Orthopaedic Passmedicine Flashcards
What is first line for back pain?
NSAIDs
What investigation should be offered to those with non-specific back pain?
MRI - ONLY if results likely to change management (i.e. where malignancy, infection, fracture, cauda equina or AS is suspected)
What advice should you give to people with back pain?
Encourage self management
Stay physically active
Exercise
What patients should be co-prescribed PPIs if they are given NSAIDs?
> 45y
What are some other treatments of back pain?
Exercise programme
Manual therapy - spinal manipulation, mobilisation, massage
Radiofrequency denervation
Epidural injections of LA/steroid for acute severe sciatica
What is the only imaging technique that allows you to see soft tissue structures?
MRI
What is a common cause of lateral knee pain in runners?
Iliotibial band syndrome
Where is the tenderness in iliotibial band syndrome?
2-3cm above lateral joint line
What is involved in the management of iliotibial band syndrome?
Activity modification, iliotibial band stretches
If not improving –> physio referral
What may compartment syndrome follow?
Fractures
Ischaemia reperfusion injury in vascular patients
What is compartment syndrome?
Raised pressure within a closed anatomical space –> compromises tissue perfusion –> necrosis
What are the two main fractures that cause compartment syndrome?
Supracondylar fractures
Tibial shaft injuries
What are the features of compartment syndrome?
Pain (esp on movement, even passive, rapidly progressive, non-responsive to analgesics) Paraesthesiae Pallor Arterial pulsation may still be felt Paralysis of muscle group may occur
How can you still feel an arterial pulsation in compartment syndrome?
Necrosis results due to microvascular compromise SO presence of a pulse does not rule out compartment syndrome
How is compartment syndrome diagnosed?
Measuring intracompartmental pressure (>20mmHg abnormal, >40mmHg diagnostic)
How is compartment syndrome managed?
Prompt + extensive
fasciotomies
Debridement of necrotic tissue
What complication may occur following fasciotomy?
Myoglobulinuria –> renal failure (these pts need aggressive IV fluids)
How long does it take for muscle groups to die in compartment syndrome?
4-6h
What does myoglobuinuria look like?
Dark, brown coloured urine that drips positively for blood
What are some specific causes for Dupuytren’s contracture?
Manual labour Phenytoin treatment Alcoholic liver disease DM Trauma to the hand
Who is more at risk of Dupuytren’s contracture?
Older male patients
Those with FH
What fingers tend to be affected in Dupuytren’s contracture?
Ring finger, little finger
How is Dupuytren’s contracture managed?
Surgery - fasciectomy
When should you consider surgery for Dupuytren’s contracture?
When unable to straighten out metacarpophalangeal joints and hand cannot be placed flat on table
What are the features of a prolapsed disc?
Clear dermatomal leg pain + assoc. neurological deficits
Leg pain usually worse than back
Pain worse when sitting
What features are in line with an L3 nerve root compression?
Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
What features are in line with an L4 nerve root compression?
Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
+ve femoral stretch tests
What features are in line with an L5 nerve root compression?
Sensory loss dorsum of foot
Weakness in foot + big toe dorsiflexion
Reflexes intact
+ve sciatic nerve stretch test
What features are in line with an S1 nerve root compression?
Sensory loss posterolateral aspect of leg + lateral aspect of foot
Weakness in plantarflexion of foot
Reduced ankle reflex
+ve sciatic nerve stretch test
How is prolapsed disc managed?
Analgesia (anti-neuropathic), physio, exercises
If symptoms persist >4-6w then refer for consideration of MRI
What are the Ottawa ankle rules?
X-ray only req. if pain in malleolar zone +
- inability to wt bear for 4 steps
- tenderness over distal tibia
- bone tenderness over distal fibula
What is a popular classification system for describing ankle fractures?
Weber
What is the Weber classification?
Related to level of fibular fracture
A. below syndesmosis
B. fracture starts at level of tibial plafond + may extend proximally to involve syndesmosis
C. above syndesmosis (incl. syndesmosis)
What is a Masionneuve fracture?
Spiral fibular fracture that leads to disruption of the syndesmosis with widening of the ankle joint
How is a Masionneuve fracture managed?
Surgery
What is the management of ankle fractures?
Prompt reduction to remove pressure on overlying skin + subsequent necrosis
What kind of ankle fractures will req. surgery?
Young patients with unstable, high velocity or proximal injuries
What does surgery for ankle fractures usually involve?
Compression plate
Who tends to get conservative management for ankle fractures?
Elderly, potentially unstable injuries
as their bone doesn’t hold metalwork as well
How should stable/minor ankle fractures be managed?
Weight bearing as tolerated in a controlled ankle motion (CAM) boot
Define discitis
Infection in the intervertebral disc space
What is a complication of discitis?
Sepsis
Epidural abscess
What are the features of discitis?
Back pain General features (pyrexia, rigors, sepsis) Neurological changes - e.g. changing lower limb neurology if epidural abscess develops
What is the most common cause of discitis?
Staph aureus
Apart from bacteria what else can cause discitis?
Viruses
TB
Aseptic
What is the best imaging for discitis?
MRI
CT guided biopsy may be req. to guide antimicrobial treatment
How is discitis treated?
6-8w of IV antibiotics
How do you decide what antibiotics to give in discitis?
Culture (CT guided biopsy or blood culture)
What further investigations might you do in discitis?
Check for endocarditis (e.g. TOE/TTE) - esp. if it due to staph
What kind of movements usually result in meniscal tears?
Twisting movements
What are the features of meniscal tears?
Pain worse on straightening the knee Knee may give way Displaced meniscal tears may --> knee locking Tenderness along joint line Thessaly's test +ve
What is Thessaly’s test?
Wt bearing at 20 degrees of knee flexion, pt supported by doctor, positive if pain on twisting the knee
What is Froment’s test used for?
Assess for ulnar nerve palsy
Tests adductor pollicis muscle function
How do you perform Froment’s test?
Hold piece of paper between thumb and index finger and pull it away
If ulnar n. palsy unable to hold paper and will flex flexor pollicis longus to compensate (flexion of thumb at IP joint)
What is Phalen’s test used for?
Assessing for carpal tunnel syndrome
Which of Phalen’s and Tinel’s is more sensitive?
Phalen’s
How do you perform Phalen’s test?
Hold wrist in maximum flexion (reverse prayer sign) for 30-60s + test +ve if there is numbness in median n. distribution
What is tinel’s test used for?
Assessing for carpal tunnel syndrome
How do you perform tinel’s test?
Tap median nerve at the wrist
+ve if tingling/electric like sensations over distribution of median nerve
Why is avascular necrosis a risk in displaced hip fractures?
Blood supply to femoral head runs up the neck
What are the features of a hip fracture?
Pain
Shortened and externally rotated leg
What are the two different locations hip fractures can occur in?
Intracapsular (sucapital): from edge of femoral head to insertion of capsule at hip joint
Extracapsular: can be trochanteric or subtrochanteric
What structure divides subtrochanteric and trochanteric fractures?
The lesser trochanter
What system is used to classify hip fractures?
Garden system
What is the Garden system?
Type I: Stable fracture with impaction in valgus
Type II: Complete fracture but undisplaced
Type III: Displaced fracture, usually rotated and angulated, but still has boney contact
Type IV: Complete boney disruption
What Garden types most commonly lead to bloody supply disruption?
3 and 4
How should an undisplaced intracapsular hip fracture be managed?
Internal fixation
Hemiarthroplasty if unfit
How should a displaced intracapsular fracture be managed?
Young + fit (<70) - reduction and internal fixation
Older + reduced mobility - hemiarthroplasty or THR
How should extracapsular hip fractures be managed?
