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mrcs - General > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

Commonest malignant primary bone tumour

A

Oseosarcoma

50% around the knee

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2
Q

Complications of colle’s fracture

A

Compression on median nerve

Rupture of extensor pollicis longus tendon

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3
Q

Imaging for scaphoid fractures

A

If first x-ray NAD

Fix for two weeks then re-x-ray

If still NAD –> MRI

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4
Q

Lasègue’s straight leg raise test

A

Increases tension along the sciatic nerve (L5 and S1 nerve roots)

97% sensitive for disc prolapse

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5
Q

Intrinsic muscle wasting of the hand

A

Ulnar nerve palsy T1

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6
Q

Thenar wasting

A

Median nerve palsy C8

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7
Q

Hypothenar wasting

A

Ulnar nerve palsy T1

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8
Q

Medial epicondylitis

A

Golfer’s elbow

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9
Q

Lateral epicomdylitis

A

Tennis elbow

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10
Q

Morton’s neuroma

A

Thickening of the tissue that surrounds the digital nerve leading to the toes as the nerve passes under the ligament connecting the metatarsals in the forefoot

It is most frequent between the third and fourth toes.

A neuroma presents with burning pain in the ball of the foot that radiates to the involved toes.

Palpate in the web space between the symptomatic toes for a mass.

Compression of the metatarsals may elicit a ‘click’ betwee the bones (Molders’ click).

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11
Q

Sites of tendon injury with age

A

Adolescents: tendon insertions

Adults: musculotendinous junction

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12
Q

Grading ligamentous injuries 0-3

A

0 = Normal ligament

1 No increase in joint laxity but there is tenderness around the injured ligament

2 Partial disruption of the ligament fibres with increased joint laxity, and a soft end point

3 Complete disruption of the ligament; there is a marked increase in joint laxity with no end point clinically

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13
Q

Management of ligamentous injuries

A

Grade 1 + 2: splinting, anaglesia and fraded mobilisation

Garde 3: surgical repair

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14
Q

Posterior impingement of the ankle and tendinopathy of the flexor hallucis longus tendon

A

Ballet dancers

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15
Q

Ottawa ankle rules

A

Bone tenderness along the distal 6 cm of the posterior margin or at the tip of the lateral malleolus

Bone tenderness along the distal 6 cm of the posterior margin or at the tip of the medial malleolus

Inability to bear weight at the time of the accident or at the time of examination

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16
Q

Cervical lordosis

A

35-45 ‘

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17
Q

Lumbar lordosis

A

40 - 80’

Mostly occurs L4 - S1

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18
Q

Thoracic kyphosis

A

20 - 50’ (mean 35’)

Increases with age

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19
Q

Radicular artery of Adamkiewicz

A

Largest anterior segmental medullary artery

Arises left posterior intercostal artery at the level of the T9 - T12 intercostal artery, which branches from the aorta, and supplies the lower two thirds of the spinal cord via the anterior spinal artery

Ligation –> ischaemia of the spinal column

During anterior approaches to the spine, segmental division is performed to avoid ligating this influental vessel

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20
Q

Cauda equina

A

Low back pain

Uni- or bilateral sciatica

Saddle anaesthesia

Motor weakness in the lower extremities

Variable rectal and urinary symptoms

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21
Q

Lasègue’s sign

A

Denotes radicular pain aggravated by ankle dorsiflexion during straight leg raise

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22
Q

Provocative discography

A

3.5 mL of radio-opaque contrast agent is injected into the disc

The contrast pattern will allow the discrimination of different degrees of disc degeneration; cottonball or lobular would be considered normal

Whereas irregular, fissured or ruptured would be considered degenerate

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23
Q

Indication for surgical intervention in cervical radiculopathy

A

Intractible pain

OR

Functional neurological deficit

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24
Q

Surgical management of cervical radiculopathy

A

Anterior cervical discectomy and fusion (using a cage packed with bone graft and plate)

Cervical total disc replacement

Posterior laminoforaminotomy

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25
Q

Cervical myelopathy

A

LMN signs AT level of lesion

UMN signs below level of lesion

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26
Q

Commonest cause of cauda equina syndrome

A

Massive central lumbar disc protrusion at L4/5

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27
Q

Lumb disc herniation

A

90% at L4/L5 or L5/S1 levels

Posterolateral disc protrusion will affect the traversing root, e.g. an L4/5 disc protrusion will affect the
L5 nerve root.

