Orthopaedic medicine Flashcards
What are the two principal symptoms in orthopaedics?
pain stiffness
which cell characterises acute disease?
polymorphic leucocytes
which cell characterises chronic disease?
lymphocytes
What is the difference between -otomy and -ectomy?
-otomy = open something up -etomy = remove something
What is osteomyelitis?
bacterial infection resulting in inflammation of bone
What is the difference between primary and secondary OA?
primary has unknown cause
What is Perthes disease?
idiopathic osteochondritis of femoral head in children
- AVN occurs causes abnormal growth
- occurs in short, active boys
Why are the lower limb joints subject to high loads?
muscles around the joint exert leverage several times body weight
eg. 3x body weight in hip during walking
Explain normal walking
contract abductor muscles in the leg we step on
lift pelvis opposite way
other leg swings forward
How does a walking stick help hip OA?
it reduces load on the hip by reducing abductor muscle activity carry stick in opposite hand lets shoulder girdle tilt the pelvis instead of the muscle tiling the pelvis
what is arthrodesis?
surgical stiffening of a joint in a position of function. Essentially, a relatively stiff and very painful joint is cut out and the remaining raw bone ends are held together either by an external splint or screws until they heal with a bony bridge
How can arthrodesis work in hip?
30° flexion and some abduction allows walking + sitting
Name some negatives of hip arthrodesis
interferes with female sexual activity
strain on adjacent joints in long-term eg. opposite hip, lumbar spine and knee
a large joint is technically difficult to fuse
In which body parts is arthodesis useful?
ankle and wrist
what is an osteotomy?
surgical realignment of a joint to redirect forces
who does osteotomy work for?
good in a joint deformity eg more wear due to bow-leg
- young people
- good ROM
- reasonable articular cartilage
If someone has bad ROM is arthrodesis or osteotomy better?
arthrodesis
is arthroplasty better in upper or lower limb? why?
lower because upper needs better ROM
what function ROM is needed in the hip after arthroplasty?
10° extension 40° flexion few ° abduction
what function ROM is needed in the knee after arthroplasty to get up and down stairs?
90° flexion stable in extension
List general complications of arthroplasty
chest infection UTI DVT PE
List specific early complications of arthroplasty
dislocation infection
List specific late complications of arthroplasty
late infection loosening and wear
4 requirements of joint replacement
functional ROM
stability
relief from pain
can withstand load
What joints are affected in rheumatoid arthritis?
Small joints affected symmetrically
- fingers (not DIP)
- wrists
- feet
- ankles
How does rheumatoid arthritis present?
chronic presentation that is more common in women
- severe pain
- swelling
- deformity
- stiffness worse in the morning
Give 2 surgical treatment for RA and who they are suitable for
synovectomy: early in disease, younger patient, retained movement but pain, good at wrist
excision arthroplasty: combined with synovectomy at wrist or elbow, good at removing pain but joint damaged so never full return to function
What sites are affected by post-traumatic AVN?
femoral head due to #fem neck
proximal scaphoid
proximal talus
what bones are affected by non-traumatic AVN?
lunate bone
femoral head
what is Caisson’s disease?
AVN of the femoral head in chronic alcohol abuse, steroids, deep sea divers
How does AVN present ?
acute and often severe joint pain, which is made worse by movement, and to some degree relieved by rest.
With the passage of time symptoms become indistinguishable from osteoarthritis and then it may be treated as such.
What causes gout?
urate crystal deposition
- dehydration post-surgery
- chemotherapy
- over-use of diuretics
Which joints does gout commonly affect?
- knee
- first MTP (base of big toe)
what can pseudogout cause in the knee?
calicification of joint surfaces and menisci
How does presentation of acute septic arthritis differ between adults and children?
children very acute illness with a stiff, hot and tender joint
adults have a minor upset of a chronically abnormal joint –> delay in recognition results in septicaemia and death
which organism causes
a) septic arthritis most commonly?
b) chronic septic arthritis?
c) acute septic arthritis in a young adult?
a) staphylococcus
b) TB
c) gonococcus
How does chronic septic arthritis present?
