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Year 4 Additional Notes > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

Risk factors for Achilles’ tendon disorders

A

Cirpofloxacin
Hypercholesterolaemia

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2
Q

Features of tendinitis

A

Gradual onset of posterior heel pain following activity
Morning pain and stiffness

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3
Q

Management of tendinitis

A

Conservative- orthotics, rest, physiotherapy, ice
Medical- analgesia
Specialist- Extracorporeal shock-wave therapy (ESWT), possibly surgery, to remove nodules and adhesions or alter the tendon, may be used where other treatments fail

NB- not steroid injections

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4
Q

Investigate a suspected Achilles’ tendon rupture

A

Simmonds triad- palpation of snapped tendon, dorsiflexed angle of declination at rest, calf squeeze (no plantar flexion)
Other feratures;
Weakness of plantar flexion of the ankle (dorsiflexion is unaffected)
Unable to stand on tiptoes on the affected leg alone

USS
Referral to orthopaedics

Treatment

Conservative- Rest and immobilisation, Ice, Elevation, ankle boot
Medical- Analgesia
Surgical- repair

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5
Q

Features of adhesive capsulitis (frozen shoulder)

A

Shoulder pain
External rotation is more affected than internal rotation or abduction
Active and passive movements affected
Painful freezing phase, adhesive phase, recovery phase
Bilateral in 20%
Episode typically lasts between 6 months-2 years

Associations- middle aged females and DM

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6
Q

Management of adhesive capsulitis

A

May want an X ray to rule out pathology
Conservative- physiotherapy
Medical- NSAIDs, intra articular corticosteroids
Surgery- surgical release of the capsule

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7
Q

Webers classification of ankle fractures

A

Describe fractures of the lateral malleolus (distal fibula). The fracture is described in relation to the distal syndesmosis (fibrous join) between the tibia and fibula.

A- below syndesmosis

B- at level of syndesmosis

C- above syndesmosis which may be damaged

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8
Q

Management of an ankle fracture

A

Orthopaedic referral
Reduce
Surgical repair (older- conservative)

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9
Q

Ottawa rules for ankle x ray

A

Pain in malleolar zone and one of following;

  • bony tenderness at medial malleolus
  • bony tenderness at lateral malleolus
  • inability to walk 4 weight bearing steps
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10
Q

What is a sprain

A

A stretching, partial, or complete tear of a ligament

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11
Q

Low ankle sprain

A

Most common- injury ATFL
Inversion injury
Usually able to weight bear unless severe of or high ankle sprain

RICE (rest, ice, compression, elevation)
Orthotics
Rarely surgery

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12
Q

High ankle sprain

A

External rotation of the foot
Weight bearing painful
Pain when fibula and tibia squeezed together

RICE (rest, ice, compression, elevation)
Orthotics
Rarely surgery (if diastisis eg. Tibia and fibula have separated)

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13
Q

Causes of a vascular necrosis of the hip

A

Long term steroids
Chemotherapy
Alcohol excess
Trauma

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14
Q

Features of AVN hip

A

Initially asymptomatic
Pain in affected joint

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15
Q

Investigations and management of AVN hip

A

X rays- may be normal (later- osteopenia and micro fractures, collapse of articular surface (crescent sign))
MRI- Gold standard

Refer to ortho- joint replacement

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16
Q

Bakers cyst

A

Can be primary or secondary to OA/ meniscal tears/ RA/ knee injuries or disease
Usually asymptomatic, if ruptured- DVT symptoms

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17
Q

Risk factors for biceps tendon rupture

A

Heavy overhead activities
Shoulder overuse/injury
Smoking
Corticosteroids (weaken tendons)

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18
Q

Features of biceps tendon rupture

A

Pop at distal or proximal tendon (with pain swelling and bruising)
Pop eye deformity if proximal/long tendon ruptures
Weakness on shoulder and elbow

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19
Q

Investigations and management of a biceps tendon rupture

A

Orthopaedic referral
Biceps squeeze (intact- forearm supination)
USS
Proximal- conservative
Distal- MRI, surgical

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20
Q

Buckle/torus fracture

A

Incomplete fracture of shaft of long bone with bulging of cortex (children)
Splinting and immobilisation

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21
Q

Carpal tunnel syndrome features

A

Compression of median nerve in carpal tunnel

Sensory- Pain/pins and needles in thumb, index, and middle fingers

Motor;
Weakness of thumb movements
Weakness of grip strength
Difficulty with fine movements involving the thumb
Wasting of the thenar muscles (muscle atrophy)

Symptoms ascend proximally
Patients shake hand to obtain relief typically at night

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22
Q

Causes of carpal tunnel

A

Idiopathic
Pregnancy
Oedema (heart failure)
Lunate fracture
Rheumatoid arthritis

Causes of bilateral carpal tunnel (look out for other features of the condition in exam)- rheumatoid arthritis, diabetes, acromegaly or hypothyroidism

