Orthopaedics Flashcards
L3 nerve root compression
Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
L4 nerve root compression
Sensory loss knee
Weak quadriceps
Reduced knee reflex
L5 nerve root compression
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
S1 nerve compression
Sensory loss lateral leg and lateral foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Types of hip replacement
Cemented hip replacement most common
Uncemented hip replacements in active patients
Advice for patients with hip replacements to avoid dislocation
Avoid flexing hip >90 degrees
Avoid low chairs
Do not cross legs
Sleep on back for first 6 weeks
Complications of joint replacement
Infection
Thromboembolism
Dislocation
How long do patients receive LMWH for after hip replacement?
4 weeks
Scoring systems to assess risk of fracture
FRAX
QFracture
What does the FRAX scoring system estimate?
10 year risk of fragility fracture
Who is FRAX valid for?
Patients age 40-90 years
Factors included in FRAX
age sex weight height previous fracture parental fracture smoking steroids RA secondary osteoporisis alcohol
What does QFracture estimate?
10 year risk of fragiity fracture
Who is QFracture valid for?
Age 30-99 years
Who should get a DEXA?
If FRAX is ‘intermediate”
If starting treatment with rapid effect on bone density
If <40 years and major risk factors
Who should be assessed for risk of fragility fracture?
Women over 65
Men over 75
Younger patients with risk factors
First line treatment for lower back pain
NSAIDs
+PPI if over 45
Who should get an MRI for their back pain?
Only if result will change management or red flags for malignancy, fracture, infection, ank spond or cauda equina
Features of acetabular labral tear
Hip/groin pain
Snapping sensation around hip
Occasional locking sensation
Associations with trigger finger
RA
Diabetes
Management of trigger finger
Steroid injection
Finger split
Surgery if no response to steroids
Investigations of Baker’s cysts
In children - ultrasound
What are myxoid cysts?
Benign ganglion cysts usually found on distal, dorsal aspect of the finger
What is associated with myxoid cysts?
Osteoarthritis
Causes of Dupuytren’s contracture
Manual labour Phenytoin Alcoholic liver disease Diabetes Trauma to hand
Ottawa rules for ankle injury
Pain in the malleolar zone AND
- bony tenderness at lateral malleolar
- bony tenderness at medial malleolar
- unable to walk 4 steps after injury and in the ED
What is a charcot joint?
Joint which has become badly disrupted and damaged secondary to a loss of sensation
Main cause of charcot joint
uncontrolled diabetes
Features of charcot joint
Joint pain
Joint is swollen, red and warm
Online risk stratification tool for lower back pain
StarT BACK
Test used for meniscal tear
Thessaly’s test
What is Thessaly’s test used for?
Meniscal tear
Features of meniscal tear
Pain worse on straining the knee
Knee may ‘give way’
Displaced meniscal tears may cause knee locking
Tenderness along joint line
Features of greater trochanteric pain syndrome
Pain over lateral side of hip/thigh
Tenderness on palpation of greater trochanter
Which nerve is compressed in carpal tunnel syndrome?
Median nerve
Causes of carpal tunnel syndrome
Idiopathic Pregnancy Oedema e.g. heart failure Lunate fracture Rheumatoid arthritis
History in carpal tunnel syndrome
Pain/paraesthesia in thumb, index, middle finger
Shakes hand at night to relieve pain
Examination findings in carpal tunnel syndrome
Weakness of thumb abduction
Wasting of thenar eminance
Tinel’s sign
Phalen’s sign
Describe Tinel’s sign
Tapping over wrist causes paraesthesia
Test for carpal tunnel syndrome
Describe Phalen’s sign
Flexion of wrist causes symptoms
Test for carpal tunnel syndrome
Management of carpal tunnel syndrome
Corticosteroid injection
Wrist splint at night
Surgery - flexor retinaculum division
Findings in talipes equinovarus
Inverted and plantar flexed foot
What percentage of talipes equinovarus are bilateral?
50%
Associations with talipes equinovarus
Spina bifida Cerebral palsy Edward's syndrome Oligohydramnios Arthrogryposis
Management of talipes equinovarus
Ponseti method
Manipulation and progressive casting from birth Corrected by 6-10 weeks May need achilles tenotomy Braces at night till age 4 15% relapse rate
Which nerve is compressed in cubital tunnel syndrome?