- chronic ill health
- weight loss
- considerable muscle wasting around the affected joint
- x-ray shows marked thinning of bone
Manage acute septic arthritis
surgical washout and IV antibiotics
how do meniscal lesions present
pain effusion locking/giving way
which meniscus is more likely to be damaged
medial
which type of meniscal lesion occurs in old age
cleavage lesion: a horizontal flap that allows in fluid –> cyst
most common type of meniscal lesion
bucket handle tear
what MOI in meniscal lesion
twisting injury
How are meniscal lesions managed surgically?
ARTHROSCOPY
- try to preserve meniscus
- suture peripheral tears
- if tear in meniscus itself remove torn part as no capacity to heal
how do loose bodies present
injury causes osteochondral fragment to break off with an initial haemarthrosiswhich settles
later pain, locking, giving way, effusion
spontaneous loose bodies in adolescents is called
osteochondritis dissecans
MOI for cruciate ligaments
hyperextension/twist with anchored foot
PC cruciate injury
“pop” haemarthrosis –> settles chronic injury
what causes patellar dislocation?
- congenital eg. Down’s syndrome
- trauma
- malformed patella/femoral condyle results in maltracking which causes muscle spasm and spontaneous dislocation
what is maltracking patella
patella does not stay in its place on femur causing abrasion
treat minor patella maltracking
split vastus lateralis
treat recurrent, severe patella maltracking
plication (medial tightening of vastus medialis)
what do we call non-nervous tissue in the spine?
spondylitides
what surrounds nerve roots exiting from vertebral foramina?
facet joints intervertebral discs
How is referred pain in the leg distinguished from sciatica?
referred pain: back to buttock to leg (not below knee) sciatica: leg to foot
where does nerve root pain in cervical spine go to?
hand and forearm
what are localising signs?
loss of sensation or muscle weakness
what are the facet joints?
joint between articular processes of adjacent vertebrae
what is the pars interarticularis?
part between inferior and superior articular processes of the facet joint
how does lifting something with a straight back and holding it close to the spine prevent back sprain?
it causes less leverage and reduces spinal load
do we see signs of nerve compression in back sprain?
no
what is mechanical backache? what causes it?
recurrent sprains of unknown cause - may be due to spondylosis or primary OA
what is spondylosis?
degeneration of the intervertebral disc leading to increased loading of the facet joints and secondary OA
what is spondylolithesis?
slippage of one vertebrae relative to the one below it
how does spondylolithesis occur?
- congenital
- acquired following acute or fatigue # of pars interarticularis
how do you manage spondylolithesis if there is severe pain?
spinal fusion
what is spondylolysis?
of pars interarticularis without forward slippage. can cause pain
how does a prolapsed lumbar disc present?
acute leg pain (down to foot) +/- backache
can be after an episode of strain or spontaneous
Why does someone get a prolapsed disc?
abnormal intervertebral disc leads to prolapse of nucleus pulposis through annulus fibrosis
Which vertebrae are most commonly affected by prolapsed discs? What does this result in?
sacrum and 5th lumbar
sciatica as sciatic nerve exists from the above nerve root so pain is perceived in the sciatic nerve
How do we confirm what disc is affected in prolapsed disc?
myelography: inject radio-opaque die into spinal fluid and it wont go where prolapse is on xray
What is impinged when the nucleus puloposus herniates
a) backwards + laterally?
b) posteriorly?
a) nerve root
b) spinal cord
What is bony root entrapment?
bony overgrowth around vertebral foramina compresses nerve root
Why does bony root entrapment occur?
secondary to degenerative change eg primary OA or disc degeneration
Does bony root entrapment occur in response to a prolapsed disc?
no
Who is affected by bony root entrapment in the lumbar spine?
over 40 hx of mechanical back pain
What characterises spodylosis?
osteophytes growing around a degenerated disc
what is cervical spondylosis?
a degenerative disease of the cervical discs leading to secondary arthritic changes in the adjacent facet joints
Who does cervical spondylosis affect?
women over 40
How does cervical spondylosis present?
dull neck ache that refers to shoulders and upper arms tingling arms
Can cervical spondylosis progress?
yes it can progress to bony nerve root entrapment
How do you manage cervical spondylosis?