Dynamic hip screws
How should reverse oblique, transverse of subtrochanteric extracapsular fractures be managed?
Intramedullary device
Should a patient with a subtrochanteric femoral fracture fixed with an intramedullary nail weight bear after the operation?
Yes - should weight bear immediately as tolerated
What is the motor supply of the femoral nerve?
Knee extension
Thigh flexion
What is the sensory supply of the femoral nerve?
Anterior and medial aspect of thigh and lower leg
What is the typical mechanism of injury of the femoral nerve?
Hip/pelvic fractures
Stab/gunshot wounds
What is the motor supply of the obturator nerve?
Adduction of thigh
What is the sensory supply of the obturator nerve?
Medial thigh
What trauma may injure the obturator nerve?
Anterior hip dislocation
What is the motor supply of the lateral cutaneous nerve of the thigh?
None
What is the sensory supply of the lateral cutaneous nerve of the thigh?
Lateral + posterior surfaces of the thigh
Where is the lateral cutaneous nerve of the thigh likely to get compressed? What results?
ASIS Meralgia paraesthetica (pain, tingling + numbness in the distribution of the lateral cutaneous nerve of the thigh)
What is the motor supply of the tibial nerve?
Foot plantarflexion and inversion
What is the sensory supply of the tibial nerve?
Sole of foot
What kind of injuries may lead to damage to the tibial nerve?
Popliteal lacerations
Posterior knee dislocation
What is the motor supply of the common peroneal nerve?
Foot dorsiflexion and eversion
Extensor hallicus longus
What is the sensory supply of the common peroneal nerve?
Dorsum of foot + lower lateral part of leg
Where does injury of the common peroneal nerve commonly occur?
Around neck of fibula
E.g. may happen if a plaster cast is applied too tightly
What does injury to the common peroneal nerve lead to?
Foot drop
What is the motor supply of the superior gluteal nerve?
Hip abduction
What is the sensory supply of the gluteal nerves?
None
What may cause damage to the superior gluteal nerve?
Misplaced IM injection
Hip surgery
Pelvic fracture
Posterior hip dislocation
What does damage to the superior gluteal nerve lead to?
+ve Trendelenburg sign
What is the motor supply of the inferior gluteal nerve?
Hip extension + lateral rotation
What does injury to the inferior gluteal nerve lad to?
Difficulty rising from seated position
Can’t jump, climb stairs
What are risk factors for congenital hip dislocation?
Female gender Breech presentation Family history Firstborn Oligohydramnios
What two tests are used to get for DDH?
Barlow
Ortolani
(those at risk have an USS)
What is the most sensitive sign of compartment syndrome?
Pain on passive stetch
What age do children tend to get transient synovitis?
2-10y
What is transient synovitis?
Acute hip pain associated with a viral infection
What is the most common cause of hip pain in children?
Transient synovitis
What is perthes disease?
Degenerative condition affecting the hips of children
What age do children tend to get perthes?
4-8y
What causes perthes?
Avascular necrosis of the femoral head
In which gender is perthes more common?
Boys
What are the features of perthes?
Hip pain - progressive over a few wks
Limp
Stiffness, reduced RoM
What findings do you see on X-ray in perthes disease?
Early changes - widening of joint space
late changes - decreased femoral head size/flattening
What age typically do children get SUFE?
10-15y
Who is SUFE more common in ?
Obese boys
What occurs in SUFE?
Displacement of the femoral head epiphysis posterior-inferiorly
In what two ways can SUFE present?
Acutely after trauma
With chronic, persistent symptoms
What are the features of SUFE?
Knee/distal thigh pain
Loss of internal rotation of leg in flexion
What is JIA?
Arthritis occurring in someone who is less than 16y, lasting >3m
What is pauciarticular JIA?
4 or less joints affected
Most common type of JIA
What are the features of pauciarticular JIA?
Joint pain + swelling - usually medium sized joints (knees, ankles, elbows)
Limp
ANA +ve (assoc. with anterior uveitis)
What is the typical presentation of septic arthritis?
Acute hip pain + systemic upset (pyrexia)
Inability/severe limitation of affected joint
What is another name for frozen shoulder?
Adhesive capsulitis
What is adhesive capsulitis associated with?
Diabetics
What movement is affected most in adhesive capsulitis?
External rotation
What are the features of adhesive capsulitis?
Active + passive movement affected
Freezing phase, adhesive phase, recovery phase
How long do episodes of adhesive capsulitis typically last?
6m-2y
How is adhesive capsulitis managed?
NSAIDs, physio, oral corticosteroids, IA corticosteroids
Define open fracture
Disruption of the bony cortex associated with a breach in the overlying skin
Any wound that is present in the same limb as a fracture should be suspected as representing what?
An open fracture
What system is used to classify open fractures?
Gustilo and Anderson system
What is the Gustilo and Anderon system?
- Low energy wound <1cm
- Greater than 1cm wound with moderate soft tissue damage
- High energy wound >1cm with extensive soft tissue damage
3A. Adequate soft tissue coverage
3B. Inadequate soft tissue coverage
3C. Associated arterial injury
In gustilo T3C injuries what system may be used to predict the need for primary amputation?
Mangled extremity scoring system (MESS)
How should open fractures be managed?
- Ex for assoc. injuries, control of haemorrhage, extent of injury
- Imaging to establish distal neurovascular status
- Cover wound with dressing + give antibiotics, take photo of wound
- Debridement + irrigation
- Stabilise
What does debridement involve?
Removing foreign material and devitalised tissue
How many Ls of fluid should be used to irrigate an open fracture wound?
At least 6L saline
What is often used to stabilise an open fracture in the first instance?
External fixator
Management of an intracapsular fracture, displaced + independently mobile, does not use more than a stick
Total hip replacement
Management of an intracapsular fracture, displaced + not independently mobile
Hemiarthroplasty, cement implants preferred
Management of a trochanteric fracture
Sliding hip screw
Management of a subtrochanteric fracture
Intramedullary nail
What is a psoas abscess?
Collection within the psoas muscle
What vertebral levels does the psoas muscle lie over?
T12-L5
Where does the psoas muscle insert?
Lesser trochanter of femur
Psoas abscess can be of primary origin or as what?
A result of spread from local sources, e.g. pyelonephritis, IBD
What are complications of psoas abscesses?
Septicaemia + multi organ failure
What is the most common organism causing psoas abscess?
Staph or strep
What are risk factors for developing a primary psoas abscess?
Immunosupression, e.g. HIV, cancer, DM
IVDA
Prev. surgery
TB
What is the pain like in psoas abscess? Is there a fever?
Increases over several days
May be a fever
How can you evidence psoas irritation?
When position of comfort is pt lying on back with slightly flexed knees
Apart from pain + fever what other feature may you see in psoas abscess?
Inability to wt bear or pain when moving the hip
What investigations should you do for suspected psoas abscess?
Bloods
Septic screen
CT abdomen/MRI
What is the gold standard imaging used to identify psoas abscess?
MRI
What is the management of psoas abscess?
Antibiotics +/- drainage
Management of RFs
What are buckle fractures?
Incomplete fractures of the shaft of a long bone characterised by bulging of the cortex
In who do buckle fractures tend to occur?
5-10yos
How are buckle fractures managed?
Usually self-limiting so can be managed with splinting + immobilisation rather than a cast
Why do children get buckle fractures instead of proper breaks in their bones?
Their bone is more elastic so axial trauma –> deformity rather than a true fracture
What sort of things tend to lead to hip dislocation?
