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Revision > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

Slipped upper femoral epiphysis

Features (5)

A 
11-15 year old child + limping
Affected limb is shorter than the other
External rotation of affected hip with increased hip flexion
Painful knee hip thigh and groin
Limited hip abduction
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2
Q

Sensory loss in the groin and pelvic girdle

Nerve root responsible?

A

L1

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3
Q

Sensory loss in the anterior thigh

Nerve root responsible?

A

L2

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4
Q

Sensory loss in the inner medial thigh and distal anterior thigh
Nerve root responsible?

A

L3

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5
Q

Sensory loss in the inner medial shin

Nerve root responsible?

A

L4

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6
Q

Sensory loss in the outer lateral shin and dorsum of foot

Nerve root responsible?

A

L5

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7
Q

Sensory loss in the lateral foot

Nerve root responsible?

A

S1

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8
Q

Boy fell vertically on foot

What is the bone likely to fracture?

A

Calcaneus
Also check for spinal fractures

Vertical falls - calcaneus & spine

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9
Q

Stress fractures of the foot mainly affect what bone?

A

Metatarsals

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10
Q

A young man presents with bone pain in the leg and its is unrelated to activity
Pain responded quickly to NSAIDs
Dx?

A

Osteoid Osteoma
= benign long bone tumours - e.g. femur , tibia

*note
Long bones
Young people
Respond quickly to NSAIDs

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11
Q

Known case of prostate ca develops perianal/groin numbness and inability to initiates urine
He also complains of back pain
Dx?

A

Cauda equina syndrome

Caused by metastasis to spine

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12
Q

Features of cauda equina syndrome (4)

A

Sciatica - low back , buttocks, hips, legs
Saddle paresthesia - anal/perianal/groin numbness
Urinary retention
Fecal incontinence - inability to control bowels

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13
Q

Commonest cause of cauda equina syndrome

Management

A

Central disc prolapse

M=
urgent MRI
Urgent referral to orthopaedic surgeon
Urgent surgical decompression

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14
Q

Lower back pain + saddle paresthesia

Next step -

A

Referral to neurosurgeon/ orthopaedic team for MRI

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15
Q

Lumbosacral disc herniation/ prolapse

Features (5)

A 
Severe lower back pain - radiates to leg
\+ve straight leg test
Pain getting up from lying position 
Lying down relieves pain 
\+/- sciatica
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16
Q

Lumbosacral disc herniation/ prolapse

Next step

A

Reassure + prescribe analgesics

If there are any red flags or ^ not given - MRI spine

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17
Q

Lumbosacral disc herniation/ prolapse

Management

A

Usually resolves in 6 weeks if not severe
NSAIDs - for pain relief + give PPI

If there is sciatica - give ** amitriptyline is preferred (or Gabapentin , pregabalin)

If + saddle paresthesia suspect cauda equina = urgent referral

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18
Q

Interbvertebral herniated discs are more common in what ages groups

A

<40

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19
Q

Intervertebral Degenerative disc more common in what age group?

A

> 40

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20
Q

Commonest site of herniated/degenerative disc

A
  1. L5/S1

2. L4/L5

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21
Q

What is cauda equina syndrome

A

Cauda equina = “horses tail” T12/L1 to coccyx)

Compression ^= surgical emergency

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22
Q

Shoulder weakness + pain raising arm above head
Plays ( volleyball/ tennis/badminton/swimming)
Or carries heavy object
Suspect?

A

Supraspinatus tendinitis

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23
Q

Elderly woman came with history of fall
On examination : painful hip, shortened externally rotated leg
Suspect?

A

Fracture of neck of femur

*elderly woman - osteoporosis - alendronate - NOF frx

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24
Q

Child (girl) - delivered breech
Comes with limping , painless leg that is shorter than the other
Examination shows unequal skin folds
Dx?