no localising signs = analgesia, NSAIDs, collar, physio
nerve root entrapment = fuse vertebrae
How can we differentiate between cervical spondylosis and cervical disc disease?
disc disease tends to have no history of cervical neck problems
What happens following cervical disc prolapse?
muscle spasm restricted movement
How do we manage cervical disc prolapse?
most will recover with
- rest, gentle traction, supporting collar
if marked localising sings / symptoms dont regress
- surgery to fuse vertebrae
Normal milestone for
a) sitting b) standing c) walking
a) 9 months
b) 1 year
c) 20 months
What is genu valgum?
knock knees - normal alignment
What is genu varum?
bow legs
Which of genu valgum and varum causes an increased gap at the feet?
genu valgum
What is the normal foot gap for children?
4cm
When do knock knees and bow legs tend to resolve?
by age 7
What are curly toes?
what toe is most commonly affected?
should they be operated on?
minor overlapping of toes
5th
discourage operating unless discomfort in shoes
Give some causes of intoeing
femoral neck anteversion tibial torsion abnormal forefoot
How does the femur develop
During the later stages of the normal development of the foetus, the leg rotates on the pelvis so that the acetabulum points almost backwards and the femoral head on the neck is orientated forwards.
What movements does a child with femoral neck anteversion do ?
- lots of internal rotation
- limited external rotation
When should femoral neck anteversion fix itself?
by age 10
What is tibial torsion?
how should it be managed?
where the bone is literally distorted or warped along its vertical axis
it is a normal variation and should be ignored.
What are the two types of flat feet?
rigid and mobile
- mobile is normal
- rigid may be due to underlying bony abnormality or RA
Which toe is particularly common to overlap?
5th toe
What age in childhood is knee pain common?
10-12
what is osgood-schlatter’s disease? what is the mechanism behind it?
inflammation of the attachment of the patellar tendon to the growing tibial epiphysis due to excessive traction by the quadriceps
The cause is unknown but it may be an overuse injury as it is more common in very active children who are often involved in organised sport.
what can arthroscopy show in a girl with adolescent knee pain?
arthroscopy can shoe chondromalacia patellae (worn out patella)
what is the occurence of CDH
1/2 per 1000 live births
How is CDH screened?
at birth manoeuvres: one to dislocate and one to reduce a dislocated hip –> positive if click/clunk screened again at 3,6,12 months
Signs of CDH
positive ortolani/barlow limb shortening asymmetrical skin creases limited abduction and a limp
how do you manage a) a click? b) a clunk?
a) refer to specialist at 3 months for x-ray b) treat from birth
how is early CDH treated?
splintage to put femoral head in acetabulum
how is late CDH treated?
not walking: gentle traction, open/closed manipulation, 3 months of splintage walking: major surgery to deepen acetabulum and reangulate femoral neck
what is the name for club foot?
talipes equinovarus
what does equinus mean?
plantarflexion
what are the two forms of club foot?
- mild postural after breech birth
- fixed form due to developmental abnormality of nerves and muscles
How is club foot managed?
manipulate at birth with 6 weeks splintage with Ponseti technique corrects hindfoot equinus then mid+forefoot varus
- severe cases may need surgery after this if correction incomplete
- follow up until feet stop growing
What are the two forms of spina bifida?
spina bifida occulta (minor bony abnormality, more common) spina bifida cystica (neural plate tissue open with little or no skin or bone cover)
What is a diastomatomyelia?
in what form of spina bifida does it occur?
tethering of spinal cord to higher lumbar vertebrae during growth
occulta
what is a meningocele?
when nerve tissue covered by a cyst
What is a meningomyelocele?
when nerve tissue is incorporated into a cyst
Which type of spina bifida may cause hydrocephalus?
cystica
what is cerebral palsy?
neuromuscular disorder with onset before 2‐3 years of age due to an insult to the immature brain before, during or after birth
how does spastic cerebral palsy present?
spaastic paralysis: some muscles to strong but uncoordinated, some weak and flacid missing milestones like walking lack of co-ordination and purpose of movement
Give an example of minor spastic cerebral palsy
how can this be treated
toe-walking in adolescence due to spastic calf muscles
–> may need tendo-achilles lengthening
What MSK problems do people with cerebral palsy suffer from?
joint contractures, scoliosis and hip dislocation (non‐congenital).
