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
2
Q
Sensory loss in the groin and pelvic girdle
Nerve root responsible?
A
L1
3
Q
Sensory loss in the anterior thigh
Nerve root responsible?
A
L2
4
Q
Sensory loss in the inner medial thigh and distal anterior thigh
Nerve root responsible?
A
L3
5
Q
Sensory loss in the inner medial shin
Nerve root responsible?
A
L4
6
Q
Sensory loss in the outer lateral shin and dorsum of foot
Nerve root responsible?
A
L5
7
Q
Sensory loss in the lateral foot
Nerve root responsible?
A
S1
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
9
Q
Stress fractures of the foot mainly affect what bone?
A
Metatarsals
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
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
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
13
Q
Commonest cause of cauda equina syndrome
Management
A
Central disc prolapse
M=
urgent MRI
Urgent referral to orthopaedic surgeon
Urgent surgical decompression
14
Q
Lower back pain + saddle paresthesia
Next step -
A
Referral to neurosurgeon/ orthopaedic team for MRI
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
16
Q
Lumbosacral disc herniation/ prolapse
Next step
A
Reassure + prescribe analgesics
If there are any red flags or ^ not given - MRI spine
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
18
Q
Interbvertebral herniated discs are more common in what ages groups
A
<40
19
Q
Intervertebral Degenerative disc more common in what age group?
A
> 40
20
Q
Commonest site of herniated/degenerative disc
A
- L5/S1
2. L4/L5
21
Q
What is cauda equina syndrome
A
Cauda equina = “horses tail” T12/L1 to coccyx)
Compression ^= surgical emergency
22
Q
Shoulder weakness + pain raising arm above head
Plays ( volleyball/ tennis/badminton/swimming)
Or carries heavy object
Suspect?
A
Supraspinatus tendinitis
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
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
25
Risk factors for DDH (5)
```
Female - x6 greater risk*
Breech presentation*
Family history *
Oligohydramnios*
First born
```
26
Commonest fracture 2ry to falling on outstretched hand
Scaphoid frx
27
Features of scaphoid fracture
Painful base of thumb
Tender snuff box
Pronation + ulnar deviation = pain
28
Management of scaphoid frx
Xray +ve - scaphoid cast 6 weeks
| Xray -ve - cast and repeat xray in 2 weeks
29
DDH is more common in which hip
Slightly more common in left hip
| 20% cases are bilateral
30
Barlow test vs Ortolani test
Barlow - attempts to dislocate articulated femoral head
| Ortolani - attempts to relocate a dislocated femoral head
31
What is used to confirm diagnosis of DDH if clinically suspected
Ultrasound
32
Management DDH
Most unstable hips stabilise by 3-6 weeks of age
Pavlik harness = dynamic flexion + abduction orthosis
- used in children < 4-5 months
33
While playing football, boy heard pop in his ankle + significant pain in the calf
He was unable to continue playing.
Next step?
Suspected Achilles’ tendon rupture
| -Acute referral (same day) to orthopaedics
34
How to diagnose Achilles’ tendon rupture
```
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
```
35
Dupuytren’s contracture
Abnormal fixed forward contracture
| - cause = thickened fibrous connection within palmar fascia
36
Dupuytren’s contracture
Common in :
Specific causes:
Older male patients
** positive family history ( 60-70%)
Specs: manual labour, phenytoin, alcoholic liver disease, hand trauma , DM , smoking
37
Treatment of dupuytren’s contracture
Fasciotomy
38
Features of trigger finger (stenosis tenosynovitis)
| 3
More common in thumb middle or ring finger
Stiff finger + snapping/click when extending
Nodule at base of affected finger
39
Causes of osteoarthritis
Mechanical wear & tear
- Localised loss of cartilage
- Remodelling of adjacent bone
- Associated inflammation
40
Osteoarthritis
```
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
```
41
```
rheumatoid arthritis
Cause
Gender
Age
Joint affected
History
```
```
RA-
Autoimmune, women
Adults - all ages
MCP,PIP
Polyarthritis always, morning stiffness - improves with use
Systemic upset
Bilateral symptoms
```
42
Xray findings OA
```
LOSS
Loss of joint space
Osteophytes at joint margins
Subchondral sclerosis
Subchondral cysts
```
43
Xray findings RA
Loss of joint space
Juxta-articulate osteoporosis
Periarticular erosions
Subluxation
44
Heberden vs Bouchard nodes
```
Heb = affects DIP
Bou= PIP
```
45
Management of OA
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
46
Dinner fork deformity
Frx?