Direct trauma, e.g. road traffic accident/fall from significant height
Large amounts of forces req. to dislocate hip
What must you be aware of in hip fractures?
Huge amounts of forces req. to dislocate hip so may be associated with fractures or life-threatening injuries
What are the features of hip dislocation?
Extreme pain
Deformity depending on type
What is the most common type of hip dislocation?
Posterior dislocation (90%)
What is the appearance of a posterior hip dislocation?
Affected leg shortened, adducted and internally rotated
What is the appearance of a anterior hip dislocation?
Affected leg abducted and externally rotated with NO leg shortening
What are the three types of hip dislocation?
Posterior
Anterior
Central
How do you manage hip dislocations?
ABCDE
Analgesia
Reduction under GA within 4h
What is involved in the long term management of hip dislocations?
Physio to strengthen surrounding muscles
Why should you reduce a hip fracture within 4h?
To reduce risk of avascular necrosis
What are complications of hip fracture?
Sciatic/femoral nerve injury
Avascular necrosis
OA
Recurrent dislocation
Why are patients who have had a hip fracture at risk of recurrent dislocation?
Due to damage of supporting ligaments
How long does it take for a hip to heal after a traumatic dislocation?
2-3m
When is prognosis best after a hip dislocation?
If hip reduced less than 12h post-injury and when there is less damage to the joint
What are baker’s cysts?
Distensions of the gastrocnemius-semimembranosus bursa
What are the two types of baker’s cysts?
Primary
Secondary - underlying condition, e.g. OA
Who are primary baker’s cysts usually seen in?
Children
Where are baker’s cysts?
In popliteal fossa
What are the feature of ruptured baker’s cyst?
Similar to DVT - pain, redness, swelling in calf
But most are asymptomatic
How should you manage baker’s cysts in children?
These typically resolve and don’t require treatment
How should you manage baker’s cysts in adults?
Treat underlying cause
How do baker’s cysts tend to present?
Asymptomatic, fluctuant swelling behind the knee
Where is the pain + tenderness in medial epicondylitis?
Medial epicondyle
What is medial epicondylitis also known as?
Golfer’s elbow
What aggravates the pain in golfer’s elbow?
Wrist flexion + pronation
What other symptoms may you get in golfer’s elbow?
Numbness/tingling in 4th + 5th finger due to ulnar nerve involvement
What most commonly causes radial tunnel syndrome?
Compression of the posterior interosseous branch of the radial nerve
What is thought to cause radial tunnel syndrome?
Overuse
What are the features of radial tunnel syndrome?
Similar to lateral epicondylitis but pain is 4-5cm distal to lateral epicondyle
Symptoms worsened by extending elbow + pronating forearm
What is cubital tunnel syndrome due to?
Compression of the ulnar nerve
What are the features of cubital tunnel syndrome?
Intermittent tingling in 4th + 5th finger
Worse when elbow resting on firm surface/flexed for extended periods
What are later features of cubital tunnel syndrome?
Numbness in 4th and 5th finger with associated weakness
What are the features of olecranon bursitis?
Swelling over posterior aspect of elbow
May be pain, warmth, erythema
What kind of injuries tend to lead to AC joint injury?
Collison sports, e.g. rugby
Fall on outstretched hand
How are AC injuries graded?
I-VI
How are AC injuries grade I-II managed?
Conservatively - rest + sling
What grades of AC injury require surgical intervention?
IV, V, VI
How are grade III AC injuries managed?
Depends on individual circumstances
What is the stimson maneuver?
Used for reduction of dislocated shoulders
What will you see on X-ray in compartment syndrome?
Typically no pathology
What sorts of people may get compartment syndrome without having had a fracture?
Those who intensively exercise
Those with bleeding disorders, e.g. haemophilia
Why is subluxation of the radial head more common in young children?
Distal attachment of the annular ligament covering the radial head is weaker in children
What are signs of subluxation of the radial head?
Elbow pain, limited supination, extension of the elbow
Child usually refuses examination
How is subluxation of the radial head managed?
Analgesia + passively supination of the elbow joint whilst elbow is flexed to 90 degrees
What is lumbar spinal stenosis?
When the central canal is narrowed by a tumour, disc prolapse or degenerative changes
How do patients with lumbar spinal stenosis present?
Back pain, neuropathic pain, claudication type symptoms
How can you distinguish the claudication from lumbar spinal stenosis from vascular claudication?
Sitting is better than standing
Easier to walk uphill/ride a bike
What is the most common cause of lumbar spinal stenosis?
Degenerative disease
Where is degeneration thought to start in lumbar spinal stenosis?
IV disc - biochemical changes, e.g. cell death + loss of proteoglycan + water content –> progressive disc bulging and collapse
–> increased stress on posterior facets which accelerates cartilaginous degeneration, hypertrophy + osteophyte formation, this is associated with thickening + distortion of the ligamentum flavum
What things narrow the central canal in lumbar spinal stenosis?
Ventral disc bulging
Osteophyte formation at dorsal facet
Ligamentum flavum hypertrophy
What does central canal narrowing mean?
Less space for neurons
What nerves are compressed in lumbar spinal stenosis?
Cauda equina nerve roots
What is the best imaging to see lumbar spinal stenosis?
MRI
How is lumbar spinal stenosis managed?
Laminectomy
What are the features of cauda equina syndrome?
Lower back pain
Urinary incontinence/retention
Reduced perianal sensation (saddle anaesthesia)
Decreased anal tone
How is cauda equina syndrome investigated?
Urgent MRI lumbar-sacral spine
How quickly should someone with suspected cauda equina syndrome be imaged?
ASAP
Target within 6h
What are the complications of cauda equina syndrome?
Incontinence
Paralysis of lower limbs
What is the other name for Charcot joint?
Neuropathic joint
What is Charcot joint?
A joint that has become badly disrupted and damaged secondary to a loss of sensation
What used to be the commonest cause of Charcot joint?
Syphilis (tabes dorsalis)
What is now the commonest cause of Charcot joint?
Diabetic neuropathy
What are the features of Charcot joint?
A joint that is a lot less painful that expected given degree of joint disruption
Joint is swollen, red, warm
What other neuropathy commonly predisposes to charcot joint?
Alcoholic neuropathy
Why do are charcot joints so disrupted and a mess?
It is on a weight bearing joint and individual cannot feel pain from damage so continues to walk on joint and make it worse
What are the cardinal features of epidural abscess?
Fever
Back pain
What is De Quervain’s tenosynovitis?
Inflammation of the sheath containing the extensor pollicis brevis + abductor pollicis longus tendon
Who does De Quervain’s tenosynovitis tend to affect?
Women from 30-50ys
What are the features of De Quervain’s tenosynovitis?
Pain on radial side of wrist
Tenderness of radial styloid
Abduction of thumb against resistance is sore
+ve Finklestein’s test
How do you carry out Finklestein’s test?
Pull thumb whilst in ulnar deviation + longitudinal traction
This causes pain over radial styloid process + along length of EPB + APL
How do you manage De Quervain’s tenosynovitis?
Analgesia
Steroid injection
Thumb splint
Surgery
What muscles are in the anterior compartment of the leg?
Tibialis anterior
Extensor digitorum longus
Peroneus tertius
Extensor hallucis longus
What nerve innervates the anterior compartment of the leg?
Deep peroneal nerve
What is the action of the tibialis anterior?
Dorsiflexes ankle joint, inverts foot
What is the action of extensor digitorum longus?
Extends lateral 4 toes, dorsiflexes ankle joint
What is the action of peroneus tertius?
Dorsiflexes ankle, everts foot
What is the action of extensor hallucis longus?