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23
Q

Examination in carpal tunnel

A

Weakness of thumb abduction
Wasting of thenar eminence (not hypothenar)
Tinnels- tapping causes parasthesia
Phalens- flexion of wrist worsens symptoms

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24
Q

Investigations

A

Observations, hand and wrist exam
Bloods- DM, B12 deficiency, other routine bloods to exclude paraesthesia
Specialist- nerve conduction studies

Treatment

Conservative- wrist splints
Medical- corticosteroid injections,
Surgical- surgical decompression (cut flexor retinaculum)

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25
Q

Cauda equina syndrome

A

Lumbar sacral nerve roots that extend beyond the spinal cord are compressed

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26
Q

Causes of cauda equina

A

Disc prolapse (L4/5, L5/S1)
Tumours
Infection
Trauma
Haematoma

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27
Q

Features of cauda equina

A

Lower back pain
Bilateral sciatica
Reduced perianal sensation
Reduced anal tone (do a DRE)
Urinary incontinence (late stage sign- insensate)
Inability to maintain an erection/numb genitals

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28
Q

Investigation and management of CE syndrome

A

Urgent MRI
Surgical decompression

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29
Q

Colles fracture

A

Fall onto an outstretched hand
Distal radius fracture with dorsal displacement of fragments (and angulation)- think of the MOI (hit ground with outstretched hand, it will get bent back/dorsally)
Dinner fork type deformity

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30
Q

Compartment syndrome

A

2 main fractures causing this are supracondylar and tibial shaft injuries

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31
Q

Features of compartment syndrome

A

Pain on passive movement (excessive use of breakthrough analgesia is worrying, pain out of keeping with clinical signs)
6 P’s (presence of pulse doesn’t rule it out however)
Death of muscle group in 4-6 hours

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32
Q

Investigations and management of compartment syndrome

A

MSK exam, observations
Bloods- CK, FBC, UE (kidney involvement), CRP
Intracompartmental pressures (20+ bad, 40+ diagnostic), nothing on XRay

Prompt and extensive fasciotomy, IV fluids (kidneys), consider amputation

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33
Q

Features of cubical tunnel syndrome

A

Compression of ulnar nerve through the cubital tunnel

Tingling and numbness in 4/5th finger, intermittent, then constant
Weakness and muscle wasting
Pain worse on leaning on affected elbow
History of OA or trauma

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34
Q

Management of cubital tunnel syndrome

A

Avoid aggravating activity
Physiotherapy
Steroid injections
Surgery

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35
Q

Features of de Quervains tenosynvovitis

A

Pain on radial side of wrist
Tenderness over radial styloid
Abduction of thumb against resistance is painful
Finkelsteins test- examiner pulls thumb in ulnar deviation and causes pain

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36
Q

Management of DQ tenosynovitis

A

Conservative- Immobilisation with thumb splint, physiotherapy
Medical- analgesia, steroid injections
Surgery- cut the extensor retinaculum, releasing the pressure and creating more space for the tendons (Abductor pollicis longus (APL), Extensor pollicis brevis (EPB))

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37
Q

Features of discitis

A

Back pain
Systemic upset- pyrexia, rigors, sepsis
Neurological features- changing lower limb neurology if epidural abscess develops

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38
Q

Causes of discitis

A

Bacteria- staph aureus (endocarditis)
Viral
TB
Aseptic

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39
Q

Investigations

A

Bedside- MSK exam, observations, Mantoux test
Bloods- FBC, UE, LFT, CRP, ABG
Imaging- echocardiogram (endocarditis vegetation), MRI, CT guided biopsy (to determine effective treatment)

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40
Q

Management of discitis

A

6-8 weeks of IV ABX therapy

Complications- sepsis, epidural abscess

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41
Q

Causes of dupuytrens contracture

A

Manual labour
Phenytoin treatment
ALD
DM
Hand trauma

FH, male gender risks

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42
Q

Management of dupuytrens contracture

A

Surgical treatment when MCP’s cannot be straightened and hand cannot be placed flat on a table

ie. needle fasciotomy, Limited fasciectomy, Dermofasciectomy (remove skin as well as fascia)

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43
Q

Features of fat embolism

A

lungs- Tachycardia, tachypnoea, dyspnoea, hypoxia, pyrexia, 72 hours after injury
skin- Red brown impalpable petechiae rash, subconjunctival and oral haemorrhage or petechiae
brain/eyes- Confusion and agitation, retinal haemorrhages and intra arterial fat globules on fundoscopy

May see peripheral ground glass appearance on CTPA

NB- diagnosis of exclusion (eg. if D-dimer was negative, CTPA was clear, and symptoms depend on where the embolus travels)