Nerve affected
Colle’s fracture = posterior displacement of distal radius
Dorsal angulation
Nerve = median n injury
47
Garden spade deformity
Smith’s fracture
| Anterior displacement of distal radius
48
Treatment of colles fracture in elderly
Closed reduction + POP cast below elbow
49
Mallet finger
Avulsion of extensor digitorum at DIP
| = flexed bent finger
50
Gamekeeper/skier’s thumb
Injury to ulnar collateral ligament
Weakness + pain when grasping things with thumb
Tenderness over MCP
Caused by forced abduction
51
Monteggia fracture
Dislocation of radial head + frx of proximal 1/3 ulna
Radial n affected
(MU -ulna frx)
52
Galeazzi frx
Distal Radio-ulna joint dislocation + frx *distal* 1/3 radius shaft
**MUGGER**
53
Paget’s disease - features
Bones affected
Lab abnormality
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
54
Xray of Paget’s disease (osteitis deformitans)
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
55
Treatment
Bisphosphonates
56
Lyric punched out lesions on xray
Multiple myeloma
57
High ALP
| Seen in??
2Bs + P
1. Bone - osteomalacia, paget’s, hyperparathyroidism, bone mets
2. Biliary tract : cholestasis (obstructive jaundice)
P - pregnancy (physiological)
58
Hypercalcemia
Think of the following :
(4)
Bone mets
SCC of lung
Multiple myeloma
1ry hyperparathyroidism - low phosphate, high/normal PTH
BONES STONES MOANS GROANS
59
What is multiple myeloma
Plasma cell cancer
| - overgrowth of plasma cells replacing bone marrow tissues + overproduction of immunoglobulins
60
Symptoms of multiple myeloma (5)
Bone pain - back, ribs
Hypercalcemia - polyuria, polydipsia, low mood, confusion
Anemia = fatigue weakness pallor dyspnea on exertion
Recurrent infections
Renal failure
61
Diagnostic investigation multiple myeloma
Bone marrow biopsy
| = abundant plasma cells
62
```
Findings in Multiple myeloma
Biopsy
Blood film
Urine/serum proteomics electrophoresis
Xray
```
1. Biopsy - abundant plasma cells
2. Serum protein electrophoresis - spike in 3.monoclonal immunoglobulins
4. Urine protein electrophoresis = bence jones protein**
5. blood film = Rouleaux formation
6. Xray = lytics lesion
- plasma cells > osteoclasts> bone lysis
63
Rouleaux formation
Linking of RBCS = stack of coins
64
Bence jones protein seen in
Multiple myeloma
Leukaemia
Polycythemia Vera
65
```
Labs in multiple myeloma
Ca
ALP
Hgb
ESR
RFT
```
```
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
```
66
Multiple myeloma
Bence jones
Plasma cells
Seen where?
Plasma cells - BM biopsy
| BJ - urine protein electrophoresis
67
Comments lab finding in multiple myeloma
Anemia
68
Absence of proximal and distal pulses in fracture femur
| Injury to?
Femoral artery
69
Posterior tibial artery supplies what ?
Posterior compartment of leg + planter surface of leg
70
Dorsalis pedis supplies?
Foot
71
Next step in any case of
| obvious deformity or neuro vascular compromise
```
ABCD
Urgent reduction under sedation / analgesia*
(Usually IV midazolam)
l
Referral or neurovasc/ortho
```
*even before XRAY
72
Femur fracture management
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
Child with painful hip + ESR and WBC mildly elevated /normal
Local exam - normal
Systemically well and happy
Dx?
Transient synovitis
74
Child with painful hip
ESR and WBC raised , fever >38.5
Systemically unwell
Dx?
Septic arthritis
75
Most likely affected nerve in frx of acetabulum
Sciatic nerve
76
Radial n injury causes
Wrist drop
77
Foot drop cause by which n damage
Common perineal - common
| Sciatic n
78
Claw hand - n damage
Ulnar nerve
79
Loss of sensation in thumb index and middle finger
| N injured?
Median nerve
80
Paresthesia of little and ring finger
| N injured?
Ulnar nerve
81
Radial n injury
| Loss of sensation where?
Dorsal aspect of thumb
| Small area b/w thumb and index
82
Axillary n injury
| Loss of sensation where?