Far-lateral disc protrusion (extraforaminal) will affect the exiting nerve root, e.g. a far-lateral L5/S1 disc protrusion will affect the L5 nerve root

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28
Q

Spinal stenosis

A

Classic symptoms: back, buttock, thigh and calf pain

Provoked by walking and extended posture

Relieved by flexed posture

Symptoms progress in up to one-third of untreated patients

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29
Q

Spondylolysis

A

Unilateral or bilateral defect in the pars interarticularis without vertebral slippage

Incidence in athletic population 15–47%

May be completely asymptomatic/incidental finding on
radiograph

Difficult to image, but MRI proving more useful

Conservative treatment: activity modification, antilordotic brace

Surgical treatment: direct repair preserving motion or spinal fusion if associated disc degeneration

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30
Q

Spondylolisthesis

A

Forward slippage of the vertebral body caused by a break in in the continuity of pars interarticularis

Wiltse classification of spondylolisthesis identifies the CAUSE = 6 types

Meyerding classification grades severity = 4 grades

Low grade slip I - II –> fusion-in-situ

High grade slips III - IV–> decompression and fusion

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31
Q

Commonest metatastic malignancy to spine

A

Breast 21%

Lung 14%

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32
Q

Benign primary spine tumours

A

Osteoid osteoma

Osteoblastoma

Chondroma

Chondroblastoma

Chondromyoixod fibroma

Giant cell tumous

Haemangioma

Lymphangioma

Lipoma

Benign tumours tend to occur in the posterior elements

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33
Q

Intermediate spinal pimaries

A

Aggressive osteoblastoma

Haemangiopericytoma

Haemangioendothelioma

Chordoma

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34
Q

Malignant spinal pimaries

A

Osteosarcoma

Chondrosarcoma

Ewing’s sarcoma

Neuroectodermal tumours

Malignant lymphoma

Myeloma

Angiosarcoma

Fibrosarcoma

Liposarcoma

Malignant tumours tend to involve the entire vertebral column

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35
Q

Neurofibroma

A

Benign tumours arising from the nerve sheath

Three types:

  • Cutaneous
  • Spinal
  • Plexiform

90% of cases they present as solitary lesions,

Multiple = patients with neurofibromatosis type 1 (NF1), -autosomal dominant

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36
Q

Neurofibromatosis Type 1

A

Referred to as peripheral neurofibromatosis or von Recklinghausen disease

1 in 3000

Diagnosis of NF1 (2 or more of the following):

  • At least 6 cafe au lait spots >5mm pre-puberty
  • At least 6 cafe au lait spots >15mm post-puberty
  • Two or more neurofibromas (any type)
  • Presence of plexiform neurofibroma
  • Multiple freckles in the axillary or inguinal regions,
  • Distinctive bone abnormality involving the eye socket or arm/leg bones
  • Optic glioma in the brain
  • Two or more Lisch nodules in the eye,

-Parent, sibling or child with NF1

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37
Q

Neurofibromatosis Type II

A

Central

1 in 40,000

Schwannomas on both 8th cranial (vestibular) nerves

Parent, sibling or child with NF2 plus:
-One vestibular schwannoma in a person less than 30 years of age
-Any two of the following: meningioma, glioma,
schwannoma, juvenile cataracts

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38
Q

Epidural abscess

A

Surgical emergency

Majority of cases occur within the thoracic spine.

Without treatment –> neurological deficit including paralysis may develop.

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39
Q

Indications for surgery in atlanto-axis subluxation in rheumatoid arthritis

A

AAS with a PADI of 14 mm or less

AAS with at least 5 mm of basilar invagination

Subaxial subluxation with a sagittal canal diameter of 14 mm or less

(PADI= posterior atlantodental interval)

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40
Q

Cobb angle of 10° or more

A

= Scoliosis

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41
Q

Early onset idiopathic scoliosis

A

Cause disruption to lug development

After 8 years, late onset scoliosis, the alveoli are developed

Early onset may cause cor pulmonale and RHF

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42
Q

Management of idiopathic scoliosis

A

Idiopathic curves of less than 25° are monitored with clinical and radiographic examination

In growing children (premenarchal) with curves between 20° and 29°, a brace may be indicated. Bracing is used to prevent curve progression

Curves beyond 45° are not amenable to brace treatment.

Surgery in the form of corrective instrumentation and
spinal fusion is indicated for curve progression beyond 40°, truncal imbalance and unacceptable cosmesis.

During surgery, continuous spinal cord monitoring is used in the form of somatosensory evoked potentials (SSEP), motor-evoked potentials (MEP) and free-run and stimulated electromyographic (EMG) activity to minimise the risk of neurological damage. The risk of neurological injury is 0.4% (1 in 250).

