Orthopaedics Flashcards
What does the femoral nerve supply?
Motor = knee extension and thigh flexion
Sensory = anterior and medial aspect of thigh and lower leg
What is the most common indication for elective joint replacement?
Osteoarthritis
What are options for joint replacement?
Total joint replacement
Hemiarthroplasty
Partial joint resurfacing
What are complications of a hip replacement?
VTE
Fracture
Nerve injury
What are reasons for hip replacement revision?
Aseptic loosening (most common)
Infection
Dislocation
Pain
Which bones have a vulnerable blood supply?
Scaphoid
Femoral head
Humeral head
In the foot = talus, navicular, 5th metatarsal
What is a compound fracture?
The skin is broken and the broken bone is exposed to the air
What is a stable fracture?
The bone bone remains in alignment at the fracture
What is a pathological fracture?
Bone breaks due to an abnormality within the bone
Patient has fallen onto outstretched hand and now has tenderness in the anatomical snuffbox - what is this?
Scaphoid fracture
What is the risk of a scaphoid fracture?
Avascular necrosis due to the retrograde blood supply
What fracture causes a ‘dinner fork deformity’ of the hand?
Colle’s fracture (fracture of the distal radius)
Which classification is used to classify lateral malleolus fractures? How does this affect management?
Weber classification
Described in relation to the distal syndesmosis – fibrous join between the tibia and the fibula
Tibiofibular syndesmosis = very important for stability and function of ankle joint.
A = below ankle (will leave syndesmosis intact)
B = at level of ankle (syndesmosis may be intact or partially torn)
C = above ankle (syndesmosis will be disrupted)
If syndesmosis disrupted - surgery more likely to be needed
Which are the main cancers which metastasise to bone
PoRTaBLe
Prostate
Renal
Thyroid
Breast
Lung
What are complications of fractures?
Damage to local structures
Haemorrhage
Compartment syndrome
Fat embolism
Avascular necrosis
Infection
What is a fat embolism and how does it present?
Fat globules get released into the circulation following fracture of a long bone (e.g. femur)
Systemic inflammatory response - respiratory distress, petechial rash, cerebral involvement
Management is supportive
What are signs of a scaphoid fracture?
Tenderness over the anatomical snuffbox
Wrist joint effusion
Pain on ulnar deviation
Loss of grip/pinc strength
How can a scaphoid fracture be diagnosed?
MRI
How is a scaphoid fracture treated?
Initial management is to immobilise with a splint
Then..
Undisplaced = cast for 6-8 weeks
Displaced or in the scaphoid pole = surgical fixation required
After a fall on outstretched hands, the elbow is in a semi-flexed position with swelling - what is it?
Supracondylar fracture of the humerus
Sharp pain in elbow on pronation/supination after FOOSH - what is it ?
Radial head fracture
How is a rib fracture diagnosed?
CT chest
How is a rib fracture managed?
Conservatively with analgesia
Surgery if not healed by 12 weeks
What is a buckle fracture?
A type of fracture that occurs in children
One side of bone bends without breaking, forming a small buckle
What is a greenstick fracture?
Paediatric fracture
When only one side of the cortex is breached
What is a complete fracture?
Both sides of the cortex are breached
What are causes of pathological fractures in children?
Osteogenesis imperfecta
Osteopetrosis
What are risk factors for hip fractures?
Increasing age
Osteoporosis
Female
Prev fracture
parent w fracture
What are the two types of hip fractures? What are these in relation to?
In relation to the intertrochanteric line
Extracapsular (below the intertrochanteric line) –> This can be split into intertrochanteric and subtrochanteric
Intracapsular (above the intertrochanteric line)
Which type of hip fracture is more severe?
Intracapsular
How can we classify intracapsular hip fractures?
Garden classification
Type I = incomplete, non-displaced
Type II = complete, non-displaced
Type III = complete, partially displaced
Type IV = complete, completely displaced
How do you manage an intracapsular hip fracture? Displaced vs. non-displaced
Displaced = requires total hip arthroplasty or hemiarthroplasty
Non-displaced = internal fixation
What criteria does a patient need to meet for a total hip arthroplasty?
Able to walk independently
No cognitive impairment
Medically fit for procedure + anaesthesia
How is an extra capsular hip fracture managed?
Dynamic hip screw
How does a hip fracture present?
Pain in groin/hip
Pain may radiate to knee
Unable to weight bear
Shortened, abducted and externally rotated leg
What can you look for on pelvic x-ray to indicate a hip fracture?
Disruption of Shenton’s line
What are the two types of hip dislocation and how do they present?