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44
Q

Fracture management

A

Reduce, stabilise (surgery), preserve blood supply, rehabilitate

Immobilise including proximal and distal points
Monitor neuro vascular status
Manage infection esp. open fractures eg. IV broad spectrum ABX and tetanus prophylaxis
Closed- internal fixation device
Open- IV ABX, imaging, cover with wet dressing, debrided, lavaged and external fixation within 6 hours

Physio, occupational health, pathological- address underlying disease

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45
Q

Greater trochanteric pain syndrome (trochanteric bursitis)

A

Women 50-70
Pain over lateral side of hip/thigh
Tenderness on palpation of greater trochanter

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46
Q

Causes of an iliopsoas abscess

A

Haematogenous spread of bacteria eg. Staph aureus
Crohns (most common secondary cause)
Diverticulitis
CRC
UTI
Endocarditis
IVDU

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47
Q

Features of an iliopsoas abscess

A

Fever
Back/flank pain
Limp
Weight loss

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48
Q

Tests to diagnose iliopsoas inflammation

A

Supine- knee flexed and hip externally rotated. Place hand on affected side knee and get patient to push (pain)

Lie on unaffected side- hyperextend the affected hip (pain)

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49
Q

Investigations and management of an iliopsoas abscess

A

Usual tests (esp. blood cultures, septic screen)
CT abdomen is investigation of choice

ABX
Percutaneous drainage initial approach
Surgery if this fails or intra abdominal pathology

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50
Q

Iliotibial band syndrome

A

Cause of lateral knee pain in runners
Physio referral if activity modification doesn’t work

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51
Q

ACL injury features

A

Mechanism: high twisting force applied to a bent knee (PCL- hyperextension)
sudden ‘popping’ sound
knee swelling
instability, feeling that knee will give way
Anterior drawer test (90 degrees)
Lachmann test-30 degrees- better (3mm more than uninsured side)
Rapid swelling

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52
Q

Meniscal tear

A

Twisting injuries

Pain worse on straightening knee
Knee may give way
Knee locking
Delayed swelling
Tenderness along joint line (medial or lateral tenderness suggests M/L meniscus)
Thessalys test- weight bearing, 20 degrees knee flexion, positive if pain on twisting knee
May report popping sensation during injury

NB- MRI is initial imaging modality of choice, arthroscopy is gold standard

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53
Q

Red flags for lower back pain

A

Age <20 or 50+
Previous malignancy
Night pain
Pain at rest
Radicular, band like pain
History of trauma
Systemically unwell eg. Weight loss, fever
Thoracic pain
Cauda equina signs/symptoms

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54
Q

Investigations for lower back pain

A

Observations and MSK exam
No XRay (unless AS suspected), and only MRI if results may change management and where malignancy/infection/fracture/CES

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55
Q

Management of non specific lower back pain

A

NSAIDs first line (with PPI)
Exercise eg. Physiotherapy
Epidural injections of steroids if acute/severe sciatica

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56
Q

Features of lumbar spinal stenosis

A

Back pain , neuropathic pain, symptoms mimicking claudication

How to differentiate from vascular claudication- sitting better than standing, patients find it easier to walk uphill than downhill

Treat with laminectomy, always do ABPI to exclude vascular claudication

NB- due to degeneration, trauma, iatrogenic (ie. previous surgery), congenital

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57
Q

Meralgia paraesthetica risk factors

A

Lateral femoral cutaneous nerve (LCFN)

Obesity
Pregnancy
Ascites
Trauma
Iatrogenic (abdominal surgery)
Idiopathic

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58
Q

Features of meralgia parasthetica

A

Upper lateral thigh
Burning tingling, coldness, shooting pain
Numbness
Deep muscle ache
Aggregated by standing and extending hip, relieved by sitting
Mild, may resolve spontaneously, or may be severe
Hair loss

Signs;
Reproduce symptoms by deep palpation belie ASIS or extension of hip
Altered sensation over upper lateral aspect of thigh
No motor weakness

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59
Q

Investigations for MP

A

Nerve conduction studies
USS- possible cause

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60
Q

5th metatarsal fracture

A

Most commonly fractured and most common mid foot fracture
Often follows inversion injury of the ankle

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61
Q

Metatarsal stress fracture

A

Runners
2nd metatarsal shaft

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62
Q

Osteoarthritis hand features

A

Usually bilateral
CMC and DIP’s affected more than PIP’s
Episodic joint pain- worse with movement, relieved by rest
Stiffness esp. morning but not as long as RA
Swellings eg Heberdens (DIP), Bouchard (PIP)- bony osteophyte formation
Squaring if the thumb (fixed adduction)
Weak grip
Reduced range of motion

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63
Q

Features of OA of the hip

A

Chronic history of groin ache following exercise and relieved by rest

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64
Q

Complications of a total hip replacement

A

VTE (TED stockings, LMWH 4 weeks after hip replacement, started 6 hours post-op)
Intraoperative fracture
Nerve injury (sciatic)