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43
Q

Stener lesion

A

Occurs due to gamekeepers thumb

Aponeurosis of ABductor pollicis longus interposed between the ruptured ulnar collateral ligament (UCL) of the thumb and its site of insertion at the base of the proximal phalanx

No longer in contact with its insertion site, the UCL cannot spontaneously heal

Mx: surgicalk attachment

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44
Q

Scheuermann’s kyphosis

A

Wedging og T7 - T10 vertebrae

Apical pain and lower back pain
–> attempts by lumbar musculature to compensate for the thoracic hyperkyphosis

Mx
Physiotherapy
Bracing in skeletally immature

Surgical:
-Pain (apical or low back pain produced by
compensatory hyperlordosis)
-Progressive deformity greater than 70°,
-Unacceptable cosmesis and neurological and/or cardiopulmonary compromise

Anterior release followed by posterior correction and
fusion.

Posterior chevron osteotomies carried out at the time of posterior instrumentation may prevent the need for the initial anterior release

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45
Q

Diastematomyelia

A

An abnormal bony or cartilaginous spur projecting across the middle of the vertebral canal

–> dividing the dural tube and spinal cord in two

Between 50% and 70% of patients are seen to have a skin naevus, dimple or hairy patch when the spine is examined

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46
Q

Management of osteoporotic spinal fractures

A

Providing no neural comprimise

Bed rest
Analgesia

If painful

  • -> Kyphoplasty
  • ->Vertebroplasty
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47
Q

Sprengel’s shoulder

A

Abnormal descent of the scapular from its embryonic mid-cervical position

High, small, rotated scapular that remains attached to the cervical spine by a:

  • bony bar, or
  • fibrous band, or
  • omovertebral body
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48
Q

Klippel-Feil syndrome

A

Congenital abnormality involving fusion of at least two cervical vertebrae

–> short neck and reduced mobility, causes apparent low hair-line

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49
Q

Risk factors for frozen shoulder

A

Diabetes

Cardiovascular disease

Thyroid disease

Female gender

Age

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50
Q

Treatment of calcific tendonitis

A

Acute pain with restricted movement around the shoulder due to subacromial calcific deposits

BUT external rotation possible

Tx:
Corticosteroid injections
Barbotage: aspiration and flushing
Surgical decompression if persistent

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51
Q

Changes in rheumatoid arthritis

A

Osteoporosis

Destruction of articular cartilage

Synovial proliferation

Pannus formation

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52
Q

Rupture of the long head of the biceps

A

Tends to be proximal tendon rupture in elderly patients due to abrasion under the anterior acromion

  • -> bulge appears in arm
  • ->sometimes pain of biceps tendonitis is relived by rupture

In elderly it doesn’t alter function –> conservative management

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53
Q

Types of shoulder instability

A

Traumatic

Atraumatic

Habitual

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54
Q

Types of shoulder instability

A

Traumatic
-Surgery

Atraumatic
-Surgery

Habitual
-Not for surgery

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55
Q

Bankart’s lesion

A

Detachment of the anteroinferior labrum

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56
Q

Hill-Sach’s lesion

A

Damage to the humeral head

Cortical depression on posterolateral humeral head

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57
Q

Management of traumatic recurrent shoulder instability

A

Repair of labrum
Tightening of anterior capsule

+/- graft of Hill-Sachs

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58
Q

Posterior shoulder dislocation

A

Forced internal rotation

  • Electrocution
  • Seizure
  • Restraint
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59
Q

Rheumatoid elbow

A

Radial head excision

Elbow arthroplasty

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60
Q

Points of ulnar compression

A

Within the cubital tunnel (behind medial epicondyle)

Junction of arcade of Struthers

Medial intermuscular septum as nerve passes into posterior compartment of distal humerus

Between heads of flexor carpi ulnaris

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61
Q

Froment’s sign

A

Weakness of adductor pollicis

= ulnar nerve palsy

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62
Q

Edinburgh position of safety

A

Hand splinting position to prevent collateral ligament shortening and deformity during times of immobiliation

= Wrist extension
=MCP flexion
=IPJ extension

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63
Q

Thumb ulnar collateral ligament injury

A

= Gamekeepers thumb

Chronic overuse –> stretching of ulnar collateral ligament of thumb

Skier’s thumb = forceful abduction causing acute tear

Surgical Mx: pollicis abbductor tendon slips between two ends and prevents healing

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64
Q

Triangular fibrocartilage complex injuries

A

Triangular fibrocartilage complex:

  • Ulnocarpal ligaments
  • Extensor carpi ulnaris tendon
  • Meniscus-like structure between distal ulna and carpus