Dorsiflexes ankle, extends big toe
What are the muscles of the lateral compartment of the leg?
Peroneus longus
Peroneus brevis
What nerve innervates the lateral compartment of the leg?
Superficial peroneal nerve
What is the action of the peroneus longus?
Everts foot, assists in plantarflexion
What is the action of the peroneus brevis?
Plantaflexes ankle
What are the muscles of the superficial posterior compartment of the leg?
Gastrocnemius
Soleus
What nerve innervates the posterior compartment of the leg?
Tibial nerve
What is the action of the gastrocnemius?
Plantarflexes foot, flexes knee
What is the action of soleus?
Plantarflexor
What are the muscles of the deep compartment of the leg?
Flexor digitorum longus
Flexor hallucis longus
Tibialis posterior
What is the action of flexor digitorum longus?
Flexes lateral four toes
What is the action of flexor hallucis longus?
Flexes great toe
What is the action of tibialis posterior?
Plantarflexes, inverts foot
What nerve is most likely to be damaged if an individual develops foot drop after a revision of a total hip replacement?
Sciatic
What is the most common cause of cauda equina syndrome?
Herniation of an IV disc
What are other causes of cauda equina syndrome?
Tumours
Infection (e.g. epidural abscess)
Haematoma
Who can be assessed using the FRAX tool?
40-90 year olds with or without a BMD
What tools do NICE recommend for assessing risk of fragility fractures?
QFracture, FRAX
Who should be assessed for risk of fragility fractures?
All women 65+ and all men 75+ Younger pts if they have: - Had a prev. fragility fracture - Hx of falls - Current/frequent recent uses of oral/systemic glucocorticoids - FH hip fracture - Other 2ndary causes of osteoporosis - BMI <18.5 - Smoking - Alcohol intake >14u/w
What do FRAX and Qfracture assess?
Risk of fragility fracture in the next ten years
Which of QFracture and FRAX are based on UK and which is based on international data?
QFracture = UK FRAX = international
What factors does FRAX assess?
Age Sex Wt Ht Prev. fracture Parental fracture Current smoking Glucocorticoids RA Secondary osteoporosis Alcohol intake BMD optional
What score of FRAX should prompt you to arrange a DEXA scan?
Intermediate
What age groups can QFracture be used for?
30-99
What things are included in the QFracture risk factors?
CV dx Hx falls Chronic liver disease RA T2DM TCAs
In which situations should you go straight to a DEXA scan and miss out FRAX/QFracture?
Before starting medications that may have a rapid adverse effect on BMD
In those <40 who have a major risk factors
What major risk factors may make you go straight to giving someone a DEXA scan if they are <40?
Hx of multiple fragility fractures
Major osteoporotic fracture
Current/recent use of high dose oral/system glucocorticoids
What treatments may have a rapid adverse effect on BMD?
Sex hormone deprivation for breast cancer/prostate Rx
What scores can you get from doing a FRAX without a BMD what scores can you get and what do these mean?
Low risk - reassure + lifestyle advice
Intermediate risk - offer BMD test
High risk - offer bone protection treatment
What scores can you get from doing a FRAX with a BMD what scores can you get and what do these mean?
Reassure
Consider treatment
Strongly recommend treatment
What kind of results does QFracture produce?
Raw data which then needs interpreted alongside guidelines
When should we reassess risk of fragility fracture (i.e. repeat FRAX/QFracture)?
If original risk was in the region of intervention threshold for a proposed treatment and only after a min of 2y or there has been a chance in someone’s RFs
what group of drugs will worsen compartment syndrome?
Anticoagulants
What are the three things that can cause a fracture?
Trauma - excessive force to bone
Stress related
Pathological
What is a pathological fracture?
Abnormal bone that fractures during normal use or following minimum trauma
What causes stress fractures?
Repetitive low velocity injury
What should you ensure to do when examining a fracture site?
Check site + type of injury
Check for assoc. injuries and distal NV deficits
May have to radiograph proximal + distal joints
What is an oblique fracture?
Fracture that lies obliquely to long axis of bone
What is a comminuted fracture?
> 2 fragments
What is a segmental fracture?
More than one fracture along a bone
What is a transverse fracture?
Perpendicular to long axis of bone
What is a spiral fracture?
Severe oblique fracture with rotation along long axis of bone
What are the key points about managing fractures?
Immobilise fracture including joint above + below
Monitor NV status
Tetanus prophylaxis
IV antibiotics if open
How quickly should open fractures be debrided and lavaged?
6h of injury
What are the types of paediatric fractures?
Complete fracture Toddler's fracture Plastic deformity Greenstick fracture Buckle fracture Growth plate fractures
What is a complete fracture?
Both sides of cortex are breached
What is a toddler’s fracture?
Oblique tibial fracture in infants
What is a plastic deformity?
Stress on bone resulting in deformity without cortical disruption
What is a greenstick fracture?
Unilateral cortical breach only
What is a buckle fracture?
Incomplete cortical disruption leading to a periosteal haematoma only
What system is used to classify growth plate fractures?
Salter-Harris
What is the salter-harris classification?
I - fracture through physis only
II - fracture through physis and metaphysis
III - fracture through physis + epiphysis to include joint
IV - fracture involving physis, metaphysis + epiphysis
V - crush injury involving physis
What do SH type 1 fractures look like on X-ray?
Often look normal (same with V)
If you get growth plate tenderness but a normal x-ray what is it best to assume it is?
Still safer to assume it is an underlying fracture
How do you manage SH type III, IV and V fractures?
Surgery
What are type V SH fractures associated with?
Disruption to growth
What things may be indicative of NAI?
Delayed presentation Delay in attaining milestones Lack of concordance with proposed and actual mechanism of injury Multiple injuries Sites not commonly exposed to trauma Child on at risk register
What causes OI?
Defective osteoid formation due to congenital inability to provide adequate intracellular materials, e.g. osteoid, collagen, dentine
OI is due to a failure of ______ maturation in all the connective tissues.
Collagen
What might you see on radiology in OI?
Translucent bones, multiple fractures, esp. in long bones
Wormian bones
Trefoil pelvis
What is wormian bones?
Irregular patches of ossification
What are the types of OI?
I-IV
What is type I OI?
Collagen is normal quality but insufficient
What is type II OI?
Poor collagen quantity and quality
What is type III OI?
Collagen poorly formed but normal quantity
What is type IV OI?
Sufficient collagen quantity but poor quality
What is osteopetrosis?
Bones are harder and more dense
How is osteopetrosis inherited?
AD
Who is osteopetrosis most common in?
Young adults
What do you see on radiology in osteopetrosis?
Lack of differentiation between cortex and medulla described as marble bone
What is talipes quinovarus?
Club foot
Inverted + plantarflexed foot
Where is club foot normally picked up?
On newborn Ex
In which gender is club foot more common?
Males
What % of cases of club foot are bilateral?
50%
What are most cases of clubfoot associated with?
They are idiopathic!
What are some associations of club foot?
Spina bifida Cerebral palsy Edwards syndrome oligohydramnios Arthrogryposis
How is club foot diagnosed?
Clinically
How is club foot managed?
Ponseti method mostly
surgery
Night time braces until 4yo
What does the Ponseti method involve?
Manipulation and progressive casting starting soon after birth
How long does it take the Ponseti method to work usually?
6-10w
What is needed in 85% cases of club foot if using the ponseti method to treat it?
Achilles tenotomy
What causes the majority of lower back pain?
Non-specific muscular nature
What are red flags for lower back pain?
age < 20 years or > 50 years history of previous malignancy night pain history of trauma systemically unwell e.g. weight loss, fever
What are the features of facet joint lower back pain?