How are MSK problems in CP managed ?
- careful physio
- baclofen and botox to reduce spasticity
- surgery to lengthen tight muscles, denervate them, move them
- hip surgery to help sit in a wheelchair
- splintage can make spasms worse
How is spina bifida managed?
surgery on feet to keep normal shape keep mobile till adolescence using splints + hand-held aids
Are orthopaedic problems more severe in spina bifida or cerebral palsy?
CP
What is scoliosis?
abnormal lateral curvature of the spine with a rotatory abnormality of the vertebrae
What is the underlying cause for scoliosis?
- most idiopathic
- neuromuscular disorder eg spina bifida
- congenital abormality of vertebrae
- tumour
is scoliosis painful?
it should not be painful - sometimes pain secondary to distress about condition
how does scoliosis occur?
abnormal lordosis leads to buckling and twisting of vertebral column due to muscles and gravity
Why would scoliosis warrant an operation?
progressive curve distressing to patient to allow to sit in wheelchair restrictive lung defect in severe cases
What does a limp from birth indicate?
? CDH or hip infection
What are imaging findings for perthes?
xray may be normal at first then fragment excess fluid on US
how do you manage perthe’s?
leave minor cases alone
more severe may need splintage, osteotomy periods of traction
What are the long-term effects of perthe’s disease in older children?
secondary OA
What age does perthe’s disease present?
4-10 years
which two groups get a SUFE?
boys age 12 who are sexually immature girls age 14 who have had recent growthspurt
Where does SUFE tend to cause pain?
pain in the knee due to obturator nerve radiation
How do you manage a) minor SUFE? b) major SUFE?
a) pin hip b) gentle manipulation of head back on to neck –> high risk of AVN
do you need to observe the other hip in perthes or sufe?
SUFE
when does osgood-schlatters present?
age 10-12
which gender are affected more by Perthes?
boys
What is an enthesis?
the short, fibrous origin of a muscle
Name 2 common sites of enthesopathy
- Golfer’s elbow: flexor muscles of forearm 2. Tennis elbow: extensor muscles of forearm
What is the prognosis for elbow enthesopathy
good esp if known cause - most resolve spontaneously
How do you manage severe or chronic enthesopathy?
anti-inflammatories steroid injection into point of max tenderness surgery to scrape origin off bone + decompress
What is neuropraxia?
compression/stretching injury to nerve
Which nerve is most commonly damaged by extrinsic causes?
common peroneal nerve as it winds around fibula
What nerves are commonly damaged by intrinsic causes?
median and ulnar nerves at the wrist ulnar nerve at the elbow posterior tibial nerve at the ankle
What symptoms should make you suspicious of nerve entrapment?
numbness or tingling
What symptoms are diagnostic of nerve entrapment?
weakness and real sensory loss
How do we manage nerve entrapment?
remove obvious cause surgical decompression
What is a bursa?
a small sac of fibrous tissue lined with synovial membrane and filled with fluid
What do bursae do?
acts as natural bearing to improve muscle and joint function by reducing friction where tendons and ligaments pass over bone
How does bursitis present?
chronic discomfort that might be exacerbated with movement or pressure swelling
How does an infected bursa present?
- tense swelling
- cellulitis
- malaise
How do you treat a) asymptomatic b) tender c) infected bursitis?
a) dont b) excise and treat cause c) incise and drain
What may painful, spasmodic flat feet indicate?
- infection
- chronic inflammatory disease
- impending rupture of tibialis posterior if acute
How do you manage painful flat feet?
medial heel lift –> subtalar joint fusion (disturbs foot and ankle joint)
What is a bunion?
fluid-filled bursae around bony prominences
Where do bunions most commonly occur?
distal part of 1st metatarsal
What is a corn?
painful excessive skin
Why do bunions and corns form?
natural response to pressure that indicates underling abnormality
What is hallux valgus?
the turning away of the phalanges of the big toe from the mid-line, usually because of a deformity at the joint line.