A

Developmental dysplasia of the hip

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25
Q

Risk factors for DDH (5)

A 
Female - x6 greater risk*
Breech presentation*
Family history *
Oligohydramnios*
First born
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26
Q

Commonest fracture 2ry to falling on outstretched hand

A

Scaphoid frx

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27
Q

Features of scaphoid fracture

A

Painful base of thumb
Tender snuff box
Pronation + ulnar deviation = pain

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28
Q

Management of scaphoid frx

A

Xray +ve - scaphoid cast 6 weeks

Xray -ve - cast and repeat xray in 2 weeks

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29
Q

DDH is more common in which hip

A

Slightly more common in left hip

20% cases are bilateral

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30
Q

Barlow test vs Ortolani test

A

Barlow - attempts to dislocate articulated femoral head

Ortolani - attempts to relocate a dislocated femoral head

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31
Q

What is used to confirm diagnosis of DDH if clinically suspected

A

Ultrasound

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32
Q

Management DDH

A

Most unstable hips stabilise by 3-6 weeks of age

Pavlik harness = dynamic flexion + abduction orthosis
- used in children < 4-5 months

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33
Q

While playing football, boy heard pop in his ankle + significant pain in the calf
He was unable to continue playing.
Next step?

A

Suspected Achilles’ tendon rupture

-Acute referral (same day) to orthopaedics

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34
Q

How to diagnose Achilles’ tendon rupture

A 
Clinically - Simmonds triad 
Ask patient to lie prone w/ feet over edge 
1. Abnormal angle of declination 
- more dorsiflexed 
2. Gap in tendon 
3.Thompson test = squeeze calf muscle 
-plantar flexion is seen = normal 
Affected = absent / negative plantar flexion
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35
Q

Dupuytren’s contracture

A

Abnormal fixed forward contracture

- cause = thickened fibrous connection within palmar fascia

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36
Q

Dupuytren’s contracture
Common in :
Specific causes:

A

Older male patients
** positive family history ( 60-70%)

Specs: manual labour, phenytoin, alcoholic liver disease, hand trauma , DM , smoking

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37
Q

Treatment of dupuytren’s contracture

A

Fasciotomy

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38
Q

Features of trigger finger (stenosis tenosynovitis)

3

A

More common in thumb middle or ring finger
Stiff finger + snapping/click when extending
Nodule at base of affected finger

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39
Q

Causes of osteoarthritis

A

Mechanical wear & tear

  • Localised loss of cartilage
  • Remodelling of adjacent bone
  • Associated inflammation
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40
Q

Osteoarthritis

A 
OA - 
M=F, commonly seen in elderly 
Hip knee (weight bearing joints affected), DIP PIP joints 
Mono arthritis, pain following use
*Improves with rest*, no systemic upset 
\+/- crepitus
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41
Q 
rheumatoid arthritis 
Cause
Gender
Age
Joint affected
History
A 
RA-
Autoimmune, women 
Adults - all ages
MCP,PIP 
Polyarthritis always, morning stiffness - improves with use
Systemic upset 
Bilateral symptoms
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42
Q

Xray findings OA

A 
LOSS
Loss of joint space 
Osteophytes at joint margins
Subchondral sclerosis
Subchondral cysts
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43
Q

Xray findings RA

A

Loss of joint space
Juxta-articulate osteoporosis
Periarticular erosions
Subluxation

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44
Q

Heberden vs Bouchard nodes

A 
Heb = affects DIP 
Bou= PIP
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45
Q

Management of OA

A

Exercise + physiotherapy + weight loss

  1. Pain = paracetamol
  2. +NSAIDs oral or COX-2 inhibitors (if no RF for gastric ulcers)
  3. Opioids - codeine

Always give PPI with NSAIDs

Surgery is last option

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46
Q

Dinner fork deformity
Frx?
Nerve affected

A

Colle’s fracture = posterior displacement of distal radius
Dorsal angulation

Nerve = median n injury

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47
Q

Garden spade deformity

A

Smith’s fracture

Anterior displacement of distal radius

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48
Q

Treatment of colles fracture in elderly

A

Closed reduction + POP cast below elbow

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49
Q

Mallet finger

A

Avulsion of extensor digitorum at DIP

= flexed bent finger

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50
Q

Gamekeeper/skier’s thumb

A

Injury to ulnar collateral ligament
Weakness + pain when grasping things with thumb
Tenderness over MCP