Superior aspect of upper arm just below shoulder joint
83
Fracture neck of fibula
| N injury ?
Common peroneal
84
Acetabulum fracture
| N injury?
Sciatic nerve
85
NOF frx
| N injury?
Sciatic nerve
86
Posterior dislocation of hip
| N injury ?
Sciatic n
87
Fracture of humeral shaft
| N injury?
Radial nerve
88
Humeral neck fracture
| N injury?
Axillary
89
Monteggia frx
| Nerve injury?
Radial nerve
90
Colles fracture
| Nerve injury
Median nerve
91
Suspected bone mets
Initial investigation
Most appropriate test
II- serum ca
| Most app - MRI if not given , bone scintigraphy
92
Gold standard for bone mets
MRI
| 2. Bone scintigraphy
93
Skeletal survey is done in
Multiple myeloma
| - lyric punched out lesions XRAY
94
Side effects of long term steroid use (4)
Osteoporosis
Cataract
Peptic ulcers
Hypergylcemia
95
Most common tumour in children
Osteosarcoma
96
Young boy came with painful knee + gait abnormality
Tender smooth mass on side of knee on examination
Dx?
Osteosarcoma
97
Young boy
Tender smooth mass (fixed) on side of knee
+fever + weight loss and tiredness
Dx?
Ewing sarcoma
98
2nd most common bone tumour in children
Ewing’s sarcoma
99
Radius head vs radius neck frx
Head - adults
Neck - children (up to 16)
Same features = lateral elbow swelling, limited elbow movement,
Increased pain with passive rotation of elbow
100
Pt. w/ fracture femur; had surgery
24-72 hours later - decline in oxygen salts and level of consciousness
What do you suspect?
Fat embolism
| - common in long bone fractures, multiple fractures
101
Treatment of colles fracture in young
Above elbow backslab cast
102
Colles fracture with incongruity or intra-articular frx
| Treatment
ORIF
103
Common sites of bone mets
| From ? In males + females
Spine > pelvis> ribs > skull> long bones
Males - prostate, lung
Females - breast, lung
104
Features of paget’s
Knee pain
Heart failure
Kyphosis
Hearing loss
105
Carpal tunnel syndrome
Cause?
Treatment
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
Important Risk factor for carpal tunnel
Pregnancy - due to fluid retention
107
Pregnant w/ carpal tunnel
| Treatment
Wrist splint until delivery
(Usually resolves after delivery)
If doesn’t resolve - release flexor retinaculum
108
Tinel test
Percussion over area of median n in carpal tunnel
Not always +ve
Very low sensitivity
109
most common joints that experience strain
Ankle wrist
Sprain = torn ligament
110
Management of sprain
P.R.I.C.E
Protect, rest, ice, compress, elevate
Elevate - eg high arm sling
111
Septic arthritis
Common organism
Site commonly involved
Staph aureus
In young sexually active = n.gonorrhoea
Knee
112
RF for septic arthritis
DM
Steroids
HIV
RA
113
Dx septic arthritis
Aspiration of synovial fluid
| Blood culture
114
Management septic arthritis
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
Reactive arthritis vs septic arthritis
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
Management of reactive arthritis
NSAIDs, intra-articular steroids
Persistent disease - sulfasalazine, methotrexate
Symptoms rarely >12 months
117
Child fell on outstretched arm
Absent radial and brachial pulse
Structure likely damaged?
Brachial a.
Think angulate supracondylar fracture of humerus
118
Most common frx of fall on outstretched arm in children
Supracondylar extension type fracture
4-10 years
If this option not given - green stick frx
119
Toddlers 1-3 yrs old with fracture
Fall on outstretched arm
Nothing seen on xray
Spiral fracture - might not be seen on Xray
120
Features of meniscal tear (2)
Meniscal tear vs ant cruciate ligament injury
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
How are meniscal tears best seen
MRI
122
Mc Murray’s test
```
Mc Murray =
Supine, tested knee fully flexed
Rotate tibia medically - extend
Rotate tibia laterally - extend
+ve - if clicking or locking or pain seen,
```
123
Apley test
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
When should you suspect posterior cruciate ligament injury
Hyper flexion to anterior direct impact injury
| Ex- dashboard injury
125
Direct impact to lateral side + +ve valgus stress test
Medial collateral ligament injury
126
Direct impact to medial side + +ve varus stress test
Lateral collateral ligament injury
127
Valgus stress test
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
Varus stress test
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
Lachman test for?