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65
Q

Features of osteochondritis dissecans

A

Children and young adults

Knee pain and swelling typically after exercise
Knee catching, locking or giving away
Feeling a clunk when flexing or extending the knee
Joint effusion
Tenderness on palpation of the articular cartilage
Wilson’s sign- internal rotation causes pain

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66
Q

Osteomyelitis causes

A

Haematogenous- bacteraemia. Sickle cell, IVDU, immunosuppression eg. Steroids or HIV, infective endocarditis

Non Haematogenous- spread of infection from adjacent soft tissue or direct injury to bone. Diabetic foot ulcers, DM, PAD, pressure sores, open fractures, joint surgery etc.

Staph aureus most common, except in sickle cell where it’s salmonella

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67
Q

Investigations and management of osteomyelitis

A

MRI

Flucloxacillin for 6 weeks (clindamycin if allergic)

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68
Q

Management of patellar fractures

A

Undisplaced with intact extensor mechanisms can be managed non operatively with a hinged brace for 6 weeks

Displaced or loss of extensor mechanism- surgery and then knee brace

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69
Q

Flail chest

A

Caused by 2 or more rib fractures along 3 or more consecutive ribs (anteriorly)
Flail segment moves paradoxically during respiration and impairs ventilation of lung on side of injury
Surgery and invasive ventilation

NB- predisposes to a tension pneumothorax

70
Q

Management of rib fractures

A

Conservative- analgesia to ensure breathing isn’t affected by pain, as inadequate ventilation may predispose to chest infection

71
Q

Rotator cuff injury

A

Shoulder pain worse on abduction
Painful arc of abduction (subacromial impingement, between 60 and 120, with tear, may be in first 60)
Tenderness over anterior acromion

Acute rupture- acute severe pain and loss of strength ie. inability to abduct arm

72
Q

Causes of a scaphoid fracture

A

FOOSH
Contact sport eg. Rugby

73
Q

Scaphoid blood supply

A

Dorsal carpal branch (branch of radial artery) retrograde- liable to necrosis if this is damaged

74
Q

Signs of scaphoid fracture

A

Maximal tenderness over anatomical snuffbox (sensitive but not specific)

Wrist joint effusion

Pain via telescoping of thumb

Tenderness of scaphoid tubercle

Pain on ulnar deviation of the wrist

75
Q

Investigations for schaphpid fracture

A

Would do plain film radiographs, but MRI is actually what NICE recommend first line after clinical examination (but not common practice)

76
Q

Management of a scaphoid fracture

A

Immobilise with futuro splint or standard below elbow backslab before X ray
Refer to orthopaedics (if inconclusive- further imaging 7-10 days later)
Undisplaced- cast for 6-8 weeks
Displaced of proximal scaphoid pole fractures- surgical fixation

77
Q

Shoulder dislocations

A

Anterior- 95% of cases
arm is abducted and externally rotated

Posterior- seizure or electric shock
Recent dislocation- reduction can be attempted without analgesia/sedation (may require analgesia however)

MRI findings (damaged glenoid labrum)- Bankart and Hill-Sachs lesions

78
Q

Subluxation of radial head (pulled elbow)

A

Most common upper limb injury in children under 6
Child often refuses examination due to the pain

Management- analgesia, passive supination of elbow whilst elbow is flexed at 90 degrees

79
Q

Associations of talipes equinovarus (club foot)

A

Spina bifida
Cerebral palsy
Edwards syndrome (Trisomy 18)
Oligohydroamnios

80
Q

Trigger finger

A

Abnormal flexion of the digits
Idiopathic, but associated with women, RA, DM

Stiffness and snapping when extending a flexed digit, a nodule may be present

Steroid injections, finger splints, surgery if no response

81
Q

Risk factors for a fracture

A

Older age, long term bisphosphanate or corticosteroid use, bone tumour, osteoporosis, low BMI, prior fracture, trauma

82
Q

Investigations for a fracture

A

A-E, physical exam (neuro vascular), observations
Booods
Imaging- XRay (2 planes 90 degrees to one another, pre reduction and post reduction)

83
Q

Differentials for compartment syndrome

A

DVT
Acute limb ishcaemia
Rhabdomyolysis (crush injury, seizure- causes myalgia and generalised weakness)

84
Q

Midshaft humerus fracture

A

Radial nerve

85
Q

Fibula neck fracture

A

Common peroneal nerve

86
Q

Supracondylar fracture

A

Median nerve

87
Q

Shoulder dislocation

A

Axillary nerve

88
Q

Hip dislocation

A

Sciatic nerve

89
Q

Ways that a bone can be fixed

A

External casts
K wires
Intramedullary wires
Intramedullary nails
Screws
Plate and screws