Stabilises distal radio-ulnar joint

Injury –> ulna wrist pain and instability

Mx: arthroscopic / open repair
Debridement if chronic damage

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65
Q

Felon

A

Abscess of specialised fibrous septae in finger pulp

Can cause DIP osteomyelitis

Mx: I&D

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66
Q

Paronchyia

A

Nail bed infection

Incision, drainage and Abx

+/- partial removal of nail to allow drainage

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67
Q

Flexor tendon sheath infection

A

Kanavel’s cardinal signs

  • held in flexion
  • swelling over tendon and digit
  • tender
  • pain on passive extension

Mx: tendon sheath irrigation and IV Abx

Untreated: adhesions, necrosis, +/- proximal spread

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68
Q

Hand signs of Rheumatoid

A

Boutonniere

Swan-neck

Flexor tendon synovitis

Radial deviation of wrist + prominent ulnar head

Flexion, subluxation and ulnar deviation of MCPs

69
Q

Dupuytren’s

A

Autosomal dominant

Palmar nodules
Skin puckering
Cords
Flexion contractures
Garrods knuckle pads over dorsal of PIPs
Associated with:
Smoking
Trauma
Epilepsy
AIDS
Hypothyroidism
Alcohol liver cirrhosis
Mx: when patient can't put hand flat on table
OR
Flexion develops in the PIP joint
--> surgery
Z-plasties
Digital nerves at-risk

Proceed to amputation if finger restricting useful movements

70
Q

Trigger finger

A

Tendon size mismatch between flexor tendon sheath pulley A1 and size of flexor tendon

  • -> locking / snapping of finger
  • -> pain

Mx:
Corticosteroid injection
Proceed to pulley release

In thumb in children –> resolved spontaneosuly

71
Q

De Quervain’s

A

Tenosynovitis of abductor pollicis longus and extensor pollicis brevis within first dorsal extensor compartment
1st EC

Associated:
Female patients during pregnancy (New mother’s wrist)
Inflammatory arthritis

Test: Finkelstein’s

72
Q

Associations with carpal tunnel syndrome

A

Majority idiopathic

BUT...
Diabetes
Thyroid disease
Alcoholism 
Amyloidosis
Inflammatory arthritis
Pregnancy 
Obesity
73
Q

Tests for carpal tunnel syndrome

A

Phalen’s test: flexion of wrist

Tinnel’s test: tap on carpal tunnel

Durkin’s test: press on carpal tunnel

74
Q

Management of carpal tunnel syndrome

A

Night splinting of wrist in extension

Surgical decompression
-Transverse carpal ligament

75
Q

Guyon’s tunnel syndrome

A

Ulnar nerve compression in Guyon’s tunnel

Tingling and numbness in little and ring finger
Hypothenar wasting

Dorsal branches don’t pass through so dorsal sensation intact

Causes:
Ganglion
Ulnar artery aneurysm
Hook of hamate fracture

76
Q

Kienbock’s disease

A

Idiopathic avascular necrosis of the lunate

77
Q

Preiser’s disease

A

Idiopathic avascular necrosis of the scaphoid

78
Q

Blood supply to femoral head

A

Retinacular branches of medial circumflex femoral artery

Small contribution from ligament teres

79
Q

Causes of avascular necrosis of the femoral head

A

Avascular of the femoral head can be idiopathic (Perthe’s) or secondary

  • -> collapse of femoral head
  • ->secondary osteoarthritis

Causes:

  • Sickle cell disease
  • Haemoglobinopathies
  • Hypercoaguable states (protein C and S deficiency)
  • Caisson disease (the bends in divers)
  • Hyperlipidaemia
  • SLE
  • Gaucher’s disease
  • Antiphospholipid syndrome
  • Radiotherapy
  • Chemotherapy
  • HIV
  • Steroids
  • Chronic liver disease
  • Alcoholism
80
Q

Presentation of AVN of femoral head

A

Men aged 35-45

Bilateral in >50%

Asymptomatic initially

Ache in groin

Limp

Limitation of movement

81
Q

Radiographic changes in avascular necrosis of the femoral head

A

Initially normal, request an MRI

Early: sclerosis

Crescent sign –> subchondral bone resorption

Flattening –> femoral collapse

Graded I - IV

82
Q

Management of AVN of femoral head

A

Pre-collapsed stage –> surgical decompression using core decompression +/- inserting vascular bone graft

Collapsed –> femoral osteotomy to shift WB or replacement

83
Q

Causes of secondary osteoarthritis of hip

A

Trauma

Avascular necrosis / Perthe’s

Slipped capital femoral epiphysis

Dysplasia

Inflammatory arthtropathy = Rheumatoid

Developmental dysplasia of hip

Septic arthritis

Femeroaectabular impingement

84
Q

Posterior approach to hip replacement

A

Along the fibres of gluteus maximus, dividing short external rotators of the hip

85
Q

Anterolateral approach to hip replacement

A

=Hardinge

Parts of the gluteus medius and minimus are reflected off the greater trochanter

86
Q

Medial meniscus tears

A

Three times more common than lateral meniscus tears

Outer third of the meniscus is vascular and so tears can be repaired with the prospect of healing