Pain worse in morning + on standing
OE pain over facets
Pain worse on extension of back
What are the features of spinal stenosis?
Gradual onset of unilateral/bilateral leg pain +/- back pain, numbness, weakness
Worse on walking, better when sitting
Ex usually normal
How does AS tend to present?
Young man with lower back pain and stiffness which is worse in the morning and improves with activity
35% have peripheral arthritis
Compression of what nerve causes carpal tunnel syndrome?
Median nerve
What is a typical hx of someone with carpal tunnel syndrome?
Pins + needles/pain in thumb, index + middle finger
Pt shakes hand to obtain relief, classically at night
What might you find on Ex of someone with CTS?
Weakness of thumb abduction (APB)
Wasting of thenar eminence
+ve Tinel’s + Phalen’s sign
What are causes of CTS?
Idiopathic Pregnancy Oedema, e.g. heart failure Lunate fracture RA
What do you see on electrophysiology in CTS?
Motor + sensory: prolongation of the AP
What is the treatment of CTS?
Corticosteroid injection
Wrist splints at night
Surgical decompression
What does surgical decompression for CTS involve?
Flexor retinaculum division
What is a colles’ fracture?
- transverse fracture of radius
- 1 inch proximal to radio-carpal joint
- dorsal displacement and agulation
What tends to cause a Colles’ fracture?
FOOSH
What causes a Smith fracture?
Falling backwards onto the palm of an outstretched hand or falling ith wrists flexed
What is a Smith’s fracture?
Volar angulation of distal radius fragment
What is the deformity called in a colle’s fracture?
Dinner fork deformity
What is the deformity called in a smiths fracture?
Garden spade deformity
What is a Bennett;s fracture?
IA fracture of the first carpometacarpal joint
What tends to cause a Bennett’s fracture?
Impact on flexed metacarpal, caused by fist fights
What can you see on X-ray in a Bennett’s fracture?
Triangular fragment at ulnar base of metacarpal
What is a Monteggia’s fracture?
Dislocaton of the proximal radioulnar joint in association with an ulna fracture
What causes a Monteggia’s fracture?
FOOSH with force pronation
Why does Monteggia fractures need prompt diagnosis?
To avoid disability
What is a Galeazzi fracture?
Radial shaft fracture with associated dislocation of the distal radioulnar joint
What causes a Galeazzi fracture?
Direct blow
What is a Pott’s fracture?
Bimalleolar ankle fracture
What causes a Pott’s fracture?
Forced foot eversion
What is a Barton’s fracture?
Distal radius fractures (colles’/smith’s) + assoc. radiocarpal dislocation
What causes a Barton’s fracture?
Fall onto extended and pronated wrist
What is osteomyelitis?
Infection of bone
What is the most common cause of osteomyelitis in most pts?
Staph aureus
What is the most common cause of osteomyelitis in pts with sickle cell anaemia?
Salmonella spp.
What conditions predispose to OM?
DM Sickle cell anaemia IVDA Immunosupressed (e.g. meds/HIV) Alcohol excess
What is the imaging modality of choice in investigating suspected OM?
MRI
What is the management of OM?
IV flucloxacillin for 6w
Clindamycin if penicillin allergic
Where is the most common place for children to get OM and why?
Metaphysis of long bones (as this is highly vascular and OM tends to spread haematongeously)
Where is the most common place for adults to get OM?
Epiphysis
What analgesics should be recommended for non-specific lower back pain?
Paracetamol, ibruprofen
Codeine if have CDK
What features do you get in a dorsal column lesion?
Loss of vibration + proprioception
Tabes dorsalis, SACD
What features do you get in a spinothalamic lesion?
Loss of pain, sensation and temperature
What features do you get in a central cord lesion?
Flaccid paralysis of upper limbs
What organism tends to cause OM in IVDAs?
Staph aureus
What organism tends to cause OM in those who are immunocompromised?
Funguses
What organism tends to cause OM in the thoracic region?
TB
What are the features of spinal cord infarction?
Dorsal column signs (loss of proprioception + fine discrimination)
What features do uou get in cord compression?
UMN signs
What tends to cause brown sequard syndrome?
Hemisection of the cord
What features do you get in brown sequard syndrome?
Ipsilateral paralysis
Ipsilateral loss of proprioception + fine discrimination
Contralateral loss of pain + temperature
What myotome is responsible for elbow flexion (biceps)?
C5
What myotome is responsible for wrist extension?
C6
What myotome is responsible for elbow extension (triceps)?
C7
What myotome is responsible for long finger flexors?
C8
What myotome is responsible for small finger abductors?
T1
What myotome is responsible for hip flexors (psoas)?
L1 + L2
What myotome is responsible for knee extensors (quadriceps)?
L3
What myotome is responsible for ankle dorsiflexors (tibialis anterior)?
L4 + L5
What myotome is responsible for toe extensors (hallucis longus)?
L5
What myotome is responsible for ankle plantarflexors (gastroc)?
S1
What is the anal sphincter innervated by?
S2-4
What investigation is required for diagnosis of spinal stenosis?
MRI
What is cervical spondylosis?
A very common condition that results from OA
How does cervical spondylosis tend to present?
As neck pain although referred pain may mimic headaches
What are complications of cervical spondylosis?
Radiculopathy
Myelopathy
Radiculopathy follows a _____ distribution
Dermatomal
What are the disorders affecting the Achilles tendon?
Tendinopathy
Partial tear
Complete rupture
What are risk factors for achilles tendon disorders?
Quinolone use
Hypercholesterolaemia (predisposes to tendon xanthomata)
What are features of achilles tedinopathy?
Gradual onset posterior heel pain, worse following activity
Morning pain + stiffness
What is the management of achilles tendinopathy?
Analgesia
Reduction in precipitating activities
What are the features of Achilles tendon rupture?
Audible pop in ankle/sudden onset of calf/ankle pain whilst running/playing sport + unable to walk/continue sport after
What triad is used to exclude achilles tendon rupture?
Simmonds triad
What is Simmonds triad?
Altered angle of dangle
Palpable/visible gap
+ve Thompsons test
What is the management of an acute achilles tendon rupture?
Acute referral to ortho specialist
What are the features of a respiratory fat embolism?
Early persistent tachycardia
Tachypnoea, dyspnoea, hypoxia 72h following injury
Pyrexia
What are the features of a dermatological fat embolism?
Red/brown impalpable petechial rash
Subconjunctival/oral haemorrhage/petechiae
What are the features of a CNS fat embolism?
Confusion + agitation
Retinal haemorrhages + intra-arterial fat globules on fundoscopy
How should you manage a fat embolism?
Prompt fixation of long bone fractures
DVT prophylaxis General supportive care
What is a risk factor for fat embolism?
Recent fracture
What is the pathophysiology of Paget’s disease?
Focal resportion followed by excessive + chaotic bone deposition
Where does Paget’s affect the most?
In order@
Spine, skull, pelvis, femur
What blood marker is raised in Paget’s?
ALP
What do you see on X-ray in Paget’s?
Abnormal thickened, sclerotic bone
There is a risk of cardiac failure if there is >…% of bony involvement in Paget’s?
15
What is there a small risk of in Paget’s disease?
Sarcomatous change
What is the pathophysiology of osteoporosis?
Excessive bone resportion –> demineralised bone
What are the symptoms of osteoporosis?
Asymptomatic, just greater risk of fracture
How can secondary bone tumours damage bone?
Bone destruction and tumour infiltration can occur
What scoring system is used to predict risk of fracture in secondary bone tumours?
Mirel
What tends to cause sclerotic secondary bone tumours?