Posterior hip dislocation = shortened, adducted, internally rotated
Anterior hip dislocation = abducted, externally rotated
What are complications of a hip dislocation?
Sciatic nerve injury
Avascular necrosis
Osteoarthritis
What are risk factors for avascular necrosis?
Long term steroid use
Chemotherapy
Alcohol excess
Trauma
What are signs of a vertebral fracture?
Loss of height
Kyphosis (curvature of spine)
Localised tenderness to palpation
What is seen on spinal X-ray in a vertebral fracture?
Wedging
What is compartment syndrome?
Complication that can occur following fractures/trauma
Causes increased pressure within the compartment which compromises tissue perfusion and leads to necrosis
What are the 2 main fractures that cause compartment syndrome?
Supracondylar fracture
Tibial shaft injuries
How does compartment syndrome present?
Disproportionate pain
Parasthaesia
Pallor
Pulses = present
Pulses may become absent in. later stages
How is compartment syndrome diagnosed?
Primarily clinical diagnosis
Needle manometry can show elevated intracompartmental pressure <40 = diagnostic
How is compartment syndrome managed?
Initial = elevate, remove any bandages
Emergency fasciomomy
What is the main acute complication of fasciotomy?
Myoglobinuria causing AKI
What is the most common mode of infection to bone in osteomyelitis?
Haematogenous - through the blood
Can also be via ulcer/fracture/surgery
What is the most common causative organism of osteomyelitis?
Staph aureus
What are risk factors for osteomyelitis?
Diabetes
Increasing age
Peripheral vascular disease
Immunocompromised
How does osteomyelitis present?
Fever
Pain
Signs of local inflammation - erythema, tenderness, swelling
May be some evidence of ulcer/skin break
How is osteomyelitis diagnosed?
If there is a wound can do a wound swab
MRI = diagnostic
What is seen on x-ray in osteomyelitis?
Periosteal reaction
Local osteopenia
Cortical loss
Bone lysis
How is osteomyelitis managed?
IV 6 week course of flucloxacillin
Clindamycin if pen-allergic
Which bone malignancy causes a sunburst appearance on x-ray?
Osteosarcoma
Which bone malignancy causes an onion skin appearance on x-ray?
Ewing’s sarcoma
Which bone malignancy causes a fluffy popcorn calcification appearance on x-ray?
Chondrosarcoma
How is mechanical back pain managed?
NSAIDs
Codeine
What is Sciatica and how does it present?
Pain caused by compression of sciatic nerve
Pain from button to back of thigh/knee
Shooting/electric pain
Paraesthesia
Numbness
Motor weakness
What are causes of sciatica?
Herniated disc
Spinal stenosis
Spondylolithesis
What should you consider in bilateral sciatica?
Cauda equina syndrome
How can the pain be managed in sciatica?
1st line = NSAIDs/Codeine
2nd line = Amitriptyline/Duloxetine
What is cauda equina syndrome?
A surgical emergency
Nerve roots of the cauda equina are compressed - emergency decompression required
What are causes of cauda equina syndrome?
Herniated disc
Tumour/metastases
Spondylolisthesis
Abscess
Trauma
What are red flag signs for cauda equina syndrome?
Saddle anaesthesia
Urinary/faecal incontinence
Bilateral sciatica
Bilateral motor weakness of the legs
Reduced anal tone on PR
Lower motor neurone signs = reduced tone, reduced reflexes
How does metastatic spinal cord compression present?
Similar to cauda equina
Worse on coughing/straining
What is spinal stenosis? What are the causes?
Narrowing of a part of the spinal canal - leads to compression of the spinal cord
Most commonly affects the lumbar spine
Causes = degenerative changes, herniated disc, spinal fractures
How does spinal stenosis present?
Depends on degree of narrowing
If severe - presents as cauda equina syndrome
Otherwise gradual onset of -
Intermittent neurogenic claudication
Lower back pain
Leg pain
Leg weakness
Problems absent at rest.
An ABPI should be conducted to rule out PAD
Bending forwards improves symptoms
Symptoms may be worse on walking downhill
Sitting is better than standing
What improves/worsens symptoms in spinal stenosis?
Flexing spine (bending forwards) improves symptoms
Standing straight worsens symptoms
Easier to walk downhill than uphill
How is spinal stenosis diagnosed?
MRI spine
How is spinal stenosis managed?
Laminectomy
What is meralgia paraesthetica?
Localised sensory symptoms on the outer thigh due to compression of the lateral femoral cutaneous nerve
How does meralgia paraesthetica present?
Abnormal sensation or loss of sensation in the outer upper thigh
May be burning/numbness/coldness
Symptoms worse on standing and better on sitting
What is trochanteric bursitis?