90
Q

Management of rotator cuff injury

A

X-Ray to rule out fracture

Physio, reduced overhead lifting, ICD packs
NSAIDs, intrarticular corticosteroid injection, nerve blocks
Surgical repair

91
Q

What to remember with any joint pain

A

Think, could it be inflammatory ie. Do I need to check CRP and antibodies to rule out RA or another joint disease (rather than just thinking, okay, this is definitely adhesive capsulitis, think about what to say in OSCE- good to use them as differentials)

92
Q

Features of transient synovitis

A

Inflammation of hip affecting young children

Occur within a week of viral illness, gradual onset of limp, refusal to weight bear, groin or hip pain, positive leg roll, abducted and externally rotated hip, low or mild fever, otherwise well

93
Q

Management of transient synovitis

A

Ibuprofen and paracetamol
Rest
Follow up in a few days time with GP

NB- safety netting, if they develop fever and symptoms worsen, straight to AE (septic arthritis)

NB- child less than 3 with a new onset limp, urgent assessment

94
Q

Investigations for osteomyelitis

A

Bedside- examination, observations
Bloods- FBC ESR CRP VBG UE LFT blood cultures and sensitivities
Imaging- X ray (nothing for 2 weeks, then sequestrum, destruction, periostea, reactions), MRI (most sensitive- 5 days)
Specialist- bone biopsy (culture and sensitivities)

95
Q

Management of osteomyelitis

A

Local hospital guidelines for IV ABX (2 weeks IV, 4 weeks oral)- flucloxacillin, possibly with rifampicin or fuscidic acid added for the first 2 weeks
Consider surgical debridement

96
Q

Perthes disease

A

Idiopathic a vascular necrosis of the femoral head (unilateral or bilateral, between ages of 4-10)

97
Q

Features of Perthes disease

A

Slow onset of worsening symptoms (not acute or traumatic), with pain in hip or groin, limp (antalgic gait), restricted hip movements, referred pain to knee

98
Q

Investigations for perthes disease

A

Same as osteomyelitis, but also do MRI if x ray is normal and symptoms persist

99
Q

Management of Perthes disease

A

Analgesia
Mobilisation and physiotherapy
Non surgical containment (cast splint)
Surgical intervention
Regular X rays (assess healing)

100
Q

Slipped upper (capital) femoral epiphysis

A

Where head of femur is displaced along the growth plate

101
Q

Features of SUFE

A

Typically an obese, adolescent male undergoing a growth spurt (may also be history of minor trauma)

Hip, groin, thigh, or knee pain, restricted range of hip movement, antalgic gait, externally rotated hip, restricted movement in hip (internal rotation), trendelenburgs gait, obese

102
Q

Management of SUFE

A

Analgesia
Physiotherapy
Treat endocrinopathy if relevant
Surgical repair

103
Q

Developmental dysplasia of the hip (DDH)

A

Represents a spectrum of conditions affecting the proximal femur and acetabulum, ranging from acetabula immaturity to hip subluxation and frank hip dislocation

(The most common congenital abnormality of skeletal development)

104
Q

Features of DDH

A

Picked up during newborn examinations or when child presents with hip asymmetry (length/shape), limp, reduced range of movement in hip, asymmetric skin folds, buttock flattening

105
Q

Screening for DDH

A

Looked at during neonatal examination at birth and 6-8 weeks old
Findings that suggest it;

Different leg lengths
Restricted hip abduction on one side
Bilateral restriction in abduction
Difference in knee level when hips flexed
Clunking of hips on special tests (USS)

106
Q

Management of DDH

A

Conservative- most will heal normally
Less than 6 months- Pavlik harness
More than 6 months- surgery with hip spica cast

107
Q

Investigations for OA

A

MSK exam
Bloods- ESR CRP rheumatoid factor and anti CCP (all to exclude RA), FBC UE LFT (before giving diclofenac)
Imaging- XRay affected area

108
Q

Cervical spondylosis

A

OA of the cervical vertebrae
Neck pain, complications- Radiculopathy and myelopathy (carpal tunnel, imbalance, limb stiffness)- refer to neurosurgery immediately
Think JW

109
Q

What to do after hip replacement

A

Avoid flexing hip at 90 degrees
Avoid low chairs
Don’t cross legs
Sleep on back for 6 weeks

110
Q

VTE prophylaxis

A

LMWH
28 days post elective hip replacement
14 days post elective knee replacement

111
Q

Hand signs

A

Trousseaus- hypocalcaemia, carpal spasm when BP cuff inflated above systolic

Phalen- carpal tunnel syndrome

Chvostek- hypocalcaemia, tapping parotid causes facial muscles to twitch

Froments- ulnar nerve palsy

Finklesteins- de Quervains tenosynovitis

Tinnels- tapping wrist causes pain (carpal tunnel)