87
Q

Bundles of the ACL

A

Two bundles

Anteromedial bundle: tight in flexion

Posterolateral bundle: tight in extension

88
Q

Bundles of the PCL

A

Two bundles:

Anterolateral bundle: tight in flexion

Posteromedial bundle: tight in extension

89
Q

Lisfranc’s Injury

A

Disruption to the cornerstone second metatarsal

2nd metatarsal is recessive in relation to 1st and 3rd

–> Loss of transverse arch and flat foot

90
Q

Superficial posterior compartment of leg

A

Gastrocnemius

Soleus

Plantaris

91
Q

Deep posterior compartment of leg

A

Tibialis posterior

Flexor digotorium longus

Flexor hallucis longus

92
Q

Lateral compartment of leg

A

Peroneus longus

Peroneus brevis

93
Q

Anterior compartment of leg

A

Tibialis anterior

Extensor digitorum longus

Extensor hallucis longus

Peroneus tertius

94
Q

Morton’s neuroma

A

Pain in the second or third web space

Compression of common digital nerve between third and fourth metatarsal

–> pain

Usually secondary to other foot deformities

95
Q

Freiberg’s disease

A

Avascular necrosis of epiphysis of metatarsal

–> re-shaping osteotomy

96
Q

Management of Charcot

A

Immediate off-loading and casting to correct deformity

97
Q

Plasmacytoma

A

= solitary mass of myeloma

98
Q

Osteosarcoma

A

Osteogenic tumours

Two peaks: Adolescence
Second in elderly patients with Paget’s disease or post radiotherapy treatment

99
Q

Onion-skinning

A

= Ewing’s sarcoma

100
Q

Familial conditions with high risk of bone and cartilage cancers

A

Maffuci syndrome
-Enchondromatosis and soft tissue angiomas

Ollier disease
-Enchondromatosis

Familial retinoblastoma syndrome

101
Q

Ollier disease

A

Nonhereditary sporadic disorder where intraosseous benign cartilaginous tumors (enchondroma) develop close to growth plate cartilage

102
Q

Maffuci syndrome

A

Maffucci syndrome is a sporadic disease characterized by the presence of multiple enchondromas associated with multiple cavernous hemangioma and phlebolith.

103
Q

Conditions associated with moderate risk of cancerous transformation

A

Hereditary multiple exocytoses

Polyostotic Paget’s

Radiation osteitis

104
Q

Low risk of malignant change

A

Osteomyelitis

Osteonecrosis

Fibrous dysplasia

Osteogenesis imperfecta

Osteoblastoma

Chondroblastoma

105
Q

Batson’s venous plexus

A

Retroperitoneal veins with no valves that allow haematgenous mets to the spine + proximal long bones

106
Q

Sclerotic bone mets

A

Pancreatic metastasis

107
Q

Osteoid osteoma

A

Bening bone-forming lesion
-Usually occur in children and adolescents

Small but very painful

Pain occurs at night

Responds to NSAIDs

Commonly in proximal femur, and cause a dense cortical reaction in the centre of which is a nidus

108
Q

Osteomablastoma

A

Larger version of osteoid osteoma - still benign

> 2cm

More aggressive counterpart of osteoid osteoma that more typically occurs in the spine.

109
Q

Osteosarcoma

A

Malignant bone-forming tumour

Most common site: distal femur

Classification:

  • Sclerotic
  • Chondroblastic
  • Telangiectatic

Usually intraosseous

110
Q

Osteoid tumours

A

Osteoid osteoma – small, painful; produce dense cortical reaction

Osteoblastoma – larger and more aggressive than osteoid osteoma

Osteosarcoma – malignant; commonest in lower femur and upper tibia

111
Q

Osteochondroma

A

Benign cartilage-capped bony projection

Continuity between cortex of bone and frowth - characteristic finding

Bony projection always grows away from the joint towards the diaphyseal region of the bone.

Osteochondromas can be pedunculated with a stalk or sessile (without a stalk)

Usually solitary, but some patients have multiple osteochondromas (hereditary multiple exostoses, autosomal dominant inheritance)

Cause compressive symptoms: nerve impingement, vascular pseudoaneurysm, fracture and infarction

112
Q

Hereditary multiple exostoses

A

Autosomal dominant

113
Q

Enchondroma

A

Benign cartilagenous neoplasm

Within the intramedullary cavity of bone

50% are in the hands and feet: enchondromas are the most common bone tumours in the hand. A

Pain, swelling or pathological fracture, many are
asymptomatic

Patchy calcification, expansion and scalloping can be visible on radiographs

Ollier disease is a developmental condition characterised by multiple enchondromas

Maffucci syndrome, multiple enchondromas are associated with multiple angiomas

Malignant transformation to chondrosarcoma can occur in approximately 20% of patients with Ollier disease and is almost inevitable in patients with Maffucci syndrome.