Inflammation of a bursa over the greater trochanter on the outer hip
Causes pain localised to the outer hip
What are causes of trochanteric bursitis?
Friction
Trauma
Inflammatory conditions
Infection
How does trochanteric bursitis present?
Gradual onset of-
Lateral hip pain (aching/burning)
Tenderness over greater trochanter
How is trochanteric bursitis diagnosed? How is it managed?
Trendelenberg test
Rest, ice, analgesia
Can take 6-9 months to heal
How does a torn meniscus present?
History of twisting movement of knee e.g. sports
Pain, swelling, stiffness of knee
Reduced ROM
Locking of the knee
Instability or knee ‘giving way’
How is a torn meniscus diagnosed?
MRI
How does an ACL injury present?
History of twisting movement of knee
Instability of knee
Tibia can move anteriorly below the knee - anterior drawer test
What is Osgood-Schlatter disease?
Inflammation at the tibial tuberosity - where the patella ligament inserts
Common in adolescents
Due to multiple minor avulsion fractures that occur where the patella ligament pulls away tiny pieces of bone, leading to a growth of the tibial tuberosity and a visible lump below the knee
How does Osgood-Schlatter disease present?
A visible/palpable hard lump at the tibial tuberosity
Pain in anterior aspect of knee - exacerbated by physical activity, kneeling, knee extension
What is a Baker’s cyst? How does it present?
A distention of the gastrocnemius-semimembranous bursa in the popliteal fossa
Palpable lump/Swelling in the popliteal fossa - more apparent on standing with legs fully extended
Pain/discomfort
How is a Baker’s cyst diagnosed?
ultrasound
What are the two types of Achilles tendinopathy?
Insertion tendinopathy
Mid-portion tendinopathy
What are risk factors for Achilles tendinopathy?
Sports
Inflammatory conditions - RA/AS
Increased cholesterol - can cause tendon xanthomata
Quinolone Abx - e.g. Ciprofloxacin
How does an Achilles tendon rupture present?
Sudden onset pain in achilles/calf
Snapping sound/sensation
Feeling as though something has hit them in back of leg
Which medication can cause Achilles tendon pain/rupture?
Quinolone antibiotics e.g Ciprofloxacin
How does plantar fasciitis present?
Gradual onset of pain on plantar aspect of foot
especially on heel
Worse with pressure (walking/standing)
Worse when walking on toes
What is Morton’s neuroma? How does it present?
A benign neuroma affecting the intermetatarsal plantar nerve - most commonly between the 3rd and 4th toes
Pain in-between 3rd and 4th toes
Burning/shooting
Worse on walking
Sensation of something in shoe
Mulder’s click - painful click when squeezing metatarsals togehter
What is the key risk factor for adhesive capsulitis (frozen shoulder)?
Diabetes
How does adhesive capsulitis (frozen shoulder) present?
3 phases
- Painful phase - shoulder pain
- Stiff phase/adhesive phase - shoulder stiffness develops. most affected = external rotation
- Recovery phase - gradual improvement
How do rotator cuff tears present?
Shoulder pain worse on specific movement - usually on abduction (Supraspinatus)
Which rotator cuff muscle is most commonly injured?
Supraspinatus
What is the most common type of shoulder dislocation?
Anterior dislocation
What is the main complication of shoulder dislocation?
Axillary nerve damage (loss of sensation over lateral deltoid)
What is olecranon bursitis?
Inflammation and swelling of the bursa over the elbow
Often due to leaning on elbow
How does olecranon bursitis present?
Swollen, warm, tender elbow
How does lateral epicondylitis present?
Pain worse on resisted wrist extension or supination of forearm
How does medial epicondylitis present?
Pain worse on resisted wrist flexion or pronation of the forearm
What is DeQuervain’s tenosynovitis? Which tendons does it affect?
Swelling and tenderness of the tendon sheaths in the wrist
Primary affects - abductor policus longs and extensor pollicus brevis
How does DeQuervain’s tenosynovitis present?
Symptoms at radial aspect of wrist - near base of thumb
Pain
Aching
Burning
Weakness
Numbness
Positive Finkelstein’s test - patient makes his with thumb inside fingers. then adduct wrist (towards ulnar). If painful = positive.
What is trigger finger?
Abnormal flexion of the digits
Stiffness when trying to move the affected finger
Painful
Stuck in flexed position
A nodule may be felt at the base of the affected finger
How is trigger finger treated?
1st line = steroid injections
If no improvement - surgery
What is Dupuytren’s contracture? How does it present?