112
Q

Most common reason for hip revisions

A

Aseptic loosening is the most common reason total hip replacements need to be revised

113
Q

Management of carpal tunnel syndrome

A

Conservative- watch and wait, wrist splints
Medical- NSAIDs, corticosteroid injections
Surgery- surgical carpal tunnel release

114
Q

Investigations for osteomalacia

A

Vitamin D is low (this causes osteomalacia)
Serum calcium is low
Serum phosphate is low
Serum alkaline phosphatase may be high
Parathyroid hormone may be high (secondary hyperparathyroidism)
Xrays may show osteopenia (more radiolucent bones)
DEXA scan shows low bone mineral density

115
Q

Management of osteomalacia

A

Treatment is with supplementary vitamin D (colecalciferol). There are various regimes suggested by the NICE CKS on vitamin D deficiency. They involve correcting the initial vitamin D deficiency with one of the following:

50,000 IU once weekly for 6 weeks
20,000 IU twice weekly for 7 weeks
4000 IU daily for 10 weeks

A maintenance supplementary dose for of 800 IU or more per day should be continued for life after the initial treatment.

Patients with vitamin D insufficiency can be started on the maintenance dose without the initial treatment regime.

116
Q

Management of meralgia parasthetica

A

Conservative- rest, weight loss, physiotherapy
Medical- paracetamol, NSAID, neuropathic painkillers, steroid injections
Surgical- decompression or transection of the nerve (lateral femoral cutaneous nerve)

117
Q

What is trochanteric bursitis

A

Inflammation of a bursa over the greater trochanter on the outer hip.

118
Q

Management of trochanteric bursitis

A

Conservative- Rest, Ice
Medical- Analgesia (e.g., ibuprofen or naproxen), Physiotherapy, Steroid injections

119
Q

Ottawa rules for a knee Xray

A

Age 55 or above
Patella tenderness (with no tenderness elsewhere)
Fibular head tenderness
Cannot flex the knee to 90 degrees
Cannot weight bear (cannot take 4 steps – limping steps still count)

120
Q

Management of a meniscal tear

A

Conservative- RICE, physiotherapy, knee brace
Medical- NSAIDs
Surgical- repair or reconstruction (arthroscopy) using quadriceps/hamstring tendon

121
Q

Meniscal vs collateral ligament injuries

A

Meniscal- knee locking

Collateral ligament- knee instability

122
Q

Management of a collateral ligament tear

A

Conservative- RICE, physiotherapy, knee brace
Medical- NSAIDs
Surgical- repair (arthroscopy)

123
Q

Osgood-Schlatter disease

A

Inflammation at the tibial tuberosity where the patella ligament inserts. Visible or palpable hard and tender lump at the tibial tuberosity

124
Q

Management of a Bakers cyst

A

Conservative- Modified activity to avoid exacerbating symptoms, Physiotherapy
Medical- Analgesia (e.g., NSAIDs), Steroid injections
Further- Ultrasound-guided aspiration

125
Q

Olecranon bursitis

A

Students elbow

Swollen
Warm
Tender
Fluctuant (fluid-filled)

It is important to identify where bursitis is caused by infection. Features of infection are:

Hot to touch
More tender
Erythema spreading to the surrounding skin
Fever
Features of sepsis (e.g., tachycardia, hypotension and confusion)

NB- in septic arthritis, it is the elbow joint, not the bursae, that is swollen and erythematous (and reduced ROM)

126
Q

Olecranon bursitis

A

Students elbow

Swollen
Warm
Tender
Fluctuant (fluid-filled)

It is important to identify where bursitis is caused by infection. Features of infection are:

Hot to touch
More tender
Erythema spreading to the surrounding skin
Fever
Features of sepsis (e.g., tachycardia, hypotension and confusion)

NB- in septic arthritis, it is the elbow joint, not the bursae, that is swollen and erythematous (and reduced ROM)

127
Q

Management of olecranon bursitis

A

Conservative- Rest, Ice, Compression, Protecting the elbow from pressure or trauma
Medical- Analgesia (e.g., paracetamol or NSAIDs), Steroid injections may be used in problematic cases (where infection has been excluded)
Further- Aspiration of fluid may be used to relieve pressure

NB- where infected bursae is suspected, aspirate fluid for miscopy, culture, and sensitivities, and then give flucloxacillin

128
Q

Management of epicondylitis

A

Conservative- rest, adapt activities, physiotherpay, orthotics
Medical- Analgesia (e.g., NSAIDs), Steroid injections
Surgical and specialist- Extracorporeal shockwave therapy or surgery to release tendons

129
Q

Features of a hip fracture

A

Pain in the groin or hip, which may radiate to the knee
Not able to weight bear
Shortened, abducted, and externally rotated leg

