscus - parrot beak tear (type of oblique tear)
tear due to degneneration - degenerative tear

torn part gets jammed in joint stopping it extending
peripheral tears can be reattached with sutures. tears within the substance cant be repaired so the peripheral part should be removed - do this by arthroscopy - menisectomy - recover quicker

Question 38

what are loose bodies and what are symptoms and treatment

Answer 38

they are fragments of bone/cartilage (osteochondral fragments) sheared off in injury
knee swells from ass. bleeding (haemarthrosis)
invisible on x ray as most of body is cartilage
first incident may settle, but months/years after patient presents with locking, pain, giving way, often with effusion.
need to be removed by arthroscope
v rarely in teens osteochondral fragments can occur spontaneously - osteochondritis dissecans. in this case the condition settles spontaneously but loose bodies require removal

Question 39

describe cruciate ligament lesions

Answer 39

soft tissue injury to collateral ligaments heal spontaneously because they have good blood supply. ligament tears are different.

ligament tears are caused by hyperextension/twisting and they dont heal spontaneously as the torn blood supply is lost. in rare cases the torn ligament may be pilled off the bone with a fragment of bone. if it is put back within a few hours the whole ligament may survive.

in acute injury - knee swells (haemarthrosis). patient may report a pop. swelling resolves after a few weeks

Question 40

what does loss of cruciate ligament mean and what are treatment options

Answer 40

loss of cruciate ligs mean loss of antero-posterior stability which is bad for sports people . many only experience symptoms when descending stairs/twisting .

ligament should be left untreated while knee muscles rehabilitate . offer treatment if interferes with daily life/want to return to sport. replace torn lig with synthetic one - unknown life span and no sensory receptors so if it gets overstretched brain doesnt detect it so muscles action doesnt occur to protect it

Question 41

describe dislocation of the patella, and treatment

Answer 41

associated with malformation of the patella or lat fem condyle so patella moves abrasively on femur (mal-tracking) which is painful because of ass. muscle spasm.

can lead to dislocation and failure of quads to act as extensor so the person falls to the ground

minor degrees of mal tracking are dealt with by splitting the vastus lateralis muscle insertion into the patella so patella falls back into normal relationship with femur

if recurrent and severe - medial tightening (plication) of the vastus medialis muscle may be required. in adults the patella tendon may be resisted more medially

dont confuse with anterior knee pain in teen girls

Question 42

goals of arthroplasty

Answer 42

capable of functional and pain free ROM but able to withstand forces without undue wear and tear and without working loose, as well as having the same stability as a natural joint.