Orthopaedics Flashcards
What are some features of mechanical back pain?
Generally worsens with movement and prolonged standing
Better with rest, EMS < 30min
What are the most common areas of nerve impingement in the back?
L4/L5, L5/S1
What are some Red flags in lower back pain?
Saddle anaesthesia, reduced anal tone, hip or knee weakness, generalised neuro deficit, bladder and bowel dysfunction, progressive spinal deformit
Following sigificant trauma, immunocompromised/ DM/ HIV/ IV drug use, Hx of malignancy, thoracic back pain, non-mechanical (worse at night and on rest), systemic (fever, rigors, weight loss, malaise), recent significant infection
At what level does the spinal cord end?
L1/L2
What is a slipped upper femoral epiphysis?
Fracture through the femoral physis, causing the epiphysis to slip posteriorly and inferiorly
~10-16 year olds
How might someone with a slipped upper femoral epiphysis present?
Complaining of groin pain that goes down to thigh or knee
Limp, pain on movement especially internal rotation and reduced ROM, shortened and externally rotated hip, localised tenderness around the hip joint
What features on X-ray would you see in a SUFE?
Disruption of Shenton’s line
Disruption of Kleins line (trethowans sign)
Widening of physis and smaller looking epiphysis
Steel sign (shadow behind the superior femoral neck)
More prominent lesser trochanter due to being in ER
What are common areas affected by osteonecrosis?
Hip and shoulder
How might a patient with osteonecrosis present?
Pain
Groin pain worse with weight bearing and motion
Rest ± night pain
What are some risk factors for osteonecrosis?
Alcohol abuse, history of trauma, especially dislocation, sickle cell anaemia/ haemoglobinopathies, cushings disease or corticosteroid use
HIV, renal disease, SLE, bisphosphonates
What is the T score?
The number of SD below the mean someones BMD is compared to a young healthy adult’s BMD
-1- (-2.5) = osteopenia
What is the Z score?
The number of SD below the mean someones BMD is compared to the mean for their age
What management is available for osteoporosis?
Lifestyle measures
Vitamin D and calcium
Bisphosphonates * = Alendronate, risedronate, zolendronic acid
Calcitonin, Teriparatide
Denosumab, strontium ranelate, raloxifene
What is a Holstein-Lewis fracture?
Spiral fracture of the distal 1/3 of the humeral shaft with a radial nerve palsy
What is subacrominal impingement and how might it present?
Inflammation of the subacromial bursa
Insidious onset of shoulder pain, worse on overhead activities ± night pain
What examination findings would you see in subacromial impingement?
Painful arc - pain between 60 - 120 degress
Hawkins test - pain on passive forward flexion to 90 and internal rotation
Neer impingement sign - pain on passive forward flexion >90
What might you think of is someone complains of shoulder pain worse with overhead activities?
Rotator cuff injury such as a tear or subacromial impingement
What position may the arm sit in, in shoulder dislocation?
ER and abducted slightly
What is rickets and osteomalacia?
Defective bone mineralisation leading to soft bones
Rickets is before the growth plates fuse
What are some clinical features of rickets?
Genu varum
Richitic rosary
prominent frontal bone
Protruding abdomen
What are some clinical features of osteomalacia?
Diffuse bone and joint pain, increased risk of fractures, waddling gait
What structures pass through the carpal tunnel?
Median nerve
Flexor pollicus longus
4 x flexor digitorum superficialis
4 x flexor digitorum profundus
How might a patient with carpal tunnel syndrome present?
Nocturnal wakening with tingling (relieved by shaking hand)
Altered or reduced sensation in median nerve distribution
Wasting of thenar eminence, difficulty with pincer grip (picking things up), clumsiness
+ve tinel’s and phalen’s sign
Reduced/ weak thumb abduction
Where is the cubital tunnel?
Behind the medial epicondyle of the elbow, formed by the cubital retinaculum, between the 2 heads of the FCU
How might a patient with cubital tunnel syndrome present?
Nocturnal wakening with tingling in ulnar distribution Altered sensation Reduced power in finger abduction Claw posture if severe** \+ve Tinel's sign at elbow Hypothenar and interosseous wasting
In a major haemorrhage, how much blood can you lose into your long bones?
1.5L
In a major haemorrhage, how much blood can you lose into your pelvis?