130
Q

What is the danger with intracapsular NOF fractures

A

Disruption of blood supply leading to avascular necrosis of the hip

131
Q

Gardener classification for intracapsular NOF fractures

A

Grade I – incomplete fracture and non-displaced
Grade II – complete fracture and non-displaced
Grade III – partial displacement (trabeculae are at an angle)
Grade IV – full displacement (trabeculae are parallel)

III onwards is displaced

132
Q

Management of a NOF fracture

A

Appropriate analgesia
Investigations to establish the diagnosis (e.g., x-rays)
Venous thromboembolism risk assessment and prophylaxis (e.g., low molecular weight heparin)
Pre-operative assessment (including bloods and an ECG)
Orthogeriatrics input

133
Q

Morton’s neuroma

A

Injury of nerve between the 3rd-4th metatarsals
Burning, numbness or “pins and needles” felt in the distal toes

134
Q

Ganglion Cyst

A

Ganglion cysts can appear rapidly (over days) or gradually. Patients present with a visible and palpable lump. It is not usually painful

Can disappear on their own, or be drained via needle aspiration

135
Q

Spondylolisthesis

A

A condition in which the vertebral bodies slip forward in relation to the vertebrae beneath.

136
Q

Features of a disc prolapse

A

Acute onset of severe back pain
Stabbing or resembling electric shock (most commonly of the lower back, called lumbago)
Radiates to the legs (sciatic pain) or the arms
Paraesthesia of affected dermatome
Muscle weakness and atrophy
Loss of deep tendon reflexes in the indicator muscles
Pain increases with pressure (e.g., from coughing or sneezing)
Short walks and changing position reduce the pain

137
Q

Management of a disc prolapse

A

Conservative- physiotherapy, modification of activity, TENS device
Medical- analgesia, intraarticular steroids
Surgical- last resort (often a discectomy)

138
Q

Mechanical back pain

A

Mechanical back pain is an umbrella term that covers a range of conditions. These include lumbar muscle sprain/strain, which typically cause spasms on movement, and sometimes stiffness lasting less than 30 minutes. Mechanical back pain is usually aggravated by movements, and certain postures.

You would expect it to last 2-4 weeks (longer- think of another diagnosis)

139
Q

Red flag spinal fracture

A

Sudden onset of severe central spinal pain which is relieved by lying down.
There may be a history of major trauma (such as a road traffic collision or fall from a height), minor trauma, or even just strenuous lifting in people with osteoporosis or those who use corticosteroids (vertebral wedge fracture)
Structural deformity of the spine (such as a step from one vertebra to an adjacent vertebra) may be present.
There may be point tenderness over a vertebral body.

140
Q

Red flag malignancy back pain

A

The person being 50 years of age or more.
Gradual onset of symptoms.
Severe unremitting pain that remains when the person is supine, aching night pain that prevents or disturbs sleep, pain aggravated by straining (for example, at stool, or when coughing or sneezing), and thoracic pain.
Localised spinal tenderness.
No symptomatic improvement after four to six weeks of conservative low back pain therapy.
Unexplained weight loss.
Past history of cancer — breast, lung, gastrointestinal, prostate, renal, and thyroid cancers are more likely to metastasize to the spine.

141
Q

Imaging and spinal pathology

A

X ray not helpful, unless ankylosing spondylitis
MRI is imaging modality of choice

142
Q

What you must always do with a patient when you believe that the diagnosis isn’t sinister

A

Safety net ie. what red flags to look out for, present to AE immediately

143
Q

Management of sciatica

A

The initial management of sciatica is mostly the same as acute low back pain.

The NICE clinical knowledge summaries (updated 2020) state not to use medications such as gabapentin, pregabalin, diazepam or oral corticosteroids for sciatica. They state not to use opioids for chronic sciatica.

They suggest considering a neuropathic medication if symptoms are persisting or worsening at follow up, but not gabapentin or pregabalin, leaving at the main choices of:

Amitriptyline
Duloxetine

Also physio, intra articular steroids, decompression etc.

144
Q

Management of sciatica

A

The initial management of sciatica is mostly the same as acute low back pain.

The NICE clinical knowledge summaries (updated 2020) state not to use medications such as gabapentin, pregabalin, diazepam or oral corticosteroids for sciatica. They state not to use opioids for chronic sciatica.

They suggest considering a neuropathic medication if symptoms are persisting or worsening at follow up, but not gabapentin or pregabalin, leaving at the main choices of:

Amitriptyline
Duloxetine

145
Q

Features of osteomalacia

A

Young children- rickets
Adults- Bone pain, tenderness and proximal myopathy (waddling gait)

146
Q

Features of talipes equinovarus (club foot)

A

Inverted + plantar flexed foot

147
Q

Acromioclavicular joint injury

A

Injury to the AC joint is relatively common and typically occurs during collision sports such as rugby following a fall on to the shoulder or a FOOSH (falls on outstretched hand).