Fascia of the hand becomes thickened and tight which leads to contracture of the fingers
Thick nodular cord from palm to affected finger
No pain
How is Dupuytren’s contracture treated?
Fasciotomy
What are risk factors for carpal tunnel syndrome?
Pregnancy
Rheumatoid arthritis
Obesity
Acromegaly
Hypothyroidism
Diabetes
What are features of carpal tunnel syndrome?
Pain, numbness, parasthesia over the thumb, index finger and middle finger
May be weakness
How is carpal tunnel syndrome managed?
Wrist splints
Surgical decompression via splitting the flexor retinaculum
Which shoulder problem is associated with diabetes?
Adhesive capsulitis (frozen shoulder)
Systemic inflammatory response (respiratory distress, petechial rash) after a long bone fracture – what to consider?
Fat embolus
What is the classic presentation of a supracondylar fracture of the humerus?
Elbow in semi-flexed position
Swelling
What is the classic presentation of a radial head fracture?
Sharp pain in elbow on pronation/supination
What is the most common cause of needing a hip fracture revision?
Aseptic loosening
What is a Type I intracapsular fracture?
Incomplete, non-displaced
What is a Type II intracapsular fracture?
Complete, non-displaced
What is a Type III intracapsular fracture?
Complete, partially displaced
What is a Type IV intracapsular fracture?
Complete, completely displaced
What is osteopetrosis?
Genetic condition where there the bones are hard and dense
What does disruption of Shenton’s line on XR indicate?
Hip fracture
What is the pelvic compression test and what is it used for?
Used for diagnosing meralgia paraesthetica
Deep palpation just below the ASIS can reproduce symptoms
What will reproduce symptoms in meralgia paraesthesia?
Hip extension
Deep palpation below the ASIS
What is McMurray’s test used for?
Diagnosing a meniscal tear
How to differentiate between meniscal tear and ACL/PCL injury?
Both diagnosed with MRI knee
Meniscal tear = McMurray’s test
ACL injury = Anterior draw test
What is the most common causative organism of discitis?
Staph aureus
What other organ needs to be investigated if a patient is diagnosed with infective discitis?
Needs echocardiogram to look for endocarditis
How is a subtrochanteric fracture managed? (below the lesser trochanter)
Intramedullary nail
When does pain in the ankle warrant an x-ray?
Bony tenderness at the posterior edge of the medal or lateral malleolus
Inability to bear weight for 4 steps
What are signs of osteogenesis imperfecta?
Several fractures during childhood Long bowing Short stature Hearing loss Blue sclerae
What kind of fracture is it when the bone is exposed to air?
Compound
How can you tell the difference between Dupuytren’s contracture and Trigger finger?
Trigger finger = passively correctable, painful
Dupuytren’s contracture = cannot be passively corrected, no pain
What XR sign is pathognomonic for a posterior shoulder dislocation?
Lightbulb sign
What is cubital tunnel syndrome and how does it present?
Compression of the ulnar nerve as it passes through the cubital tunnel
Tingling and numbness of the 4th + 5th fingers
Pain worse on leaning on elbow
Which movement is most affected in adhesive capsulitis?
External rotation
Which nerve is compressed in meralgia paraesthetica?
Lateral femoral cutaneous nerve
What are the actions of the 4 rotator cuff muscles?
Supraspinatus - abduction (up to 15 degrees then taken over by deltoid)
Infraspinatus - external rotation
Teres minor - external rotation
Subscapularis - internal rotation
Which muscle is responsible for the first 15 degrees of arm abduction? Which muscle is responsible for the rest?
First 15 degrees = Supraspinatus
Rest = Deltoid
Which imaging to look for rotator cuff pathology?
MRI
What is subacromial impingement and how does it present?
Tendons of rotator cuff muscles become compressed
Painful arc of abduction
How does L3 nerve compression present?
Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
How does L4 nerve compression present?
Sensory loss in anterior knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
How does L5 nerve compression present?
Sensory loss - dorsum of foot
Weakness of foot + big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
How does S1 nerve compression present?
Sensory loss in the posterolateral aspect of the leg and lateral aspect of foot
Weakness of foot plantarflexion
Reduced ankle reflexes
Positive sciatic nerve stretch test
What are the Salter-Harris fractures? How are they classified?
Growth plate fractures I = Physis only II = Physis + Metaphysis III = Physis + Epiphysis IV = Physis, Metaphysis + Epiphysis V = Crush injury
What is a Charcot foot?
AKA Neuropathic jont
joint body is damaged/disrupted due to loss of sensation
usually largely swollen, loss of sensation
Destruction of the bones
Most commonly seen in diabetics
