Ortho, Vascular, breast Flashcards
Osteoarthritis- definition
Degenerative disease –> loss of hyaline cartilage + new bone formation at joint surface
Symptoms of osteoarthritis
Pain - worse at night + after movement
- Commonly affects knees, hip, PIP, DIP, base of thumb
Reduced ROM: ‘gelling’ after rest for -30min
Deformity (mild)
Investigations for suspected osteoarthritis
Bloods:
U+Es (renal function before giving NSAIDs)
Autoantibodies (exclude inflammatory arthritis)
X-Ray
Mx of osteoarthritis
Conservative: weight loss, PTOT
Medical: paracetamol, NSAIDs (+PPI), joint injection
Surgical: Hip/knee replacement, osteotomy for younger pt w medial knee OA + thumb OA,
Define Thrombophlebitis
Inflammation of a superficial vein, due to a thrombus
Hard + painful vein
Thrombophlebitis
Management of thrombophlebitis
NSAID + compression stocking + increased mobility
if infected –> flucloxacillin QDS
Most common pathogen causing cellulitis
Strep pyogenes
Green dischARGE + mass under nipple
USS shows duct dilatation and inflammation
- Diagnosis? Mx?
Duct ectasia (widened ducts due to inflammation)
Mx: usually goes away w paracetamol
If troublesome –> excision of duct
RFs for periductal mastitis
eczema, smoking, psoriasis, piercings
2 types of bone
Woven bone - disorganised bone (embryonic skeleton + fracture callus)
Lamellar bone - mature bone. can be either CORTICAL (dense, outer layer) or CANCELLOUS (porous, central)
Fracture healing - 3 phases
Reactive phase (-48hrs) - Haematoma + inflammatory cell recruitment
Reparative phase (-2 weeks)
- Callus formation (osteoblasts + fibroblasts proliferate)
- Endochondral ossification (formation of lamellar bone)
Remodelling phase (- years) - Remodelling of lamellar bone to cope w mechanical stresses (Wolff's law)
Fracture classification
Traumatic
Stress (repeated strain –> bone fatigue)
Pathological (due to diseased bone)
Greenstick fracture
Young soft bone which bends + breaks
Comminuted fracture
> 2 fragments
Angulation - how is it described
the direction of the distal portion of the distal fragment
Fracture in the growth plate?
What types are there
Salter Harris fracture (Straight, Above, Lower, Through, crush) Type 1: growth plate fracture 2: growth plate + metaphysis 3: growth plate + epiphysis 4: growth plate + meta + epiphysis 5: crush fracture
Garden classification
Intracapsular NOF#
1: incomplete
2: complete, undisplaced
3: complete, partially displaced
4: complete, totally displaced
Distal radius articulates with
Scaphoid, lunate, ulna
Distal radial fracture with dorsal angulation
Colles fracture
Distal radial fracture with volar angulation
Smith fracture
Distal radial fracture involving the joint (intraarticular)
Barton fracture
Distal radial fracture + distal radioulnar dislocation
Galeazzi fracture
ulnar fracture + proximal radial head dislocation
Monteggia fracture
Mx of an open fracture
Analgesia Asses: N+V status, photograph Alignment: splint Antisepsis: wound swab, irrigation, Abx Anti-tetanus
Most dangerous complication of an open #?
Features?
clostridium perfringens
Gas gangrene + shock
4 pillars of fracture management
Resus (ABC)
Reduction (closed or open)
Restriction (slings, plaster, bracing, internal)
Rehabilitation (PTOT)
Methods of fracture reduction
Open (i.e. surgical incision)
or closed
Methods of fracture restriction
Hold = sling, plaster
Fixation = either external or internal
- External = monoplane or multiplanar
- Internal = inter medullary or extramedullary
Indications for external fixation device
Open #s
Burns
Tissue loss
Rehabilitation for fracture management
Physiotherapy - strengthen muscles
OT - mobility aids, splints
Social services - home help
Common palsies from the following #s:
- Shoulder dislocation
- Humeral shaft
- Elbow
- Hip dislocation
- Neck of fibula
-Shoulder dislocation = AXILLARY (weak shoulder abduc)
- Humeral shaft = RADIAL (wrist drop)
- Elbow = ULNAR (ulnar claw)
- Hip dislocation = SCIATIC (foot drop)
- Neck of fibula = COMMON PERONEAL (Foot drop)
Pathophysiology of compartment syndrome
Oedema from fracture –> increased compartment pressure –>reduced venous drainage
As compartment pressure > capillary pressure –> ischemia!