Grade I and II injuries are very common and are typically managed conservatively including resting the joint using a sling.

III- case-by-case assessment

Grade IV, V and VI are rare and require surgical intervention.

148
Q

Investigations for supraspinatus tendinitis/subacromial impingement

A

USS or MRI

149
Q

Management of supraspinatus tendonitis/ subacromial impingement

A

Conservative- activity modification, home exercises, referral to a physiotherapist
Medical- analgesia, intraarticular steroids

150
Q

Smith fracture (reverse colles’)

A

Volar angulation of distal radius fragment (Garden spade deformity)
Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed

151
Q

Bennets fracture

A

Intra-articular fracture of the first carpometacarpal joint
Impact on flexed metacarpal, caused by fist fights
X-ray: triangular fragment at ulnar base of metacarpal

152
Q

Monteggias fracture

A

Dislocation of the proximal radioulnar joint in association with an ulna fracture
Fall on outstretched hand with forced pronation
Needs prompt diagnosis to avoid disability

153
Q

Galeazzi fracture

A

Radial shaft fracture with associated dislocation of the distal radioulnar joint
Direct blow

154
Q

Potts fracture

A

Bimalleolar ankle fracture
Forced foot eversion

155
Q

Bartons fracture

A

Distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation
Fall onto extended and pronated wrist

156
Q

Chondromalacia Pataellae

A

Teenage girls, following an injury to knee e.g. Dislocation patella
Typical history of pain on going downstairs or at rest
Tenderness, quadriceps wasting

157
Q

Patellar tendonitis

A

More common in athletic teenage boys
Chronic anterior knee pain that worsens after running
Tender below the patella on examination

158
Q

Management of intracapsular hip fractures (Gardener)

A

Undisplaced- internal fixation, or hemiarthroplasty if unfit.

Displaced- arthroplasty (total hip replacement or hemiarthroplasty)

NB- total hip replacement is favoured to hemiarthroplasty if patients:
-were able to walk independently out of doors with no more than the use of a stick
-are not cognitively impaired
-are medically fit for anaesthesia and the procedure.

NB- #NOF is intracapsular (so internal fixation or arthroplasty)

NB- X-ray first line, MRI for occult fractures not seen on xray

159
Q

Management of extracapsular hip fractures

A

Stable intertrochanteric fractures: dynamic hip screw

Reverse oblique, transverse or sub trochanteric fractures: intramedullary device

NB- mobility not a factor

160
Q

Types of hip dislocation

A

Posterior dislocation: Accounts for 90% of hip dislocations. The affected leg is shortened, adducted, and internally rotated.

Anterior dislocation: The affected leg is usually abducted and externally rotated. No leg shortening.

161
Q

Complications of a hip dislocation

A

Sciatic or femoral nerve injury
Avascular necrosis
Osteoarthritis: more common in older patients.
Recurrent dislocation: due to damage of supporting ligaments

162
Q

Acromioclavicular dislocation

A

Prominent clavicle
Step deformity

163
Q

Management of neck of femur fractures based on Gardener’s classification

A

1+2= dynamic hip screw

3+4= throw the joint on the floor ie. arthroplasty

164
Q

What is an an effective and commonly used method of analgesia for elderly patients with a neck of femur fracture

A

An iliofascial nerve block

165
Q

Normal lower limb variants in children

A

Flat feet (pes planus)- resolves 4-8 years

In toeing- resolves

Out toeing- resolves by 2 years

Bow legs (genu varum)- resolves by 4-5 years

Knock knees (genu valgum)- resolves

166
Q

Imaging choice of osteoporotic vertebral fracture

A

X ray

167
Q

ACL vs meniscal damage

A

While a meniscal tear can present similar to an ACL injury, you can differentiate the two by the timing of the swelling. ACL injuries swell immediately due to haemarthrosis, meniscal tears typically swell over time.

168
Q

Knee injury comparisons

A

pass med page

169
Q

Cauda equina vs sciatica

A

Sciatica;

Pain that radiates around the lower back, buttocks and/or leg(s)
A tingling sensation in the affected areas
Numbness in the affected areas
Generalised lower back pain
Muscle weakness in the legs

Cauda equina. Same Sx as sciatica but also;

Bladder/bowel disturbance
Numbness around the buttocks, perineum and genitals (saddle anaesthesia)
Reduced anal tone
Foot drop and poor reflexes in the lower limbs

170
Q

Frozen shoulder on xray

A

no findings (OA- LOSS signs)

171
Q

Intraoperative hypothermia

A

can cause excessive bleeding

172
Q

Contaminated (farmyard) open wounds

A

Definitive surgical fixation can be done initially only if it can be followed by definitive soft tissue coverage. However more often than not an external fixation device is used as an interim measure while soft tissue coverage is achieved (which should be done within 72 hours).

Year 4 Additional Notes (17 decks)

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