Ulnar nerve
Features of cubital tunnel syndrome
Paraesthesia of 4th and 5th finger
Weakness and muscle wasting
Pain worse on leaning on affected elbow
Risk factors for osteoporotic fractures
Advancing age Previous fragility fracture Steroid use Falls Family history of hip fracture Low BMI Smoking Alcohol history
Signs of osteoporotic vertebral fractures
Loss of height
Kyphosis
Localised tenderness
Investigations for osteoporotic vertebral fractures
Xray spine 1st line
CT spine
MRI to check for other causes e.g. tumour
DEXA scan
What percentage of frozen shoulder is bilateral?
20%
How long does frozen shoulder last?
6 months to 2 years
Features of frozen shoulder
Active and passive movement restricted
External rotation most affected
Features of intersection syndrome
Pain in distal forearm, 5-10cm proximal of wrist
Swelling and erythema
Who is affected by intersection syndrome?
Skiers
Tennis players
Weight lifters
Canoeists
What is intersection syndrome?
A tenosynivitis
Symptoms in forearm above wrist
Seen in sporty folk
Features of de Quervain’s tenosynovitis
Pain over radial side of wrist
Tenderness over radial styloid process
Abduction of thumb against resistance is painful
Finkelstein’s test
What is the test for de Quervain’s tenosynovitis
Finkelstein’s test
What does Finkelstein’s test test for?
De Quervain’s tenosynovitis
Malignant fibrous histiocytoma
May arise from soft tissue and bone
Most common sarcoma in adults
What is the most common cause of anterior heel pain?
Achilles tendon disorders
Risk factors for achilles tendon disorders
Quinolones (e.g. ciprofloxacin)
Hypercholesterolaemia causing tendon xanthomata
Features of achilles tendinopathy
Gradual onset posterior heel pain
Worse after activity
Morning pain and stiffness
Management of achilles tendinopathy
Simple analgesia
Reduce activities that trigger pain
Calf muscle eccentric exercises
History given in achilles tendon rupture
Sudden onset pain whilst playing sport
Audible pop
Can’t walk or continue exercise
Examination findings in achilles tendon rupture
Palpable gap
Simmonds triad
Investigations for achilles tendon rupture
Ultrasound
In a patient with possible hip OA, which red flags should make you reconsider?
Rest pain
Night pain
Morning stiffness >2 hours
Risk factors for hip OA
Increasing age
Female
Obesity
Developmental dysplasia of the hip
Reasons for total hip replacement revision
Aseptic loosening (most common)
Pain
Dislocation
Fracture
What is lumbar spinal stenosis?
Central canal narrowed by tumour, disc prolapse or other degenerative changes
Features of lumbar spinal stenosis
Back pain Neuropathic pain, sciatica Sitting relieves pain, sitting forward relieves pain Walking uphill easier than downhill Paraesthesia in leg Foot drop Sexual dysfunction
Investigations for lumbar spinal stenosis
MRI
Management of lumbar spinal stenosis
Laminectomy
Features of lateral epicondylitis
Pain and tenderness at lateral epicondyle
Pain worse on resisted wrist extension with elbow extended
Pain worse on supination of forearm with elbow extended
What is lateral epicondylitis also called?
Tennis elbow
Formal name for tennis elbow
Lateral epicondylitis
Features of medial epicondylitis
Pain and tenderness at medial epicondyle
Pain worse by wrist flexion and pronation
Paraesthesia of 4/5th finger due to ulnar nerve compression
What is medial epicondylitis also called?
Golfers elbow
Formal name for golfers elbow
Medial epicondylitis
Features of olecranon bursitis
Swelling over posterior aspect of elbow
Pain, warmth, erythema
Who usually gets olecranon bursitis?
Middle aged men
Radial tunnel syndrome features
Pain 4-5cm distal to lateral epicondyle
Worse on extending forearm and pronating forearm
Lower back pain - red flags
Age <20 or >50 history of malignancy night pain history of trauma systemically unwell (fever, weight loss)
When to refer a patient with sciatica?
consider MRI if persistent symptoms at 4-6 weeks
Management of lower back pain
Stay active
NSAIDS (+PPI if over 45)
Morton’s neuroma - features
Forefoot pain - shooting/burning, worse on walking
Mulder’s click
Loss of sensation distally in toes
What is Morton’s neuroma?