Post-op patient
w extreme pain
Pain on passive muscle stretching
Reduced pulses
COMPARTMENT SYNDROME
Causes of malunion
Infection
Ischemia - AVN
Interposition of tissue between fragments
Disease - malignancy, malnutrition
Cause of cubitus varus
Gunstock deformity from malunion of a supracondylar #
AVN - what is the consequence
Soft + deformed bone –> pain + stiffness + OA
Scaphoid fracture - common method of injury?
O/E?
FOOSH
tenderness in anatomical snuffbox
Tenderness on scaphoid tubercle (volar surface)
Scaphoid fracture - how long until visible on XR?
10 days after injury
Therefore, return to # clinic 10 days later for re-XR
Mx of scaphoid fracture? Main complication?
Plaster
Risk of scaphoid AVN –> pain + stiffness
2 types of shoulder dislocation?
Common causes of both?
Anterior: trauma, falling on hand
Posterior: epileptics
Bankart lesion
Associated w should dislocation
Damage to anteroinferior glenoid labrum
Hill Sach lesion
Associated w anterior shoulder dislocation
Cortical depression of posterolateral humeral head
Presentation of shoulder dislocation
Severe pain
Shoulder appears square
Bulge in subclavicular fossa
Arm supported by other hand
Ix + Mx of shoulder dislocation
NEUROVASCULAR ASSESSMENT
- Regimental badge area for axillary nerve damage
XR: AP and lateral view
Reduction: under sedation (propofol)
Restriction: Sling for 3-4 weeks
Rehab: Physio
2 complications of shoulder dislocation
Recurrent dislocation
Axillary nerve palsy
Impingement syndrome - pathology?
Entrapment of supraspinatus tendon + subacromial bursa
Trapped btw ACROMION + GREATER TUBEROSITY of humerus
Presentation of impingement syndrome
Painful arc 60-120
+ve Hawkins test
Mx of impingement syndrome
Conservative: rest + physio
Medical: NSAIDs, steroid injection
Surgical: Arthroscopic acromioplasty
Differential of painful arc
Impingement syndrome
Partial rotator cuff tear
OA of acriomoclavicular joint
Findings on examination of frozen shoulder
reduced ROM, esp EXTERNAL ROTATION and shoulder abudction
Rotator cuff tear: O/E
Partial: painful arc
Full tear: Active abudction possible after passive abduction up to 90 degrees
Commonest type of supracondylar fracture
Extension i.e. distal fragment is posteriorly displaced
Complication of supracondylar fracture
1) Neuromuscular damage: -Brachial artery, Radial nerve, Median nerve
2) COMPARTMENT SYNDROME: pain on passive extension of fingers
3) Gunstock deformity (cubitus varus)
Mx of ruptured ACL
autograft from SEMITENDINOSUS
Tendon threaded through heads of tibia + femur, held using screws
Definition of disc prolapse
Herniation of nucleus pulposus through annulus fibrosis
- Loss of sensation on inner dorsum of foot
- Foot drop and weak inversion
Intact reflexes
L5 root compression
Aching buttock on walking
Rapid onset
Pain on spine extension (leaning back\0
Spinal stenosis
Spinal stenosis - presentation
Pain on spine extension
Heavy, aching buttock on walking (spinal claudication)
Sx of acute cord compression
Pain - bilaterally at back + radicular
UMN signs below lesion
LMN signs at compression level
Sx of cauda equina syndrome
Asymmetrical symptoms
- radicular pain
- Saddle anaesthesia
- Faecal/urinary incontinence
2 causes of painless genital ulcers
Syphilis
Chlamydia
How to examine a pt post-mastectomy
Scar: location? healed?
Skin + axilla
LNs + arm swelling
Pec major - ask pt to press down on hips
Palpate the other side
Check sensation in T1
palpate spine for mets + listen to lung bases
palpate for hepatomegaly
Indications for mastectomy
Usually, WLE + SNL to conserve as much breast as possible
Indications:
- Large tumour in small breast
- Patient preference
- Nipple involvement
- Multifocal disease
Types of mastectomy
Simple = most common. Breast only
Radical = breast + pec major + minor + axilla
Examination of post-breast reconstruction
Look:
Scar, surrounding skin, does breast lie higher/rounder? Radiotherapy tattoos?
- Ask pt to lift head off bed (TRAM flap?)
