Orthopaedics Flashcards
1
Q
In the major haemorrhage protocol, what baseline bloods should be taken pre-transfusion?
A
FBC
Group and save
Clotting
Clauss fibrinogen assay (measures function of fibrinogen)
2
Q
In which major haemorrhage scenarios can tranexamic acid be given, and how should it be prescribed?
A
If trauma within 3 hours
Dose is 1g bolus over 10 mins followed by 1g infusion over 8 hours
3
Q
When examining a joint, what 3 things should you assess for?
A
Pain
Effusion
Temperature
4
Q
What are the 3 main tests to do when examining any joint?
A
Look
Feel
Move
5
Q
Describe the tests for each muscle of the rotator cuff
A
Supraspinatus tendon: Empty can test
Infraspinatus: External rotation against resistance
Teres minor: Hornblower test
Subscapularis: Internal rotation against resistance
6
Q
What 2 special tests can be doe on examination for carpel tunnel syndrome? Describe them
A
Tinel’s test: tap along nerve from index finger down through wrist towards antecubital fossa, is positive if tingling or paraesthesia down median nerve as is tapped
Phalen’s test: put hands in like a downwars pray position with backs of hands together, positive if tingling/ paraesthesia in distribution of median nerve
7
Q
What does the Trendelenburg test assess?
A
Abductor (gluteus medius and minimus) abnormality
8
Q
What is a positive trendelenburg test?
A
Dip in hip when lifting GOOD side leg
9
Q
How do you perform Thomas’ test, and what does it assess?
A
Ask pt to lie down, and to bring their knee up to their chest to ‘hug’ it
Positive test = other leg lifts off bed
Tests for fixed flexion deformities eg iliopsoas tightness, ACL tear, osteoarthritis…
10
Q
How can you identify if leg shortening is tibial or femoral in nature?
A
Galeazzi test
Get pt to lie down, flex hips to 45 degrees and knees to 90 degrees
Test is positive when knees are a different heights
If lower knee displaced towards foot = shortened tibia, if displaced towards body = shortened femur
11
Q
What can you do on examination to test for Achilles tendon rupture?
A
Simmond’s test
Calf squeeze –> foot movement
12
Q
What can you do on examination to test for Morton’s neuroma?
A
Mulden’s test
Clasp metatarsals and poke plantar side of foot - positive test will be pain/ tingling
13
Q
After an orthopaedic examination in PACES, what can you say you would like to do to finish your examination?
A
Assess neurovascular status
Assess joints above and below
Test the contralateral joint
14
Q
What are the 4 stages of fracture healing and how long does each one last?
A
- Reactive: first 48 hours
Reparative phase = 2 days - 2 weeks - Proliferation (reparative phase part 1)
- Consolidation (reparative phase part 2)
- Remodelling = 1 week - 7 years
15
Q
What is an avulsion fracture?
A
When small chunk of bone attached to a tendon/ligament gets pulled away from the main part of the bone. Common in young athletes
16
Q
What radiographs do you need to image a fracture properly?
A
Orthogonal radiographs (at right angles) –> request AP and lateral films
17
Q
What is an open vs closed fracture?
A
Open breaks the skin, closed doesn’t
18
Q
What is an extraarticular fracture?
A
One that doesn’t cross the surface of a joint
19
Q
What is fracture angulation?
A
Where the normal axis of the bone has been altered such that the distal portion of the bone points off in a different direction
20
Q
What is fracture translation?
A
Movement of the fractured bones away from each other
21
Q
What are the 4 elements of fracture ‘deformity’ you might comment on?
A
Translation (‘translocation’)
Angulation
Rotation
Impaction
22
Q
What are the ‘four Rs’ of fracture management?
A
Resuscitation
Reduction
Restriction
Rehabilitation
23
Q
Recall the principles of resuscitation in fracture management
A
- ATLS - Trauma assessed in primary survey (C spine, chest, pelvis) with secondary survey addressing #
- Assess neurovascular status and look for dislocations
- Stabilise BEFORE imaging
24
Q
Recall the ‘6 As’ of managing open fractures
A
Analgesia
Assess: NV status, soft tissues, photograph
Alignment: align # and splint
Anti-sepsis: wound swab, copious irrigation, cover with betadine-soaked dressing
Anti-tetanus: check status (booster lasts 10 years)
Antibiotics: flucloxacillin 500mg IV/IM, benzylpenicillin 600mg IV/IM)
25
What system can be used to classify open fractures?