Benign neuroma affecting the intermetatarsal plantar nerve
Most common location of Morton’s neuroma
3rd inter-metatarsophalangeal space
Morton’s neuroma - diagnosis
Clinical
Ultrasound may be helpful
Morton’s neuroma - management in primary care
Avoid high heels
Metatarsal pad
Refer if symptoms >3 months despite these
Morton’s neuroma - management in secondary care
Metarsal dome orthotic
Corticosteroid injection
Neurectomy
Injury of which nerve causes foot drop?
Common peroneal nerve
Which area gets sensation from lateral cutaneous nerve of the thigh?
Lateral and posterior thigh
Origin of axillary nerve
C5, C6
Origin of median nerve
C6, C8, T1
Sensory supply of median nerve
Palmar aspect of lateral 3 1/2 fingers
Wrist lesion of median nerve presentation
Paralysis of thenar muscles and opponens pllicis
Carpal tunnel
Elbow lesion of median nerve presentation
Loss of pronation of forearm
Weak wrist flexion
Origin of ulnar nerve
C8, T1
Motor supply of ulnar nerve
Intrinsic hand muscles
Sensory supply of ulnar nerve
Medial 1 1/2 fingers
What nerve is injured in claw hand?
Ulnar nerve
How is the ulnar nerve commonly injured?
Medial epicondyl fracture
Origin of long thoracic nerve
C5-C7
Which muscle is innovated by the long thoracic nerve?
Serratus anterior
Causes of long thoracic nerve injury
Sports injury e.g. chest wall collision
Complication of mastectomy
What does damage to the long thoracic nerve result in?
Winged scapula
Origin of radial nerve
C5-C8
Motor function of radial nerve
Extension
Sensory supply of radial nerve
Dorsal aspect between 1st and 2nd metacarpals
Causes of injury to radial nerve
Humeral midshaft fracture
What does radial nerve injury result in?
Wrist drop
Origin of musculocutaneous nerve
C5-C7
Motor function of musculocutaneous nerve
Elbow flexion and supination
Sensory supply of musculocutaneous nerve
Lateral part of forearm
What is osteochondritis dissecans?
A small part of bone separates due to lack of blood supply
Causes fragmentation of articular surface and intraarticular loose bodies
Types of osteochondritis dissecans
Adult
Juvenile - when growth plate still open
Features of osteochondritis dissecans
Subacute onset Knee pain and swelling after exercise Knee catching and giving way "Clunk" when flexing/extending Joint effusion
Investigations of osteochondritis dissecans
Xray = subchondral crescent sign, loose bodies
MRI
Management of osteochondritis dissecans
Conservative = analgesia, immobilise, PT
Surgery
Osteoarthritis of the hand - xray findings
Osteophytes
Joint space narrowing
Osteoarthritis of the hand - features
Bilateral Carpometacarpal joints, DIP joints, PIP joint Heberden's nodes Bouchard's nodes Squaring of the thumb Episodic pain provoked by movement Stiffness after rest lasts minutes
What does Heberden’s nodes mean?
OA
What does Buchard’s nodes mean?
OA
Where are Heberden’s nodes found?
DIP
in OA
Where are Buchard’s nodes found?
PIP
in OA
What is meralgia paraesthetica?
Paraesthesia in distribution of lateral femoral cutaneous nerve
Meralgia paraesthetica - causes
Entrapment of nerve under inguinal ligament
Iatrogenic - after surgery
Idiopathic
Trauma
Neuroma
Meralgia paraesthetica - risk factors
Obesity Pregnancy Tense ascites Trauma Diabetes Sports = gymnastics, football, body building
Meralgia paraesthetica - features
Symptoms in upper lateral aspect of thigh
Burning, tinging, shooting pain, numbness
Deep muscle ache
Worse on standing better sitting
Reproduce symptoms by deep palpation below ASIS
Meralgia paraesthetica - investigations
Clinical diagnosis with pelvic compression test
Ultrasound
Injecting nerve with LA abolishes pain
Meralgia paraesthetica - management
Lose weight NSAIDS TENS Pregabalin Severe - decompressive surgery