Caused by forced abduction

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51
Q

Monteggia fracture

A

Dislocation of radial head + frx of proximal 1/3 ulna
Radial n affected

(MU -ulna frx)

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52
Q

Galeazzi frx

A

Distal Radio-ulna joint dislocation + frx distal 1/3 radius shaft

MUGGER

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53
Q

Paget’s disease - features
Bones affected
Lab abnormality

A

Increased bone turnover - bendy, thickens and becomes spongy
Commonly - axial bone, long bone , skull
Area is warmer - highly vascular === high cardiac output failure

Normal Ca + normal Phosphate + HIGH ALP

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54
Q

Xray of Paget’s disease (osteitis deformitans)

A

Cortical sclerosis
Coarse trabecular pattern
= blade of grass lesion - v shape b/w healthy and diseased bone
=multi focal sclerotic patches - cotton wool pattern in skull

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55
Q

Treatment

A

Bisphosphonates

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56
Q

Lyric punched out lesions on xray

A

Multiple myeloma

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57
Q

High ALP

Seen in??

A

2Bs + P

  1. Bone - osteomalacia, paget’s, hyperparathyroidism, bone mets
  2. Biliary tract : cholestasis (obstructive jaundice)

P - pregnancy (physiological)

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58
Q

Hypercalcemia
Think of the following :
(4)

A

Bone mets
SCC of lung
Multiple myeloma
1ry hyperparathyroidism - low phosphate, high/normal PTH

BONES STONES MOANS GROANS

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59
Q

What is multiple myeloma

A

Plasma cell cancer

- overgrowth of plasma cells replacing bone marrow tissues + overproduction of immunoglobulins

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60
Q

Symptoms of multiple myeloma (5)

A

Bone pain - back, ribs
Hypercalcemia - polyuria, polydipsia, low mood, confusion
Anemia = fatigue weakness pallor dyspnea on exertion
Recurrent infections
Renal failure

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61
Q

Diagnostic investigation multiple myeloma

A

Bone marrow biopsy

= abundant plasma cells

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62
Q 
Findings in Multiple myeloma
Biopsy
Blood film
Urine/serum proteomics electrophoresis 
Xray
A
  1. Biopsy - abundant plasma cells
  2. Serum protein electrophoresis - spike in 3.monoclonal immunoglobulins
  3. Urine protein electrophoresis = bence jones protein**
  4. blood film = Rouleaux formation
  5. Xray = lytics lesion
    - plasma cells > osteoclasts> bone lysis
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63
Q

Rouleaux formation

A

Linking of RBCS = stack of coins

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64
Q

Bence jones protein seen in

A

Multiple myeloma
Leukaemia
Polycythemia Vera

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65
Q 
Labs in multiple myeloma 
Ca 
ALP
Hgb
ESR
RFT
A 
Hypercalcemia - >2.6
Normal ALP (30-150 U/L)
Anemia - normocytic normochromic 
High ESR
RFT = could be impaired (50% of cases)
- low GFR, high urea and creatinine
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66
Q

Multiple myeloma
Bence jones
Plasma cells
Seen where?

A

Plasma cells - BM biopsy

BJ - urine protein electrophoresis

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67
Q

Comments lab finding in multiple myeloma

A

Anemia

68
Q

Absence of proximal and distal pulses in fracture femur

Injury to?

A

Femoral artery

69
Q

Posterior tibial artery supplies what ?

A

Posterior compartment of leg + planter surface of leg

70
Q

Dorsalis pedis supplies?

A

Foot

71
Q

Next step in any case of

obvious deformity or neuro vascular compromise

A 
ABCD
Urgent reduction under sedation / analgesia*
(Usually IV midazolam)
  l
Referral or neurovasc/ortho

*even before XRAY

72
Q

Femur fracture management

A

Check hemodynamic stability
If stable (SBP >100)- Thomas splint first!!
- before IV fluid and ABCDE
Aim is to align frx to reduce blood loss

73
Q

Child with painful hip + ESR and WBC mildly elevated /normal
Local exam - normal
Systemically well and happy
Dx?

A

Transient synovitis

74
Q

Child with painful hip
ESR and WBC raised , fever >38.5
Systemically unwell
Dx?