Gustilo classification
26
Differentiate the 3 types of fracture in the Gustilo classification in terms of size
Type 1: <1cm
Type 2: 1-10cm
Type 3: >10cm
27
When describing the possible complications of fracture management, under what sub-headings can you classify them? Name some complications under each subheading
Anaesthetic - anaphylaxis, damage to teeth, aspiration
Intra-operative - bleeding, damage to local structures (eg neurovascular injury), treatment failure
Early post-operative - compartment syndrome, infection (surgical site, UTI, bed sores), VTE, ABx colitis
Late post-operative - scarring, fx loss, neuropathy, pain, myositis ossificans
28
What is myositis ossificans?
A condition where bone tissue forms inside muscle or other soft tissue after an injury at sites of haematoma formation
29
Describe how compartment syndrome develops
Oedema from fracture --> increased pressure --> decreased venous drainage --> increased pressure --> ischaemia
30
What are the signs and symptoms of compartment syndrome?
Pain on passive stretching
| Warmth, erythema, swelling, weak pulses, increased CRT
31
Recall 2 fracture sites that are most associated with compartment syndrome
Suprachondylar fractures
| Tibial shaft fractures
32
How should compartment syndrome be managed?
Elevate limb, remove all bandages/ splint etc -- fasciotomy
33
How should myositis ossificans be managed?
Excision
34
Recall 2 criteria that can be used to diagnose complex regional pain syndrome
Budapest criteria
| IASP criteria
35
What are the signs and symptoms of complex regional pain syndrome?
Affects a NEIGHBOURING area to the area affected by trauma
Hyperalgesia
Allodynia
Vasomotor disturbance (may be hot + sweaty or cold + cyanosed)
Swollen, atrophic and shiny skin
Hyperreflexia/ contractures/ dystonia
36
Recall some medical and surgical options for managing complex regional pain syndrome
Medical: amitriptyline + gabapentin
Surgical: regional nerve block
37
Recall the signs and symptoms of fat embolism
Looks like a PE but with neurological signs
Onset of dyspnoea, hypoxia and tachypnoea within 24 hours of multiple fractures
CNS signs: confusion, agitation, retinal haemorrhage
Dermatological: 25-50% develop a petechial rash
38
How should fat embolism be managed?
DVT prophylaxis
39
What are the Ottawa rules used for?
To decide if an x ray is needed
40
Recall the 4 criteria of the Ottawa knee rule
- Over 55 years old
- Isolated patellar tenderness
- Cannot flex to 90 degrees
- Inability to weight bear both immediately and in A&E for >4 steps
41
Recall the Ottawa ankle rule (much more complicated than knee!)
LMN FUN
Malleolar zone pain +
- Lateral malleolus posterior edge tenderness
- Medial malleolus posterior edge tenderness
- No weight bearing - both immediately and for 4 steps in A&E
Mid foot zone +
- Fifth metatarsal base pain
- Unable to weight bear immediately or for 4 steps in A&E
- Navicular tenderness
42
Recall the risk factors for #NOF
```
SHATTERED
Steroids
Hyperthyroidism/hyperparathyroidism
Alcohol/ smoking
Thin (BMI<22)
Testosterone LOW
Erosive bone disease (eg RhA, MM)
Renal failure
Early menopause
Dietary calcium low, DM
```
43
What is the key examination finding in #NOF?
Leg is shortened with external rotation
44
If someone's leg is shortened and internally rotated, what is this indicative of?
Posterior dislocation of the hip
45
What are the 3 types of intracapsular NOF#?
Subcapital
Transcervical
Basicervical
46
What are the 3 types of extracapsular NOF#?
Intertrochanteric
Subtrochanteric
Reverse oblique
47
What is the best analgesia for a #NOF?
Iliofascial nerve block
48
What is the surgical management of intertrochanteric #NOF?
Dynamic hip screw
49
How should extracapsular NOF# be managed?
ORIF (although intertrochanteric # can be managed with a DHS)
50
How can the degree of displacement of an intracapsular NOF# be classified?
Using Garden classification (grades I-IV)
51
What is the difference between a total hip replacement and a hemiarthroplasty?