What is hallux rigidus?
osteoarthritis of the first metatarsophalangeal joint.
Why does hallux rigidus occur in adolecents and how do you treat it?
osteochondral #
metatarsal bar which often fails then surgery
Describe surgical treatment of hallux rigidus
- remove osteophytes and osteotomy of proximal phalanx
- fusion
- silicone spacer arthroplasty
( physio also useful)
when is hallux valgus seen alone and how is it treated?
in women with a short 1st metatarsal in varus
realign laterally and excise bony prominence
What is a claw foot? Why does it happen?
when muscles waste to make the bones and nails look prominent
occurs due to muscle weakness or deficiency eg spinal abnormality
What is hammer toe secondary to?
metatarsophalangeal joint disruption
What is metatarsalgia?
generally sore forefoot
What is morton’s neuroma?
cutaneous nerves to the toes bcome trapped/irritated between metatarsal heads due to repetitive trauma
How does mortons’s neuroma present?
dull, throbbing with sharp exacerbations tingling sideways compression causes click
Where does the plantar fascia span from?
os calcis to base of each toe
How does plantar fascitis present?
sore instep worse on rising and if sitting for hours minimal relief from walking
How do you treat plantar fascitis?
self-limiting condition with ways to relieve symptoms
- insoles and soft shoes
- local injection of steroids + local anaesthetic to point of tenderness
- surgery to strip fascia is questionable
What is sensory neuropathy?
a loss of sensation caused by disease or injury to sensory peripheral nerves.
How does achilles tendonitis present?
pain where the tendon inserts into os calcis
Who gets achilles tendonitis?
young athletes middle aged men
How do you treat achilles tendon rupture?
equinus plaster for 8 weeks or suture
What structures can contribute to shoulder pain?
- subacromial bursa
- supraspinatous tenson
- Acriomiocalvicular joint
- biceps tendon
- rotator cuff
What condition presents with tenderness under active movement with painful arc ?
supraspinatous tendon inflamamtion or subacromial bursitis
What pathology in the acriomioclavicular joint can cause shoulder pain?
degenerative change, and osteophytes in the acromio- clavicular joint
may lead to rupture of the supraspinatus muscle which is part of the rotator cuff. Such rotator cuff tears can become large rents and even small ones cause a lot of discomfort and pain.
What is frozen shoulder? who gets it?
little or no glenohumeral movement idiopathic or after trauma eg epileptic fit or electric shock
How long does frozen shoulder last?
18 months - 2 years
What is the periosteum?
the membrane covering the outside of the bone
signs of a fracture
pain deformity tenderness swelling discolouration loss of function crepitus
What determines the position of a) the proximal fragment? b) the distal fragment?
a) muscles b) gravity
How does a radioisotope scan work?
inject radioactive material into blood, it joins to phosphate and is taken up into bone increased at fracture site because it is more metabolically active
What is a spiral #?
occurs due to twisting injury low energy easy to heal as soft tissues ok
What is an oblique fracture?
buckling/ shearing force eg deceleration/ fall from height high energy –> hard to heal
What is a transverse fracture?
bending force, cortex fails on one side in compression and other in tension. high energy –> hard to heal
What is displacement?
is the distal bone fragment aligned wrong eg posterior/anterior, medial/lateral
What is angulation?
distal fragment points elsewhere eg posterior/anterior, valgus/varus
How can we relieve pain following fracture?
drugs: inject morphine or pethidine
splintage to steady #: encompass joint above and below
When is traction useful?
to help with muscle spasm femoral neck #
How much blood is lost in a) femoral #? b) pelvic #? c) tibial #?
a) 2-3 units b) 6 units c) 1 unit
How do you manage an open fracture?
surgery ASAP - may need to open wound and excise down to bone - most left open due to concern over skin closure
What are the two stages of fracture management?
reduction and holding
What must holding allow for?
keep # in place until united and consolidated (can weight bear)
name types of holding
casts internal fixation external fixation traction
describe how casting is done
place limb in cast at appropriate length immobilise joints above and below pressure at 3 points
What are some disadvantages of casting?
heavy can’t re-examine muscle wasting due to immobilisation
What is a good alternative to casting?