A

Septic arthritis

75
Q

Most likely affected nerve in frx of acetabulum

A

Sciatic nerve

76
Q

Radial n injury causes

A

Wrist drop

77
Q

Foot drop cause by which n damage

A

Common perineal - common

Sciatic n

78
Q

Claw hand - n damage

A

Ulnar nerve

79
Q

Loss of sensation in thumb index and middle finger

N injured?

A

Median nerve

80
Q

Paresthesia of little and ring finger

N injured?

A

Ulnar nerve

81
Q

Radial n injury

Loss of sensation where?

A

Dorsal aspect of thumb

Small area b/w thumb and index

82
Q

Axillary n injury

Loss of sensation where?

A

Superior aspect of upper arm just below shoulder joint

83
Q

Fracture neck of fibula

N injury ?

A

Common peroneal

84
Q

Acetabulum fracture

N injury?

A

Sciatic nerve

85
Q

NOF frx

N injury?

A

Sciatic nerve

86
Q

Posterior dislocation of hip

N injury ?

A

Sciatic n

87
Q

Fracture of humeral shaft

N injury?

A

Radial nerve

88
Q

Humeral neck fracture

N injury?

A

Axillary

89
Q

Monteggia frx

Nerve injury?

A

Radial nerve

90
Q

Colles fracture

Nerve injury

A

Median nerve

91
Q

Suspected bone mets
Initial investigation
Most appropriate test

A

II- serum ca

Most app - MRI if not given , bone scintigraphy

92
Q

Gold standard for bone mets

A

MRI

2. Bone scintigraphy

93
Q

Skeletal survey is done in

A

Multiple myeloma

- lyric punched out lesions XRAY

94
Q

Side effects of long term steroid use (4)

A

Osteoporosis
Cataract
Peptic ulcers
Hypergylcemia

95
Q

Most common tumour in children

A

Osteosarcoma

96
Q

Young boy came with painful knee + gait abnormality
Tender smooth mass on side of knee on examination
Dx?

A

Osteosarcoma

97
Q

Young boy
Tender smooth mass (fixed) on side of knee
+fever + weight loss and tiredness
Dx?

A

Ewing sarcoma

98
Q

2nd most common bone tumour in children

A

Ewing’s sarcoma

99
Q

Radius head vs radius neck frx

A

Head - adults
Neck - children (up to 16)

Same features = lateral elbow swelling, limited elbow movement,
Increased pain with passive rotation of elbow

100
Q

Pt. w/ fracture femur; had surgery
24-72 hours later - decline in oxygen salts and level of consciousness
What do you suspect?

A

Fat embolism

- common in long bone fractures, multiple fractures

101
Q

Treatment of colles fracture in young

A

Above elbow backslab cast

102
Q

Colles fracture with incongruity or intra-articular frx

Treatment

A

ORIF

103
Q

Common sites of bone mets

From ? In males + females

A

Spine > pelvis> ribs > skull> long bones

Males - prostate, lung
Females - breast, lung

104
Q

Features of paget’s

A

Knee pain
Heart failure
Kyphosis
Hearing loss

105
Q

Carpal tunnel syndrome
Cause?
Treatment

A

Compression of median n by transverse carpal ligament
= carpal tunnel syndrome

T= release flexor retinaculum (release pressure on median n)

Flexor retinaculum = transverse carpal ligament = ant annular ligament

106
Q

Important Risk factor for carpal tunnel

A

Pregnancy - due to fluid retention

107
Q

Pregnant w/ carpal tunnel

Treatment

A

Wrist splint until delivery
(Usually resolves after delivery)
If doesn’t resolve - release flexor retinaculum

108
Q

Tinel test

A

Percussion over area of median n in carpal tunnel
Not always +ve
Very low sensitivity