114
Q

Patchy calcification, expansion and scalloping can be visible on radiographs

A

Enchondroma

115
Q

Chrondroblastoma

A

Benign cartilage-producing tumour

Occurs in EPIPHYSES of bones in CHILDREN

Commonly knee

Presents: severe pain and knee effusion

Radiograph often missed lytic lesion in centre of epiphyses
-Isotope bone scan can help identify the lesion

116
Q

Chondrosarcoma

A

Malignant tumour with cartilagenous differentiation

Low- grade –> aggressive

Pain + welling

Many arise from enchondromas or osteochondromas

Clear cell chondrosarcoma is a rare form of chondrosarcoma that occurs in the epiphysis

117
Q

Tumours of cartilage differentiation

A

Osteochondroma – cartilage capped; grows away from physis

Enchondroma – inside bone; commonest in hands and feet

Chondroblastoma – in epiphyses of adolescents

Chondrosarcoma – of varying malignancy

118
Q

Eosinophilic granuloma

A

Eosinophilic granuloma is a rare neoplasm of Langerhans cells

Unifocal (eosinophilic granuloma)

Multifocal (Hand–Schuller–Christian disease)

Disseminated (Letterer–Siwe disease).

–> Skull and the diaphyses of long bone

In the spine it can present with collapse, known as vertebra plana

Radiographs can appear aggressive and similar to Ewing’s sarcoma
-often expansion and a ground glass appearance, sometimes with cystic change

119
Q

Ewing’s Sarcoma

A

Malignant round cell sarcoma

T11:22

Arises diaphysis long bone or pelvis

Painful mass and may have systemic symptoms including fever, anaemia and increased erythrocyte sedimentation rate (ESR)

Radiologically the bone appears moth-eaten and may show an ‘onion-skin’ periosteal reaction

120
Q

Bone tumours misc

A

Simple bone cyst – proximal long bones of children

Aneurysmal bone cyst – more aggressive, expanding

Giant cell tumour – found in epiphyses around the knee

Fibrous dysplasia – may be multiple; long bones, ribs and skull

Ewing’s – round cell sarcoma; patients may have fever and anaemia

121
Q

Enneking staging system

A

Staging primary bone cancers

If breached cortex = 2B

122
Q

Trojani system

A

Staging for malignant sodt tissue tumours

Based on tumour differentiation, mitotic count and tumour necrosis,

123
Q

Relief with non-steroidal anti-inflammatory drugs may suggest

A

an osteoid osteoma

124
Q

Red flags for soft mass

A

Painful

Increasing in size

More than 5 cm in diameter

125
Q

Biopsy for ?sarcoma

A

Only biopsy once staging is completed

Biopsy should be performed at the institution undertaking the main surgery

Imaging-guided biopsy is more reliable

he biopsy track must be excised at definitive surgery

Jamshidi needles for bone, Trucut needles for soft tissues

126
Q

CT-guided thermocoagulation

A

Used in treatment of osteoid osteoma

Many recgress spontaneously

127
Q

Neoadjuvant chemotherapy

A

Pre-op chemotherapy used for:

  • Osteosarcoma
  • Ewing’s sarcoma
128
Q

Insensitive to radio or chemotherapy

A

Chondrosarcomas

129
Q

Mirel’s scoring system

A

Used to predict risk of pathological fracture

Larger, more painful, lytic lesions carry a higher risk
Lower limb higher risk vs upper limb

130
Q

Soft tissue sarcomas

A

Complete excision with biopsy tract

Not senitive to chemotherapy

Pre-op and post-op radiotherapy can be useful but can impair wound healing

131
Q

Involucrum

A

Pathological feature of osteomyelitis in which new bone is constructed around dead bone forming many sinuses

132
Q

Debridement, antibiotics and implant retention, ‘DAIR’

A

Can only be undertaken if the prosthesis is well-fixed

The surrounding infected soft tissue and bone must be
fully excised and modular components exchanged

This cannot be achieved by arthroscopic surgery

Good soft tissue cover is essential. Following debridement, the patient is treated with long-term antibiotics (frequently 6 weeks of intravenous therapy followed by 6 months or more of oral antibiotics).

Prolonged infection-free intervals will be achieved in 80% of patients but success with this strategy may be lower in infections caused by Staphylococcus aureus.