Prostate cancer
What tends to cause lytic secondary bone tumours?
Breast
How are serum calcium, ALP levels affected by a secondary bone tumour?
Raised
How is Paget’s disease managed?
Bisphosphonates
How is osteoporosis managed?
Bisphosphonates, Ca, Vit D
How are secondary bone tumours managed?
Radiotherapy
Prophylactic fixation
Analgesia
What kind of injury is an ACL rupture?
Sports injury
What mechanism tends to cause an ACL?
High twisting force applied to a bent knee
How does ACL rupture tend to present?
Loud pop, pain, RAPID joint swelling (haemoarthrosis)
How is ACL rupture managed?
Intense physio
Surgery
What kind of mechanism causes PCL rupture?
Hyperextensive injuries (e.g. knee hitting dashboard)
What are signs of PCL rupture?
TIbia lies on back of femur
Paradoxical anterior draw test
What is the mechanism of MCL rupture?
Leg forced into valgus via force outside the leg
What are signs of MCL rupture?
Knee unstable when put into valgus
What kind of injuries tend to cause meniscal tear?
Rotational sport injuries
What are the features of meniscal tear?
Joint locking
Delayed knee swelling
Recurrent episodes of pain + effusion (often following minor trauma) are common
What is the typical history of chondromalacia patellae?
Teenage girl following injury to the knee, e.g. patellar dislocation
hx of pain on going downstairs/at rest
Tenderness, quadricep wasting
What can cause a dislocated patella?
Trauma -
Direct trauma
Severe contraction of quadriceps with knee stretched in valgus + external rotation
What are risk factors for dislocated patella?
Genu valgus
Tibial torsion
High riding patella
What type of imaging is required for a patellar dislocation?
Skyline x-ray
What kind of fracture is present in %% of dislocated knees?
Osteochondral fracture
What are the two types of fractured patella?
Direct blow to patella –> undisplaced fragments
Avulsion fracture
Who do tibial plateau fractures tend to occur in?
Elderly or following significant trauma in the young
What is the mechanism that causes a tibial plateau fracture?
Knee forced into valgus/varus, but knee fractures before ligament rupture
Varus injury affects the _____ plateau, and valgus injury affects the _____ plateau.
Medial
Lateral
What system is used for classifying tibial plateau fractures?
Schatzker
Where does OA most commonly affect?
Knee then hip
What are risk factors for OA of the hip?
Increasing age
Female gender
Obesity
DDH
What are features of OA hip?
Chronic hx groin ache following exercise + relieved by rest
What are red flags that may suggest an alternative diagnosis from hip OA?
Rest pain
Night pain
Morning stiffness >2h
What score is used to assess OA hip severity?
Oxford hip score
What investigations are required for suspected OA hip?
If typical features - clinical diagnosis can be made
Otherwise X-ray first line
What is the management of hip OA?
Oral analgesia
IA injections
TRH is definitive Rx
How do IA injections help in hip OA?
Provide short term benefit
What are complications of THR?
VTE
Intraoperative fracture
Nerve injury
What are reasons for revising a total hip replacement?
Aseptic loosening (most common cause)
Pain
Dislocation
Infection
What is Leriche syndrome?
Atheromatous disease affecting the iliac vessels meaning blood flow to the pelvic viscera is compromised
How do patients with Leriche syndrome tend to present?
Buttock + thigh claudication, impotence, atrophy of the musculature of legs
What is involved in the diagnostic workup for Leriche syndrome?
Angiography
How is Leriche syndrome treated?
Iliac occlusions can sometimes be treated with endovascular angioplasty + stent insertion
Management of RFs (e.g. hypercholesterolaemia, stop smoking)
What diseases are encompassed with rotator cuff injury?
Subacromial impingement (aka. painful arc syndrome) Calcific tendonitis Rottor
What diseases are encompassed with rotator cuff injury?
Subacromial impingement (aka. painful arc syndrome)
Calcific tendonitis
Rotator cuff tears
Rotator cuff arthropathy
What are symptoms of rotator cuff injury?
Shoulder pain worse on abduction
What are signs of rotator cuff injuries?
Painful arc of abduction (60-120d) - subacromial impingement
With rotator cuff may be pain in first 60d + weakness/muscle wasting
Tenderness over ant. acromion
What can cause a rotator cuff tear?
Trauma
Chronic impingement
How can you differentiate between a rotator cuff tear and impingement?
Get muscle weakness in rotator cuff injury
How can you differentiate between a medial meniscal tear and a lateral meniscal tear?
Medial - tenderness over medial joint line and vice versa
What is the commonest cause of heel pain in adults?
Plantar fasciitis
Where is the pain usually worst in plantar fasciits?
Medial calcaneal tuberosity
How do you manage plantar fasciitis?
Rest feet where possible Manage RFs, incl wt loss Stretching Where shoes with good arch support + cushioned heels Insoles/heel pads
What exacerbates the heel pain seen in planar fasciitis?
Walking on tips of toes
Where is the pain in achilles tendonitis?
Calcneal insertion or further up tendon
What mechanism of injury tends to cause a scaphoid fracture?
FOOSH
Contact sports, e.g. football
RTA due to pt holding steering wheel
What is the blood supply of the scaphoid?
80% from dorsal carpal branch (branch of radial artery) in retrograde manner
Interruption of the blood supply to the scaphoid can lead to what?
Avascular necrosis of the head of the scaphoid
How do pts with scaphoid fracture tend to present?
Pain along the radial aspect of wrist + base of thumb
Loss of grip/pincer strength
What are signs of scaphoid fracture?
Point of maximal tenderness over anatomical snuffbox Wrist joint effusion (if acute injury) Pain elicited by telescoping thumb Tenderness on scaphoid tubercle Pain on ulna deviation of wrist
What investigations should be arranged for suspected scaphoid fracture?
X-rays in AP + lateral
Repeat X-ray in 2w if inconclusive but clinical features strongly suggest scaphoid fracture/scaphoid fracture diagnosed
When might a CT be done for scaphoid fracture?
If planning surgery or determining extent of fracture union in follow up
What is avascular necrosis?
Death of bone tissue secondary to loss of blood supply –> bone destruction + loss of joint function
Where does avascular necrosis tend to affect?
Epiphysis of long bones, e.g. femur
What can cause AVN of the hip?
Long term steroid use
Chemotherapy
Alcohol xs
Trauma
What are features of AVN of hip?
Initially asymptomatic
Then pain in affected joint
What are early signs of AVN of hip?
Osteopenia + microfractures
Collapse of articular surface may –> crescent sign
What is the investigation of choice in suspected AVN hip?
MRI
What is the management of AVN of hip?
Joint replacement may be req.
What is an effective method of analgesia for neck of femur fracture?
Iliofascial nerve block is first line
What do stress fractures result from?
Repetitive activity + loading of normal bone
How are stress fractures managed?
May need immobilisation only if severely painful and presenting at an earlier stage where this may be beneficial
What are features of OA of the knee?
Pain may be severe
Intermittent swelling, crepitus + limitation of movement
What kinds of pts tend to get OA of the knee?
> 50s, often overwt
What is associated with infrapatellar bursitis?
Kneeling
What is associated with prepatellar bursitis?
Upright kneeling
What test is +ve in ACL rupture?
Draw test
What are features of collateral ligament damage?
Tenderness over affected ligament
Knee effusion may be seen
What conditions predispose to a baker’s cyst?
Gout
Arthritis
What is Foucher’s sign?
Increase in tension of a Baker’s cyst on extension of the knee
What is a straight leg raise test?