Hx of a pt post-mastectomy or breast reconstruction
- Presentation of the breast cancer, RFs
- Current Sx: paraesthesia, lymphedema, psych, mets
2 types of breast reconstruction? what are their positives and negatives
Either implant or myocutaneous flaps
Implant: \+ easier surgery - need lots of skin - worse cosmetic result - can get leakage, capsular contracture
Flaps: \+ aesthetic \+ don't need loads of skin - Blood loss - Higher risk of complications - CI if previous abdo surgery
3 types of Flap reconstruction for breast
Lat Dorsi or TRAM flap or DIEP flap
Lat Dorsi = usually augmented w an implant. pedicled = skin, fat, muscle + blood supply
TRAM flap = Transverse rectus abdominis muscle. -ve = risk of hernia.
DIEP flap = modified TRAM flap, where only skin + fat is taken. Spares the rectus!
Signs of chronic venous insufficeincy
Haemosiderosis Atrophie Blanche Swelling Lipodermatosclerosis Eczema Gaiter ulcers Stars - venous
Varicosities on inner thigh - which vein is involved?
Great saphenous
Varicosities over the calf - which vein is involved
Short saphenous
CEAP classification
1) telangiectasia
2) Varicose veins
3) Oedema
4a) skin change = haemosiderosis, eczema
b) LDS, atrophié blanche
5) healed ulcer
6) active ulcer
3 main points of valve incompetencd
Saphenofemoral junction
Sapheno popliteal junction
Deep perforators (these drain the great saphenous vein(
Mx of Chronic venous insufficiency
Conservative:
- weight loss
- avoid prolonged standing
- compression bandages for ULCERS
- emollients for skin
- analgesia
- piriton for pruritis
Minimally invasive:
Laser
Sclerotherapy
Surgery:
Ligation + stripping of superficial veins
Ix of choice for ?venous disease
Duplex USS
what is post-phlebitic limb
Long term symptoms following a previous DVT
what is CVI?
Chronic venous insufficiency = effects on leg from persistent venous HTN
Pathophysiology of lipodermatosclerosis
- Chronic inflammation –> fibrosis –> distal shrinkage
- Venous obstruction –> proximal leg swelling
Leriche’s syndrome
Occlusion of abdominal aorta + iliac
Buttock claudication and wasting
Erectile dysfunction
Absent femoral pulses
- Buttock claudication and wasting
- Erectile dysfunction
- Absent femoral pulses
Leriche’s syndrome
occlusion of abdominal aorta + iliac
Posterior tibial artery - where is it?
Behind the medial malleolus
ABPI readings
> 1.2 = calcification (DM)
- 8-0.9 = asymptomatic + manage RFs
- 5-0.8 = Claudication + routine specialist referral
<0.5 = severe + urgent referral
How to measure ABPI
Measure both arms - take highest measurement
Measure post tibial + dorsalis pedis - take highest mesurement
Ix for ?Periph arterial disease
ABPI Bloods: FBC, U+Es (renovascular disease), glucose, lipids Imaging: Colour duplex US CT/MR angiography (gold standard)
Mx of peripheral arterial disease
Conservative:
RFs - HTN, DM, lipids, smoking, weight loss
Physio - walk through pain
FOOT CARE
Medical:
- Aspirin/clopidogrel = FOR ALL PATIENTS
Surgical:
- Angioplasty + stenting
- Endarterectomy
- Bypass
- -> amputation
surgical Mx of peripheral artery disease
Angioplasty + stenting
Endarterectomy
Bypass
Amputation
Diff btw intermittent claudication and Critical limb ischemia
Claudication
Pain relieved by rest
CLI
Rest pain + tissue loss
Indications for arterial bypass grafting
Sx arise from v short distance of walking/rest pain
Affecting QoL
significant stenosis at aortic bifurcation - what bypass may be done?
aortobifemoral
significant stenosis in one femoral artery - what bypass may be done?