```
THR = replaces femoral head and acetabulum
Hemiarthroplasty = replaces femoral head
```
52
What is the 1 year mortality for NOF#?
30%
53
What type of NOF# is most likely to be complicated by osteonecrosis and why?
Transcervical fracture
| Retinacular artery is disrupted from medial circumflex femoral artery
54
What are the signs and symptoms of osteonecrosis of the hip?
Anterior hip pain on climbing the stairs
| Insidious onset
55
How can osteonecrosis of the hip be medically managed?
Bisphosphonates
56
Recall 4 options for managing humeral fracture and the general indications for each one
Collar & cuff: 2 parts, minimally displaced, high surgical risk
ORIF: >2 parts but not highly comminuted
Arthroplasty: large displacement of humeral head and high risk of non-union
Reverse arthroplasty - irreprable rotator cuff/ previous unsuccessful replacement
57
What is the most common type of paediatric elbow fracture?
Suprachondylar humeral #
58
How will a suprachondylar humeral # appear on examination?
Elbow swollen and hand semi-flexed
59
What is the most likely artery to be severed by a suprachondylar humeral #?
Brachial artery (by sharp edge of proximal humerus)
60
What is the most likely nerve to be damaged by a suprachondylar humeral #?
Median nerve
61
What are the signs and symptoms of subluxation of the humeral head?
Elbow pain and limited supination and extension of the elbow
62
What is the 'dinner fork' deformity associated with?
Colle's #
63
What is Colle's #?
Posterior displacement and angulation of the distal radius fragment
64
What is Smith's #?
Anterior displacement and angulation of the distal radius fragment
65
What is the typical history of Colle's vs Smith's #?
Colle's = fall on an extended wrist
| Smith's fall on a flexed wrist
66
Recall 5 signs of scaphoid fracture
```
[1] Pain in the anatomical snuffbox
[2] Wrist joint effusion
[3] Pain on telescoping thumb
[4] Tenderness on scaphoid tubercle
[5] Pain on ulnar deviation of wrist
```
67
Why are scaphoid fractures particularly vulnerable to avascular necrosis?
Retrograde blood supply
| 80% is from the dorsal carpal branch of the radial artery
68
What is the most common long bone fracture?
Tibial
69
Which bone articulates with the tibia and fibula at the ankle joint?
Talus
70
What is Pott's fracture?
Bimalleolar #
71
What is a Lisfranc injury?
An injury of the foot in which one or more of the metatarsal bones are displaced from the tarsus
72
Recall some signs and symptoms of Lisfranc injury
Medial plantar bruising
Unable to weight bear
Gross midfoot swelling with severe pain
73
What is the most common metatarsal to be fractured in children vs adults?
Children: 1st
Adults: 5th
74
Recall 3 signs/symptoms of fractured patella
1. Palpable patellar defect
2. Significant haemarthrosis
3. Loss of straight leg raise
75
What 3 x ray views are recommended to image a patellar fracture?
AP
Lateral
Skyline (inferior-superior)
76
How should patellar # be managed if the # is comminuted and ORIF is not possible?
Partial patellectomy, or total patellectomy if no salvage potential
77
What are the main signs and symptoms of compartment syndrome?
Excessive use of breakthrough analgesia due to significant pain
78
Why might arterial pulses still be palpable in compartment syndrome?
Necrosis occurs as a result of microvascular compromise
79
How can a manometer be used to help diagnose compartment syndrome?
Can use to measure intracompartmental pressure (ICP)
Normal pressure = 0-10mmHg
Delta pressure <30mmHg = compartment syndrome
Absolute pressure >30mmHg = compartment syndrome
80
Recall some non-operative options for managing compartment syndrome
- Fluid resuscitation to ensure normotension (as hypoperfusion accelerates tissue injury)
- Remove circumferential bandages and casts
- Maintain limb at level of heart
81
How can compartment syndrome be managed operatively?
Fasciotomy
82
Which tendon is impinged in 'subacromial impingement'?
Supraspinatus tendon
83
What is Hawkin's test used to diagnose, and how is it performed?