109
Q

most common joints that experience strain

A

Ankle wrist

Sprain = torn ligament

110
Q

Management of sprain

A

P.R.I.C.E
Protect, rest, ice, compress, elevate

Elevate - eg high arm sling

111
Q

Septic arthritis
Common organism
Site commonly involved

A

Staph aureus
In young sexually active = n.gonorrhoea
Knee

112
Q

RF for septic arthritis

A

DM
Steroids
HIV
RA

113
Q

Dx septic arthritis

A

Aspiration of synovial fluid

Blood culture

114
Q

Management septic arthritis

A

Flucoxacillin - 4-6 weeks = 1st line
If allergic to penicillin = clindamycin

If the cause is not staph or n.g
=cefotaxine/ceftriaxone

If still not responding == repeated aspiration

IV ABx 1 week until culture -ve , swelling resolves > oral ABx 4 weeks

115
Q

Reactive arthritis vs septic arthritis

A

RA - no fever, young adults , typically after STI or GI infection (dysentery can illness)
Asymmetric, migratory oligoarthritis
Reiters triad = can’t see can’t pee can’t climb tree

Septic - arthritis
Single joint involvement, fever

116
Q

Management of reactive arthritis

A

NSAIDs, intra-articular steroids
Persistent disease - sulfasalazine, methotrexate

Symptoms rarely >12 months

117
Q

Child fell on outstretched arm
Absent radial and brachial pulse

Structure likely damaged?

A

Brachial a.

Think angulate supracondylar fracture of humerus

118
Q

Most common frx of fall on outstretched arm in children

A

Supracondylar extension type fracture
4-10 years

If this option not given - green stick frx

119
Q

Toddlers 1-3 yrs old with fracture
Fall on outstretched arm
Nothing seen on xray

A

Spiral fracture - might not be seen on Xray

120
Q

Features of meniscal tear (2)

Meniscal tear vs ant cruciate ligament injury

A

Locking
+ve Apley and Mc Murray tests
+ popping = anterior cruciate ligament injury - common w/meniscal tears

Immediate swelling - ant cruciate ligament
Delayed swelling - meniscal tear

121
Q

How are meniscal tears best seen

A

MRI

122
Q

Mc Murray’s test

A 
Mc Murray = 
Supine, tested knee fully flexed
Rotate tibia medically - extend
Rotate tibia laterally - extend 
\+ve - if clicking or locking or pain seen,
123
Q

Apley test

A

Apley = prone position 90 deg, fixate leg
traction and rotation (med/lat)
Look for excessive rotation or discomfort
Repeat w/ compression - look for decreased rotation + discomfort

Rotation + compression more painful = meniscal
Rotation + traction more painful = ligament

124
Q

When should you suspect posterior cruciate ligament injury

A

Hyper flexion to anterior direct impact injury

Ex- dashboard injury

125
Q

Direct impact to lateral side + +ve valgus stress test

A

Medial collateral ligament injury

126
Q

Direct impact to medial side + +ve varus stress test

A

Lateral collateral ligament injury

127
Q

Valgus stress test

A

Patient supine
Grab lower leg above ankle and fixate femur
Passive abduction @ knee joint

Repeat test w/ flexion

Look for excessive gapping and pain

128
Q

Varus stress test

A

Patient supine , legs fully extended
Grab lower leg above ankle and fixate femur medial side
Lateral rotation on knee
Passive adduction @ knee joint

Repeat test w/ flexion

Look for excessive gapping and pain

129
Q

Lachman test for?

A

Anterior cruciate ligament

Aka anterior drawer test

130
Q

Posterior drawer test

A

Posterior cruciate ligament

131
Q

+ve Apley & Mc Murray

Next step

A

MRI (meniscal tear)

132
Q

Fracture of humeral shaft
N injury
What is seen?

A

Radial n injury

Wrist drop - unable to dorsiflex

133
Q

Sunburst lyric lesion xray

A

Osteosarcoma

134
Q

Lytic lesion with onion skin layers

A

Ewing sarcoma

135
Q

When should MRI be done in case of bone mets

A

Within 7 days if there is only bone pain

Within 24 hrs if pain+ neurological signs

136
Q

Popeye appearance of arm

A

Proximal biceps tendon rupture

Muscle bunches up in distal arm

137
Q

Trauma + sudden sharp tearing sensation
Painful swollen elbow
Weak flexion + supination
Dx?