functional braces - but these can only be applied after a few weeks once swelling and pain go down
When is external fixation useful?
high energy injury where there is soft tissue damage
Give types of internal fixation
apposition interfragmentary compression onlay device inlay device
What is apposition? give an example
holding a fracture in alignment so it can heal eg K wires
What is interfragmentary compression?
using screws and tension band wiring
what is an onlay device?
a rigid metal plate used to strengthen structures around joints and in upper limb long bones
Which types of internal fixation stop natural healing?
onlay device
What is an inlay device?
intramedullary
When are inlay devices not useful?
around joints
Give 3 types of traction
static: uses own body as pulley
balanced: takes pressure off body by using a weight
dynamic: allows joints to move using pulleys
How does traction work as a holding method?
- application of a relatively small weight to a limbexerts a pull along the axis of the broken limb.
- This pull of at most 5 kilograms stimulates muscles to contract. Muscles completely surround a bone, and this slight contraction (which is really an increase in muscle tone), is sufficient to hold a broken bone in the position achieved at reduction.
- effectively “massage” the aligned fracture ends until natural healing takes place.
Describe fracture healing at a) 0-2 weeks b) 2-6 weeks c) 6-12 weeks
a) swelling b) callus forms c) bone forms
How do bones heal?
with micromovement along the long axis of the bone at right angles to the break
Does rigid fixation speed up bone healing?
no it slows it down as no movement
How can low energy fractures be treated?
- manipulation and casting 2. traction eg femur 3. internal fixation if early mobilisation
How should a displaced, intra-articular fracture be treated?
internal fixation screws to hold cancellous bone fragments as there is little soft tissue support
How should high energy injuries be treated?
external fixation as damage to blood supply
What does bone cancer occur secondary to?
thyroid kidney breast lung
Name 6 early complications that occur due to a fracture
- blood loss
- infection if open
- compartment syndrome
- renal failure
- soft tissue injury
- fat embolism
name 5 late complications that occur due to a fracture
- non-union
- delayed union
- mal-union
- growth arrest
- arthritis
*
name 5 early complicatios that occur due to fracture treatment
plaster disease renal stones immobility compartment syndrome infection
name 2 late complications that occur due to fracture treatment
mal-union infection
manage a) a stable fracture w infection? b) an unstable fracture w infection
a) drain + antibiotics b) external fixation, debridement + then bone graft later
How does fat embolism present?
men under 20 with long bone # 2-5 days after they have tachypnoea and confusion
Treat fat embolism?
high % o2 chest physio steroids
When does someone get renal failure following a #
major soft tissue damage person was trapped ischaemic limb in shock
What is a fascial sheath?
thick fibrous tissue surrounding a group of muscles
How does compartment syndrome happen?
causes bleeding and inflammation of adjacent compartment, inc pressure reduces blood flow and causes ischaemia
What is fracture/plaster disease?
muscle wasting stiffness skin sores
How long does normal healing take in a) upper limb b) lower limb compared to non-union?
a) 6 weeks then 10 weeks b) 12 weeks then 20 weeks
delayed union somewhere in between
Which bone is most commonly affected by non-union?
tibia
How is non-union treated?
- remove cause
- stabilise #
- autologous bone graft
What is malunion?
fixation of fracture in a bad position for function
How is malunion treated?
ORIF
Why does growth arrest occur following a #?
if it breaches the germinal layer of the epiphyseal growth plate
What are the radiological changes in AVN?
initially none
then bone dense as blood supply lost
treat TB
2 RIPE 4 RI
- 2 months Rifampicin, Isoniazid, Pyrazinamide, Ethambutol
- 4 months Rifampicin, Isoniazid
Which knee ligament repairs spontaneously and which doesn’t?
collateral repair as good blood supply
cruciate don’t
What is osteochondritis?
fragmentation of bone and underlying cartilage
How can a sore, calcified supraspinatous tendon be treated?
injection
surgery
How to treat painful arc?
steroid injection into bursa or around tendon
What causes # to the shaft of long bones?
how are they treated
most are low energy injuries
treat with
- casting and manipultation
use traction if this is difficult
internal fixation is justified if it allows for early mobilisation