Raise leg while it is straight
If pain in distribution of sciatic nerve –> +ve
How should failed conservative management of plantar fasciitis be managed?
Refer to orthopaedics (cosnider surgery) and physio
What causes Duputyren’s contracture?
Hyperplasia and then contractures of the palmar aponeurosis
What does Duputyren’s contracture look like?
Fingers bend towards the palm and cannot be fully extended
Is Duputyren’s sore?
No not normally
Can Duputyren’s contracture progress?
It is normally progressive
How is CTS formally diagnosed?
Electrophysiological studies
What are non-surgical options for the management of CTS?
Splinting
Bracing
What are Osler’s nodes?
Deposition of immune complexes
What do Osler’s nodes present like?
Painful, red, raised lesions on the hands + feet
What are Bouchard’s nodes?
Hard, bony outgrowths or gelatinous cysts on the proximal IP joints
What causes Bouchard’s nodes?
OA
caused by formation of calcific spurs of the articular cartilage
How do Heberden’s nodes develop?
Chronic swelling of affected joint or sudden onset redness, numbness, loss of manual dexterity
Initial inflammation + pain subsides + pt left will permanent bony outgrowth that often skews the fingertip sideways
Where are ganglions usually found?
Back of hand
Wrist
How are ganglions managed?
Usually asymptomatic + disappear after a few months but if troublesome can be excised
What are ganglions?
Swellings in association with a tendon sheath (usually near a joint)
What fluid are ganglions filled with?
Fluid similar to synovial fluid
What are the nerve roots of the musculocutaneous nerve?
C5-7
What is the motor supply of the musculocutaneous nerve?
Elbow flexion + supination
What is the sensory supply of the musculocutaneous nerve?
Lateral part of forearm
What are the nerve roots of the axillary nerve?
C5-6
What is the motor supply of the axillary nerve?
Shoulder abduction (deltoid)
What is the sensory supply of the axillary nerve?
Regimental badge region
What are the nerve roots of the radial nerve?
C5-8
What is the motor supply of the radial nerve?
Extension (forearm, wrist, fingers, thumb)
What is the sensory supply of the radial nerve?
Small area between dorsal aspect of the 1st and 2nd metacarpals
What are the nerve roots of the median nerve?
C6, C8, T1
What is the motor supply of the median nerve?
LOAF muscles
What is the sensory supply of the median nerve?
Palmar aspect of lateral 3.5 fingers
What does the ulnar nerve supply?
Intrinsic hand muscles expect LOAF
Wrist flexion
What is the sensory supply of the ulnar nerve?
Medial 1.5 fingers
What is the motor supply of the long thoracic nerve?
C5-7
What sort of things may cause damage to the long thoracic nerve?
Blow to ribs
Complication of mastectomy
What sign does damaged long thoracic nerve lead to?
Winging of scapula
What sort of thing can lead to damage of the ulnar nerve?
Medial epicondyle fracture
What deformity can damage to the ulnar nerve lead to?
Claw hand
What fracture can damage the radial nerve?
Humeral midshaft fracture
What do you get in radial nerve palsy?
Wrist drop
What sort of injuries can cause axillary nerve palsy?
Humeral neck fracture/dislocation
What sign do you get in axillary nerve damage?
Flattened deltoid
What features do you get if the median nerve is damage at the wrist?
Paralysis of thenar muscles, opponens pollicis
What features do you get if the median nerve is damaged at the elbow?
Loss of pronation of forearm and weak wrist flexion
What is Erb-Duchenne palsy due to?
Damage to upper trunk of brachial plexus (C5, 6)
What commonly causes Erb-Duchenne palsy?
Shoulder dystocia at birth
What does Erb-Duchenne palsy look like?
Arm hands by side, and is internally rotated, elbow extended
What is Klumpke paralysis due to?
Damage to lower trunk of brachial plexus (C8, T1)
What may cause Klumpke paralysis?
Shoulder dystocia, sudden upward jerk of hand
What condition is Klumpke paralysis associated with?
Horner’s syndrome
What are the LOAF muscles?
Lateral two lumbricals
Opponens pollis
Abductor pollis brevis
Flexor pollis brevis
What is the bests imaging modality to diagnose a meniscal tear?
MRI
How do you investigate a suspected fractured hip?
X-ray
If occult - MRI
What are the clinical features of femoral nerve damage?
Weakness in knee extension, loss of patella reflex, numbness in thigh
What are the clinical features of lumbosacral nerve damage?
Weakness in ankle dorsiflexion, numbness of calf and foot
What are the features of sciatic nerve damage?
Weakness in knee flexion, foot movements, pain and numbness from gluteal region to ankle
What are the features of obturator nerve damage?
Weakness in hip adduction, numbness over medial thigh
What are sarcomas?
Malignant tumours of mesenchymal origin
What are the two types of sarcomas?
Bone
Soft tissue
What are the bone sarcomas?
Osteosarcoma
Ewings sarcoma
Chondrosarcoma
What cells do chondrosarcomas originate from?
Chondrocytes
What are types of soft tissue sarcomas?
Liposarcoma
Rhabdomyoarcoma
Leiomyosarcoma
Synovial sarcomas
What do liposarcomas originate from?
Adipocytes
What do rhabdomyosarcomas originate from?
Striated muscle
What do leiomyosarcomas originate from?
Smooth muscle
What do synovial sarcomas originate from?
Cell of origin unknown but not synovium
Lie close to joints
What sarcoma can arise in soft tissue and bone?
Malignant fibrous histiocytoma
What features of a mass/swelling should raise suspicion for a sarcoma?
Large >5cm soft tissue mass
Deep tissue location/intramuscular location
Rapid growth
Painful lump
How should you assess a suspected sarcoma?
MRI, CT, USS
Biopsy
Who typically gets Ewing’s sarcoma?
Males
10-20y
Where is the commonest site for a Ewing’s sarcoma?
Femoral diaphysis
What is Ewing’s sarcoma like histologically?
A small round tumour
How is Ewing’s sarcoma treated?
Chemo + surgery
How does Ewing’s sarcoma tend to spread?
Blood borne metastasis is common
What is an osteosarcoma?
Mesenchymal cells with osteoblastic differentiation
What age tend to get osteosarcomas?
15-30yos
How is osteosarcoma usually managed?
Surgery + chemo
Where are liposarcomas?
Tend to be deep locations, e.g. retroperitoneum
What age groups do liposarcomas tend to affect?
> 40s
Are liposarcomas aggressive?
Can be well differentiated + slow growing but may undergo de-differentiation + disease progression
What is the issue with doing surgery for liposarcomas?
Tumour may have a pseudocapsule that can be misleading as tumour may invade edge of pseudocapsule
What type of treatment is liposarcoma usually resistant to?
Radiotherapy
What is the most common sarcoma in adults?
Malignant fibrous histiocytoma
What are the four major subtypes of malignant fibrous histiocytoma?
Storiform-pleomorphic
Myxoid
Giant cell
Inflammatory
How is malignant fibrous histiocytoma usually managed?
Surgery + adjuvant radio
How should you manage a young person with an X-ray that could suggest bone sarcoma?
Very urgent referral to a specialist (<48h)
What is meralgia paraesthetica?
Paraesthesia/anaesthesia in distribution of the lateral femoral cutaneous nerve
What can cause meralgia paraesthetica?
Trapped LFCN
Iatrogenic after surgery
Neuroma
What segments does LFCN arise from?
L2/3
Where may the LFCN be subject to pressure or repetitive trauma?
Where it passes the ASIS
In which condition is meralgia paraesthetica more common?
Diabetes
What are RFs for meralgia paraesthetica?