133
Q

Two-stage joint revision surgery

A

Thorough excision is undertaken and all cement and loose foreign material is removed.

An antibiotic-impregnated spacer may be implanted (which may be articulating)

This is a temporary measure and cannot withstand full weight bearing.

The patient is treated with oral or intravenous antibiotics, most commonly for 6 weeks.

New prosthesis is implanted after the course of antibiotics has been completed.
Rerevision surgery for infection has a higher failure rate than a first revision, and so early referral to a specialist centre should be considered.

134
Q

Single-stage joint revision surgery

A

Removal and reimplantation are undertaken in the same operating session.

Healthy soft tissues around the new implant are essential to prevent reinfection. Some centres consider single-stage revisions when less florid signs of infection are present (i.e. absence of collections or sinus tracts), or for frail patients for whom the risk of a second operation is higher.

There are no adequate trial data comparing outcomes with the two-stage approach.

135
Q

Commonest site of acute osteomyelitis in adults

A

Vertebral column

Children: long bones

136
Q

Cierny and Mader classification

A

Classification for chronic osteomyelitis
Four stages of infection

Stage 1: medullary

  • just cancellous bone
  • ream bone and pack with Abx pellets

Stage 2: superficial
-Only the cortical bone is involved and this requires excision.
- follows skin ulceration and there may be large skin
defects which require complete excision and local or free muscle flaps

Stage 3: localised
-limited area of dead cortical bone with medullary
infection.
-staged reconstruction after excisio n

Stage 4: diffuse

  • Involves the entire circumference of the bone and surrounding soft tissue
  • All infected non-unions are Stage 4.
  • Resection must be segmental and stabilisation in an external fixator will be required. Reconstruction will involve the introduction of new bone and healthy soft tissue
  • Ilizarov method, which uses distraction osteogenesis to fill bone defects

Three host groups A- C
A, no active concurrent disease
B, compromised host
C,severe comorbidity preventing surgery

137
Q

Stages of chronic osteomyelitis

A

Stage 1: medullary

Stage 2: superficial

Stage 3: localised

Stage 4: diffuse

138
Q

Occurence of congenital limb abnormalities

A

Usually occur within 2 motnhs of fertilisation

The upper limb bud forms on the lateral wall of the embryo 4 weeks after fertilisation, followed promptly by the lower limb bud

AER controls proximal to distal differentiation and interdigital necrosis

ZPA directs posterior to anterior differentiation

Wnt influences dorsal to ventral differentiation

139
Q

Heuter-Volkmann principles

A

Compressibe forces inhibit growth

Tensile forces stimulate growth

140
Q

Wolff’s law

A

Bone deposition and resorption depend on the stresses applied

141
Q

Apical ectodermal ridge

A

Guides mesordermal proliferation in the progress zone in proximal –> distal direction

Controls digit formation

142
Q

Zone of polarising activity

A

Mesodermal zone of polarising activity directs anteroposterior limb development via the sonic hedgehog protein

143
Q

Ectodermal driven wingless- type (Wnt) signalling centre

A

Ectodermal driven wingless- type (Wnt) signalling centre develops dorsoventral axis configuration and limb alignment.

144
Q

Cause of persistent in-toeing gait

A

Femur/hip: Persistent femoral neck anteversion

Tibia: Internal tibial torsion

Foot: Metatarsus adductus

145
Q

Internal tibial torsion

A

Internal tibial torsion is assessed by the thigh–foot angle

Commonly associated with physiological tibia vara
in infants

Spontaneous correction can be expected by age 4, as the tibia also rotates as it grows.

146
Q

Normal variants of early gait

A

Children’s legs are often bowed until age 2 years and then knock-kneed until age 6 or 7 years

Neuromuscular pathology must be excluded in toe walkers, particularly when the onset is late

Intoeing or extoeing may be caused by excessive femoral or tibial torsion or foot deformity

Flexible, pain-free flat feet do not need treatment

147
Q

Flat foot

A

Flexible vs rigid

Flexible:
On tiptoe the arch is restored and the heel corrects into varus; subtalar joint movements are full and pain free

Rigid:
On tiptoe the arch fails to return and the heel remains in valgus; subtalar joint movements are restricted and often painful
=inflammation or a tarsal coalition (calcaneonavicular bar)

148
Q

Achondroplasia

A

Gain in function mutation in fibroblast growth factor receptor 3 (FGFR3)

Short arm chromosome 4

Autosomal dominant

Disproportionate short stature where the limbs are shorter than the trunk

Radiograph features:
-Splaying metaphysis 
-Over-long fibula
-Slight bowing
-Horzontal acetabulum
-Square pelvic wings
Underdevelopment of the foramen magnum and spinal stenosis can cause neurological difficulties
149
Q

McCune Albright’s

A

Precoious puverty

Cafe-au-lait spots

Fibrous dysplasia

150
Q

ground glass’ appearance

A

Fibrous dysplasia

151
Q

Developmental dysplasia of the hip screenig test

A

DDH defines the spectrum of hip instability, ranging from the hip that is in joint but has a shallow (dysplastic) acetabulum

‘pushed out’ (Barlow positive) to the dislocated hip

Irreducible (Ortolani negative).