For shoulder impingement
90 degrees shoulder and elbow flexion
Passive internal rotation of the arm --> pain
84
Recall some differentials for subacromial impingement
Adhesive capsulitis
Supraspinatus tear
Osteoarthritis/ Rheumatoid/ Septic arthritis
Gout/ Pseudogout
85
Recall some management options for subacromial impingement under the headings of 'conservative', 'medical' and 'surgical'
Conservative: rest, phyisio
Medical: NSAIDs, subacromial bursa steroid
Surgical: athroscopic acromioplasty
86
What are the 3 stages of calcific tendonitis of the shoulder?
1. Pre-calcific (pain-free fibrocartilaginous metaplasia of tendon)
2. Calcific (phases of varying levels of pain)
3. Post-calcific
87
What imaging is useful in calcific tendonitis of the shoulder?
XR (shows deposits on AP)
| US (shows extend of calcification and targets therapy)
88
What are the 4 muscles of the rotator cuff?
Supraspinatus
Infraspinatus
Subscapularis
Teres minor
89
Recall 4 risk factors for a rotator cuff tear
Age >60
Smoking
Family history
Hypercholesterolaemia
90
How can you differentiate between a partial and complete rotator cuff tear?
Partial --> painful arc
Complete --> shoulder tip pain, FULL RANGE of passive movement but with inability to abduct arm. Active abduction IS possible following passive abduction to 90 degrees. 'Drop arm' sign (lowering arm beneath 90 degrees abduction --> sudden drop)
91
Recall which muscles are involved in each stage of arm abduction
0-15 degrees = supraspinatus
15-90 degrees = deltoid
>90 degrees = serratus anterior + trapezius
92
What test can be used to test teres minor and how is it performed?
Hornblower's test
Shoulder in 90 degrees abduction and elbow in full flexion
Positive test = pain/ inability to maintain
93
What is adhesive capsulitis?
Condition characterised by loss of active AND passive movement with no clear cause
94
Recall the stages of adhesive capsulitis
Stage 1: Freezing - gradual onset of diffuse pain
Stage 2: Frozen - decreased ROM
Stage 3: Thawing - gradual return of ROM
95
What is the main associated condition with adhesive capsulitis?
Diabetes
96
What % of shoulder dislocations are anterior vs posterior vs inferior?
Anterior: 90%
Posterior: 6%
Inferior: 2-4%
97
Which direction of shoulder dislocation is associated with seizures?
Posterior
98
How does acromioclavicular joint dislocation appear on examination?
'Step' deformity and prominent clavicle
99
What are the signs of glemohumeral dislocation on examination?
Shoulder contour lost ('square shoulder')
| Bulging infraclavicular fossa
100
What is the management of glenohumeral dislocation?
Reduction with sedation
Rest in sling for 3-4 weeks
Physio
101
Which tendon of the biceps is much more likely to get ruptured?
Long
102
What is a 'popeye deformity'?
Caused by proximal biceps tendon rupture - muscle bulk results in a bulge in the middle of the upper arm
103
How can you test for biceps tendon rupture on examination?
Biceps squeeze test --> supination if tendon is intact
104
What is the best form of imaging for initial assessment of a proximal biceps tendon rupture?
USS
105
What is the best form of imaging for initial assessment of a distal biceps tendon rupture?
MRI - it's a difficult clinical diagnosis and requires surgery
106
What are the colloquial names for lateral vs medial epicondylitis?
```
Lateral = tennis
Medial = golfer's
```
107
Which movements will worsen pain in lateral vs medial epicondylitis?
Lateral: worse on wrist extension
Medial: worse on wrist flexion
108
What is the best form of imaging to investigate epicondylitis?
USS
109
What is the main symptom of olecranon bursitis?
Swelling over posterior aspect of elbow
110
Which nerve is compressed in radial tunnel syndrome, and what symptoms does this nerve compression produce?
Posterior interosseous branch of radial nerve
Symptoms very similar to lateral epicondylitis (pain in lateral epicondyle, worse on wrist extension, decreases grip strength)
111
Recall 6 associations with carpal tunnel syndrome
People who play DA HARP
Diabetes
Acromegaly
Hypothyroidism
Amyloidosis
Rheumatoid arthritis
Pregnancy
112
Which nerve is entrapped in carpal tunnel?
Median
113
Which digits get paraesthesia in carpal tunnel syndrome?
1st, 2nd and medial half of 3rd
114
What is the best investigative test for carpal tunnel syndrome?
EMG
115
How can carpal tunnel be managed conservatively?