Fem-popliteal bypass
Definition of AAA
Dilatation of the aorta to >50% of normal (>3cm)
Indications for AAA repair
Symptomatic = back pain, distal emboli, leak
Asymptomatic:
- > 5.5cm
- expanding >1cm/year
Screening for AAA
Abdo US for 65M
<3cm = no more scans 3-4.5 = annual scans 4.5-5.4 = 3monthly >5.5cm = surgical referral
Ix in AAA
Abdo USS
CT/MRI = ix of choice
Complications of AAA repair
Death MI Renal failure Spinal/mesenteric ischemia Trash foot Anastomotic leak Graft infection Aorto-enteric fistula
Popliteal aneurysm = other findings O/E
Distal emboli on feet
examine the other knee = 50% bilateral
AAA = in 50%
Mx of popliteal aneurysm
Acutely: embolectomy or fem-distal bypass
Stable: excision bypass
Causes of aneurysms
Congenital: PCKD, Marfan’s, Ehlers Danlos
Acquired: atherscleoriss, trauma,
Complications of aneurysms
Rupture
Thrombosis
Distal emboli –> trash foot
Fistula = with GIT or IVC
Indications for amputation - give 4
Trauma
PVD
Sepsis
Neurological damage
EVAR vs open repair
EVAR = has less post-op mortality
at 5 years - no difference in mortality
Types of amputation
Digital Transmetatarsal Ankle Below knee Above knee
Complications of amputation
Early:
mortality
infection
haemorrhage
Late: Contractures Phantom limb pain Poor healing --> difficult to use prosthesis Psych
Most common type of repair used for below knee amputation
Long posterior flap of Burgess
Arterial supply to leg
Aorta –> external iliac –> common femoral –> superficial femoral –> popliteal artery –> posterior tibial
Complications of carotid endarterectomy
3% risk stroke/death
Haematoma
MI
Nerve injury - Rec laryngeal, hypoglossal (tongue)
Why is CKD associated with PVD
CKD –> hyperphosphatemia –> atherosclerosis
Features of diabetic foot
- Neuropathy –> trauma –> ulcers
- Vasculopathy –> ulcers
- Amputations esp digits
- Charcot joints
Causes of gangrene
DM = most common
Embolism eg trash foot from AAA repair
Raynauds
Injury
Colour changes in Raynaud’s phenomenon
White –> blue –> crimson
Secondary causes of Raynaud’s
- Systemic disease: SLE, SS, RA
- Atherosclerosis
- Blood: polycythemia
- Trauma: vibration injury
Mx of Raynaud’s
Conservative: avoid cold, wear gloves, stop smoking
Medical: nifedipine
Ulcers - types of tissue at base of ulcer
Granulation tissue = red + shiny
Slough = stringy + white
Eschar = necrotic + black
or bone/tendon
Examination of an ulcer
Site
Size
Shape
- Edges = sloping, punched out, undermined
- Base = granulation, slough
- Discharge = serous/sanguinous
Surrounding skin = dermatitis, excoriations, LNs, sensation
Assess neurovascular status
Mx of venous ulcer
Conservative:
Optimise RFs: weight loss, smoking
Leg elevation
If ABPI >0.8 –> 4 LAYER COMPRESSION BANDAGING
- Dressing + wool bandage + crepe bandage + blue line bandage + cohesive compression bandage
Bandages changed 1-2x/week
Once healed –> grade 2 compression stockings for LIFE
Technical term for bunions
Hallux valgus
Hallux valgus - how to examine?
Look: Degree of valgus Unilateral/bilateral Swelling Calluses on heel
Feel:
Swelling? - active bursitis
Move:
Toe joint ROM
Extras: look at shoes, assess gait
Hallux valgus - aetiology?
Ix?
Mx?
Aetiology: tight fitting shoes, familial, assoc with RA
Ix:
Weight bearing x ray w orthogonal views
- Assess degree of valgus + OA at MTP joint
Mx:
conservative: footwear, physic
surgical: bunionectomy, 1st metatarsal realignment osteotomy
Flattened medial arch of foot + ulcer on medial foot
Charcot joint
Features O/E of charcot joint
Painless deformed joint
Ulcers/necrosis
Swelling
Causes of charcot joints
Due to sensory loss
- DM
- peripheral neuropathy: B12, folate, alcohol
Acute limb ishemia - thrombosis vs embolism ?
Embolism: more sudden, no Hx of claudication, commonly AF or post AAA surgery, profound ischemia, CLINICAL Dx!!
Mx of ALI- thrombosis vs embolism
Both:
1) O2, analgesia 2) NBM 3) IV fluids 4) IV heparin
Embolism:
clinical Dx!
Urgent embolectomy!! + warfarin
Thrombosis: Doppler USS + CT angiography
Thrombolysis or stenting
Carpal bones
Scaphoid Lunate Triquetrum Pisiform
Trapezium Trapezoid Capitate Hamate
Septic arthritis:
which abx for elderly/recurrent UTI/recent abdo surgery?
Ceftriaxone
Which Abx for IVDU w septic arthritis?
?Pseudomonas
Ceftazidime!!