152
Q

Management of DDH

A

Many hips that are unstable in the first few days/weeks of life do not need treatment as they improve spontaneously

Up to age 4–6 months, a harness or splint is effective
treatment

In older babies, closed reduction is often possible and
preferable to an open reduction

For failed closed treatment, open surgical reduction is
required

153
Q

Avascular necrosis eponymous conditiosn

A

Kienbock’s disease Lunate
Perthe’s: Hip

Panner’s disease Capitellum of the humerus

Freiberg’s disease Metatarsal head – usually the second

Köhler’s disease Navicular

154
Q

Hilton’s law

A

Hilton’s law, which states that a joint is supplied

by the same nerves as the muscles that move the joint,

155
Q

Osteochondritis dissecans

A

Mostly commonly affects medial epicondyle of distal femur

Osteochondral fragment becomes partially or totally separated

If partial: rest and conservative managment

Complete or mechanical symptoms: fixation or removal of loose bodies

156
Q

Osgood-Schlatter disease

A

Traction apophysitis of patellar tendon insertion

Pain, tenderness and swelling at the tibial tubercle, exacerbated by exercise, are diagnostic

Radiographs are unnecessary if bilateral, if unilateral ?maliganncy so imaging required

Mx: relative rest and analgesia, and the condition
resolves once the apophysis has fused

157
Q

Fibular hemilemi

A

Congenital failure of formation of the lateral ‘column’ of the lower leg

158
Q

Blount’s disease

A

Disordered growth in the posteromedial proximal tibial physis

Presents with porgressive and severe tibia vera + intoeing

Surgical management necessary

159
Q

Congenital pseudoarthrosis of the tibia

A

Rare condition presents clinically with an anterolateral

bow of the tibia with or without a fracture.

160
Q

Congenital pseudoarthrosis of the tibia

A

Rare condition presents clinically with an anterolateral
bow of the tibia with or without a fracture

50% are associated with neurofibromatosis

161
Q

Paediatric knee and tibial conditons

A

Osteochondritis dissecans – better prognosis in children than adults

Discoid meniscus – usually lateral, may require surgery

Anterior knee pain – treatment almost always conservative

Fibular hemimelia – associated with abnormalities from the foot proximally (foot worse than hip), the tibial bow has an anteromedial apex

Blount’s disease – clinically, a sharp proximal tibial angulation

Congenital pseudarthrosis of the tibia – the tibial bow has an anterolateral apex

Posteromedial apex tibial bow – largely physiological, the bow improves with time but the limb may be short

162
Q

Congenital talipes equinovarus

A

Deformed in three planes

  • Hindfoot is in equinus and varus
  • Midfoot cavus and
  • Forefoot lies adducted and apparently supinated, although actually pronated relative to the hindfoot.

M > F

50% bilateral

Most cases are idiopathic but neuromuscular causes include spina bifida and arthrogryposis

Scoring systems (Pirani/Dimeglio), are used to assess the severity

163
Q

Radial club hand

A

Associated with VACTERL syndrome
-abnormal vertebrae, anus, cardiovascular system, trachea, oesophagus, renal system and limb buds

  • short radius
  • deformed ulna
  • +/- an absent thumb

Mx: balance of conservative measures, including physiotherapy and splinting, and judicious surgery to centralise and stabilise the hand and wrist on the single bone forearm

164
Q

Radioulnar synostosis

A

Presents with a fixed forearm position in childhood

165
Q

Congenital radial head dislocation

A

Usually posterolateral vs traditional traumatic anterior

166
Q

Congenital toricollis

A

Usually caused by moulding but may present with fixed sternocleidomastoid contracture or with a palpable ‘tumour’ within the muscle.

There is a strong correlation with DDH

Most cases resolve with stretching

Persistent cases develop facial asymmetry and require surgical release of the sternocleidomastoid at one or both ends.

167
Q

Kocher et al. Septic arthritis

A

Fever > 38.5

Non-weight bearing

ESR >40

WCC >12

0: 2%
1: 9.5%
2: 35%
3: 72.8%
4: 93%

168
Q

Tibial metaphyseal corner injuries

A

= Non-accidental injury

mrcs - General (24 decks)

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