A

Distal biceps tendon rupture

“Feels like something in cubital fossa has ruptured”

138
Q

Washer woma / mammy thumb

A

De Quervain’s disease

Tenosynovitis - pain under root of thumb

139
Q

Tennis elbow

A

Lateral epicondylitis

Wrist extensors affected - pain on resisted extension

140
Q

Golfers elbow

A

Medial epicondylitis

Flexors affected - pain on resisted flexion

141
Q

Colles fracture in osteoporosis

A

DEXA scan to assess risk for future fracture

142
Q

T score -2.5 or lower

A

Osteoporosis

Give bisphosphonate

143
Q

Swelling in popliteal fossa
Asymptomatic
Round smooth non tender

A

Baker cyst

144
Q

Patient on warfarin

What is the most important symptom they need to report

A

Headache

-liable to subdue all hematoma

145
Q

Important symptoms to be urgently reported in pots on bisphosphonates

A

Severe sudden heartburn
Chest pain

  • dyspepsia/reflux is common after use in 1st month , improves with continuous use
146
Q

DEXA scan frequency

A

On bisphosphonate - every 3-5 yrs

If they stopped - check after 2 years

147
Q

How are bisphosphonates given

A

Oral alendronic acid
70 mg once a week
OR
10 mg once daily

NO MONTHLY REGIMEN

148
Q

T score for osteopenia

A

between -1 and -2.5

149
Q

Normal T score

A

-1 or higher

150
Q 
Perthes  disease
Joint affected
Ages seen
Cause
Gender
A

Degenerative condition - affects hip joint (10% are bilateral)
Children 3-9 yrs

Avascular necrosis of femoral head (femoral epiphyses)
M>F - 5:1

151
Q

Features of Perthe’s disease (4)

A 
Hip pain 
Limping
Reduced ROM of hip + stiffness
Xray = widening joint space- early
Late - decreased size femoral head/flattening , radiolucency of proximal metaphysis
152
Q

Ddx of perthes disease
<3 years
3-9
>9

A

<3 - DDH, toddlers fracture
3-9 - perthe’s
>9 - slipped upper femoral epiphysis

153
Q

Torus (buckle) fracture
Features
Age group
Treatment

A

Incomplete fracture of shaft of long bone
- bulging of cortex
Children 5-10

Self limiting / splint & immobilisation

154
Q

Most common type of fracture in childhood

Most common site

A

Buckle fracture

Distal radius

155
Q

Short leg + external rotation
Hx of hip replacement
Dx?
Next step?

A

Hip dislocation

Xray hips

156
Q

Treatment of compartment syndrome

A

Urgent fasciotomy

157
Q

How can renal failure happen in compartment syndrome

A

Compartment syndrome - myoglobinuria - renal failure

If myoglobinuria develops - aggressive IV fluid
Death of muscle group can result in 4-6 hours

158
Q

How long can death of muscle group take compartment syndrome

A

4-6 hrs

159
Q

DEXA for risk of frx assessment

A

Anyone over 50

With hx of fragility frx

160
Q

Common areas for fragility fracture

A

Vertebrae
Proximal femur
Distal radius

161
Q

RF for osteoporosis but no hx of fragility fracture

What do you do?

A

Fracture risk assessment - calculate 10 year major osteoporotic fracture risk using risk assessment tool
If >/= 10% do DEXA

162
Q

Recommended calcium for adults a day
Adults
In risk of fragility frx

A

700mg/day

Risk - at least 1000mg/day

Give ca + vit D if calcium intake is insufficient

163
Q

Indications for fascia iliaca compartment block

A

Block femoral lateral cutaneous an obituary or nerves
Injection immediately behind fascia iliaca @ Jn of lateral and middle thirds of inguinal ligament
Massaged upwards
US guided more effective

  • femur fractures - any aetiology
  • Anterior thigh wounds requiring exploration/washout
164
Q

Contraindications for fascia iliaca compartment block

A

Patient on anticoagulants - risk of bleeding with long needle
May cause hematoma

Local anaesthetic allergy
Open wounds or sign of infection at injection site

165
Q

Femur fracture pain management

A

Paracetamol>morphine> fascia iliaca block

166
Q

Management of distal radius fracture

A

Closed reduction
Then below elbow backslab

Even in minimal displacement

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