Anterior cruciate ligament
Aka anterior drawer test
130
Posterior drawer test
Posterior cruciate ligament
131
+ve Apley & Mc Murray
| Next step
MRI (meniscal tear)
132
Fracture of humeral shaft
N injury
What is seen?
Radial n injury
| Wrist drop - unable to dorsiflex
133
Sunburst lyric lesion xray
Osteosarcoma
134
Lytic lesion with onion skin layers
Ewing sarcoma
135
When should MRI be done in case of bone mets
Within 7 days if there is only bone pain
| Within 24 hrs if pain+ neurological signs
136
Popeye appearance of arm
Proximal biceps tendon rupture
| Muscle bunches up in distal arm
137
Trauma + sudden sharp tearing sensation
Painful swollen elbow
Weak flexion + supination
Dx?
Distal biceps tendon rupture
| “Feels like something in cubital fossa has ruptured”
138
Washer woma / mammy thumb
De Quervain’s disease
| Tenosynovitis - pain under root of thumb
139
Tennis elbow
Lateral epicondylitis
| Wrist extensors affected - pain on resisted extension
140
Golfers elbow
Medial epicondylitis
| Flexors affected - pain on resisted flexion
141
Colles fracture in osteoporosis
DEXA scan to assess risk for future fracture
142
T score -2.5 or lower
Osteoporosis
| Give bisphosphonate
143
Swelling in popliteal fossa
Asymptomatic
Round smooth non tender
Baker cyst
144
Patient on warfarin
| What is the most important symptom they need to report
Headache
| -liable to subdue all hematoma
145
Important symptoms to be urgently reported in pots on bisphosphonates
Severe sudden heartburn
Chest pain
- dyspepsia/reflux is common after use in 1st month , improves with continuous use
146
DEXA scan frequency
On bisphosphonate - every 3-5 yrs
| If they stopped - check after 2 years
147
How are bisphosphonates given
Oral alendronic acid
70 mg once a week
OR
10 mg once daily
NO MONTHLY REGIMEN
148
T score for osteopenia
between -1 and -2.5
149
Normal T score
-1 or higher
150
```
Perthes disease
Joint affected
Ages seen
Cause
Gender
```
Degenerative condition - affects hip joint (10% are bilateral)
Children 3-9 yrs
Avascular necrosis of femoral head (femoral epiphyses)
M>F - 5:1
151
Features of Perthe’s disease (4)
```
Hip pain
Limping
Reduced ROM of hip + stiffness
Xray = widening joint space- early
Late - decreased size femoral head/flattening , radiolucency of proximal metaphysis
```
152
Ddx of perthes disease
<3 years
3-9
>9
<3 - DDH, toddlers fracture
3-9 - perthe’s
>9 - slipped upper femoral epiphysis
153
Torus (buckle) fracture
Features
Age group
Treatment
Incomplete fracture of shaft of long bone
- bulging of cortex
Children 5-10
Self limiting / splint & immobilisation
154
Most common type of fracture in childhood
| Most common site
Buckle fracture
| Distal radius
155
Short leg + external rotation
Hx of hip replacement
Dx?
Next step?
Hip dislocation
| Xray hips
156
Treatment of compartment syndrome
Urgent fasciotomy
157
How can renal failure happen in compartment syndrome
Compartment syndrome - myoglobinuria - renal failure
If myoglobinuria develops - aggressive IV fluid
Death of muscle group can result in 4-6 hours
158
How long can death of muscle group take compartment syndrome
4-6 hrs
159
DEXA for risk of frx assessment
Anyone over 50
| With hx of fragility frx
160
Common areas for fragility fracture
Vertebrae
Proximal femur
Distal radius
161
RF for osteoporosis but no hx of fragility fracture
| What do you do?
Fracture risk assessment - calculate 10 year major osteoporotic fracture risk using risk assessment tool
If >/= 10% do DEXA
162
Recommended calcium for adults a day
Adults
In risk of fragility frx
700mg/day
Risk - at least 1000mg/day
Give ca + vit D if calcium intake is insufficient
163
Indications for fascia iliaca compartment block
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
Contraindications for fascia iliaca compartment block
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
Femur fracture pain management
Paracetamol>morphine> fascia iliaca block
166
Management of distal radius fracture
Closed reduction
Then below elbow backslab
Even in minimal displacement