Your whole circulating volume!
?Pelvic binder (apply to greater trochanters)
How might you manage a patient who has come in with an animal bite to their finger?
Check Neurovascular status and tendons (CRT, pulses, sensation, motor), tetanus status
Washout and debride!
PO augmentin (co-amox)
Review in 2-3d if it might need closure
How might you manage a patient who has come in with a human bite over his MCP joint*?
X-ray for teeth - high risk of septic arthritis Neurovascular exam and tendons Washout and debridement PO or IV Co-amoxiclav Consider and explain BBV risk
On an X-ray how might you tell if someone has had multiple shoulder subluxations?
Bankhart lesion - anterior glenoid labrum injury
Hill-sachs lesion - humeral head dip
What tests can you perform to test for subacromial impingement?
Painful arc test
Neers impingement sign - Pain on passive forward flexion >90
Hawkins test - pain on passive forward flexion to 90 and IR
What are the different types of hip fractures? (look up images)
Subcapital
Transcervical
Intertrocanteric
Subtrochanteric
Garden classification
What is the difference between a Monteggia and a Galeazzi fracture?
Monteggia - Proximal ulnar f# with proximal radioulnar joint instability
Galeazzi - Distal radial shaft f# with distal radioulnar joint instability
What causes trigger finger?
Constriction or thickening of the A1 pulley or nodules on the tendon
Finger stuck in flexion and painfully click on extension, worse in am
When would patients with a suspected disc prolapse get investigated with MRI?
> 6 weeks of radicular pain who have failed conservative therapy or patients who have developed a neurological deficit
Bilateral lower limb deficit or peroneal nerve injury sx - Urgent referral to on call ortho - rule out CES
What are some red flags in leg pain in children?
Pain that persists and gets progressively worse
Pain still there the next day
Deep boring pain that isnt helped by simple analgesia
Pain that keeps them awake at night, unremitting pain
Unilateral, same focus
Joint pain ± swelling (JIA)
Neurological sx
Systemic illness (fever, weight loss)
Loss or altered function*
Abnormal Ix or examination
What is the terrible triad in knee injuries?
Medial meniscus tear
Anterior cruciate ligament tear
Medial collateral ligamanet tear
(usually due to a lateral force)
What Plain film views do you need to diagnose SUFE?
Frog legged lateral and AP
A child presents with hip and groin pain, refusal to weight bear and a limp. On questioning you find out they have had a recent viral URTI*, what might they have?
Transient synovitis
If they have a fever - Urgent treatment for suspected septic arthritis - make sure you safety net about fever in transient synovitis!
What finding in a patients hx could help you differentiate between SUFE and perthes disease?
Hx of minor trauma = SUFE
No hx of trauma in perthes (AVN of femoral head - idiopathic)
What might Paget’s disease look like on X-ray?
Bone enlargement and deformity
“Osteoporosis circumscripta” describes well defined osteolytic lesions that appear less dense compared with normal bone
“Cotton wool appearance” of the skull describes poorly defined patchy areas of increased density (sclerosis) and decreased density (lysis)
“V-shaped defects”/ blade of grass: in the long bones are V shaped osteolytic bone lesions within the healthy bone
What is the MoA of bisphosphonates?
Reduce bone turnover, they accumulate in osteoclasts and cause they to apoptose
How do you take Alendronic acid?
Weekly
First thing in the morning, with nothing else (on en empty stomach), 30min before breakfast or any calcium/milk, sitting upright for 30min
What are some side effects of bisphosphonates?
ON of the jaw
Atypical femoral fractures (subtrochanteric)
Oesophagitis
Hypophosphataemia
How can you treat DDH in <6m?
Pavlik harness - flexed and abducted
How can you treat DDH in >6m?
Closed reduction or
?open reduction
Spica cast for 3m
What is the webers classification for ankle fractures? (A-C)
A - below the level of the syndesmosis
B - at the level of the syndesmosis
C - above the syndesmosis
What is the Ottawa rules for an ankle X-ray?
An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the following findings:
- bony tenderness at the lateral malleolar zone
- bony tenderness at the medial malleolar zone
- inability to walk four weight bearing steps immediately after the injury and in the emergency department
What injury to the knee swells up really quickly?
ACL - it is very vascular