Obesity
Pregnancy
tense ascites
Trauma
Iatrogenic, e.g. pelvic osteotomy, spinal surgery etc.
Various sports, e.g. gymnastics, bodybuilding
How does meralgia paraesthetica present?
Burning, tingling, coldness, shooting pain
Numbness
Deep muscle ache
What tends to aggravate symptoms in meralgia paraesthetica?
Standing
relieved by sitting
How can you often reproduce the symptoms of meralgia paraesthetica?
Deep palpation just below the ASIS + with extension of the hip
What is the motor deficit in meralgia paraesthetica?
There is no motor weakness
How is meralgia paraesthetica investigated?
Pelvic compression test v. sensitive
Injection of nerve with LA will abolish pain
US effective for diagnosis + guiding injections
Nerve conduction studies may be useful
Should you weight bear immediately after hip fracture surgery?
Yes
How do you perform McMurrays test?
Hold knee in one hand, which is placed along the joint line + flexed while the sole of the foot is held in the other hand
Pull knee towards a varus position whilst the other hand rotates the leg internally and extends the knee
If pain or click is felt –> +ve
What does +ve McMurray’s test indicate?
Meniscal tear
What are Kanavel’s signs of flexor tendon sheath infection?
Fixed flexion, fusiform swelling, tenderness + pain on passive extension
How is infective tenosynovitis managed?
Antibiotics + elevation if caught early
If not may need surgery
Where is the most common place to fracture the humerus?
Surgical neck
What kind of humeral fractures carry a risk of avascular necrosis to the humeral head?
Anatomical neck fractures which are displaced bby >1cm
What is the commonest pattern of humeral fracture in children?
Greenstick fracture throughsurgical neck
How are impacted fractures of the surgical neck of the humerus managed?
Collar + cuff for 3 weeks followed by physio
How are more significant displaced fractures of the humerus managed?
May need open reduction and fixation or use of an intramedullary device
What are the different types of shoulder dislocation and what is most common?
Glenohumeral dislocation (commonest)
Acromioclavicualr dislocation
Sternoclavicular dislocation
What is an acromioclavicular dislocation?
Clavicle loses all attachment with the scapula
What kind of glenohumeral dislocation is most common?
Anterior shoulder dislocation
What deformities do you see in anterior shoulder dislocation?
External rotation + abduction
What is anterior shoulder dislocation associated with?
Greater tuberosity fracture
Bankart lesion
Hill-Sachs defect
What three signs do you see on X-ray with a posterior shoulder dislocation?
Rim’s sign
Light bulb sig
Trough sign
How common are superior shoulder dislocations?
Rare, usually follow major trauma
How are shoulder dislocations managed?
Prompt reduction
What must you check pre and post-reduction in shoulder dislocations?
Neurovascular status
X-ray to ensure no fracture has occurred
In recurrent anterior dislocation there is usually what kind of lesion? How is this repaired?
Bankart lesion
Surgically
What kind of injury tends to cause an anterior shoulder dislocation?
Fall on arm/shoulder
What pulses/nerves should you especially check in anterior shoulder dislocation?
Axillary
What kind of things tends to ause posterior shoulder dislocation?
Seizures/electrocution
How should you manage suspected scaphoid fracture?
Refer to hospital for urgent ortho/ED review
What is Morton’s neuroma?
Benign neuroma affecting the intermetatarsal plantar nerve (most commonly in the 3rd intermetatarsophalangeal space)
What are the features of a Morton’s neuroma?
Forefoot pain (third intermetatarsophalangeal space) Worse on walking May be shooting/burning pain May feel like pebble in shoe May be distal loss of sensation in toes Mulder's click
How do you elicit Mulder’s click?
One hand squeezes the metatarsals together
Click may be heard as the neuroma moves between the metatarsal heads
How is Morton’s neuroma diagnosed?
Usually clinical
USS may help
How is Morton’s neuroma managed?
Avoid high heels
Metatarsal pads
Metatarsal dome orthotic
When should you refer for Morton’s neuroma?
If symptoms persist >3m despite footwear modifications + use of metatarsal pads
What are some secondary care options for treating Morton’s neuroma?
Corticosteroid injection
Neurectomy of involved interdigital nerve and neuroma
What are red flags for back pain?
Thoracic pain Age <20 or >55 years Non-mechanical pain Pain worse when supine Night pain Weight loss Pain associated with systemic illness Presence of neurological signs Past medical history of cancer or HIV Immunosuppression or steroid use IV drug use Structural deformity
What tests should those with red flags for back pain have?
ESR, FBC, Ca, Phosp, ALP, PSA
X-Ray
What kind of X-ray is needed to see the scaphoid?
Ulnar deviation AP
What tends to cause a radial head fracture?
FOOSH
What will you see OE in radial head fracture?
Tenderness over the head of the radius, impaired movements at the elbow, sharp pain at lateral side of elbow at extremes of rotation
What is the ulnar paradox?
Proximal lesions of the ulnar nerve produce a less prominent deformity than distal lesions
How should you manage children with an unexplained bone swelling/pain?
Very urgent X-ray to assess for bone sarcoma (<48h)
What is the initial imaging modality of choice for suspected Achilles tendon rupture?
USS
What is an iliopsoas abscess?
Collection of pus in the iliopsoas compartment
What is causes a primary iliopsoas abscess?
Haematogenous spread usually staph aureus
What can causes a secondary iliopsoas abscess?
Crohn's (commonest cause in this category) Diverticulitis, colorectal cancer UTI, GU cancers Vertebral osteomyelitis Femoral catheter, lithotripsy Endocarditis
What is the difference in prognosis between primary and secondary iliopsoas abscesses?
Primary has a much lower mortality
What are the clinical features of iliopsoas abscess?
Fever
Back/flank pain
Limp
Wt loss
What position do those with an iliopsoas abscess tend to lie in?
Supine with knee flexed and hip mildly externally rotated
What tests can you do to diagnose iliopsoas inflammation?
Put hand above pts ipsilateral knee and ask them to lift thigh against hand –> pain due to contraction of psoas
Lie pt on normal side and hyperextend affected hip –> pain as psoas is stretched
What is the gold standard imaging for iliopsoas abscess?
CT
How is iliopsoas abscess managed?
Antibx
Percutaneous drainage
Surgery if failure of percutaneous draining or presence of another intra-abdominal pathology req.s surgery
What is the medical term for joint replacement?
Arthoplasty
What is the most common type of hip replacement?
Cemented hip replacement
What pts may not want a cemented hip replacement?
Younger
More active pts
What other option is there for hip replacement?
Hip resurfacing
What do pts receive post-hip replacement?
Physio
Course of home exercises
Walking sticks/crutches to use for up to 6w post-hip or knee replacement
what basic advice should you give to those who have had a hip replacement to minimise the risk f dislocation?
Avoid flexing hip >90d
Avoid low chairs
Do not cross legs
Sleep on back for first 6w
What are complications of joint replacement?
Wound and joint infection
VTE
Dislocation
What is given to those undergoing a hip replacement to reduce the risk of VTE?
LMWH for 4w following operation
What nerve is most likely to be damaged during a knee arthroplasty?
Common peroneal nerve
What is thought to cause trigger finger?
Disparity between the size of the tendons and pulleys through which they pass, i.e. tendons become stuck and cannot pass smoothly through the pulley
What things are associated with trigger finger?
Being female
RA
DM
In which fingers is trigger finger most common?
Thumb, middle or ring finger
What are the features of trigger finger?
Initially stiffness + snapping when extending a flexed digit
Nodule may be felt at base of affected finger
What is the management of trigger finger?
Steroid injections + splinting
Surgery if this fails