Wrist splints at night
116
How can carpal tunnel be managed if conservative management is unsuccessful?
Corticosteroid injection --> surgical decompression
117
What is cubital tunnel syndrome?
Ulnar nerve entrapment at elbow
118
What is Guyon canal syndrome?
Ulnar nerve entrapment at wrist
119
Recall some risk factors for both Cubital Tunnel Syndrome and Guyon Canal Syndrome
Cubital tunnel: cycling, ganglion cyst pressure
| Guyon canal: leaning on elbow
120
What are the signs and symptoms of ulnar nerve entrapment?
Pins and needles in 4th and 5th digit
| Claw hand
121
Recall some conservative and surgical options for managing ulnar nerve entrapment
Conservative: wrist splints at night
Surgical: Corticosteroid injection --> surgical decompression
122
What is the aetiology of De Quervain's Tenosynovitis?
Sheath containing extensor pollicis brevis + abductor pollicis longus tendons becomes inflamed
123
Recall some signs and symptoms of De Quervain's Tenosynovitis
Tenderness over radial styloid and radial side of wrist
Abduction of thumb is painful
124
What is Finkelstein's test used to investigate and how is it performed?
Used to investigate De Quervain's Tenosynovitis
Examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction --> pain in the radial styloid and along the length of EPB and APL
125
How can De Quervain's Tenosynovitis be managed?
Analgesia + activity modification
Steroid injections + thumb splint --> surgery (if conservative measures have failed after 6 months)
126
What is Dupuytren's contracture?
Progressive, painless and fibrotic thickening of the palmar fascia
127
What is the aetiology of Dupuytren's contracture?
Fibroblasts replaced by myofibroblasts which produce a contractile element
128
Recall the associations of Dupuytren's contracture
BAD FIBRES
Bent penis (Peyronie's)
AIDS
Diabetes mellitus
```
Family history
Idiopathic (most common)
Booze (ALD)
Riedel's thyroiditis
Epilepsy and anti-epileptics
Smoking
```
129
What is a trigger finger?
Tendon nodule which catches on proximal side of tendon sheath --> triggering on forced extension
130
How can a trigger finger be managed?
```
Steroid injection (high recurrence)
Surgical release of 1st pulley
```
131
What is a ganglion?
Smooth, multilocular cystic swellings
132
What is the aetiology of ganglions?
Mucoid degeneration of joint capsule / sheath which may communicate with joint capsules/ tendons
133
What are the signs and symptoms of ganglion?
Subdermal swellings, fixed to deeper structures + limits planes of movement +/- pain on nerve pressure symptoms
134
How should ganglions be managed?
50% disappear spontaneously
Aspiration +/- steroid and hyaluronidase injection
Surgical excision
135
If someone has the symptom of knee locking, what are the differentials?
Obstructive causes:
- Meniscal/ cruciate tear
- Osteochondritis dissecans
- Osteophytes
136
What is the O'Donoghue Unhappy Triad?
Describes 3 soft tissue injuries that commonly occur together following a lateral blow to the knee on a fixed foot (eg football/ rugby)
- Ruptured ACL
- Ruptured MCL
- Damaged medial meniscus
137
Describe the typical presentation of ACL rupture
Rotational sports injury
Loud crack with pain
Rapid swelling due to haemarthrosis
138
Recall 2 signs of PCL rupture
1. Tibial lies posterior to femur
| 2. Paradoxical anterior draw test
139
What is the key sign of MCL rupture
Knee unstable in valgus stress test
140
What are the signs and symptoms of a torn meniscus in the knee?
- DELAYED knee swelling (immediate more likely to be ACL rupture)
- Joint locking
- Recurrent pain/ effusions
- McMurray's test positive
141
What cause of knee pain typically affects teenage girls?
Chondromalacia patellae
142
Why would a visible fluid level in the knee (lipohaemarthrosis) on X ray lead you to perform an MRI?
It is either a # or a cruciate ligament tear
143
What is the most obvious sign on examination of a medial/ lateral cruciate ligament tear
Extreme valgus/ varus
144
What movement produces the most pain in a meniscal tear?
When loading knee in flexion (going downstairs)
145
How can meniscal tears be managed?
Arthroscopic debridement or repair (depends on site)
146
How does site of meniscal tear affect management?
Lateral 1/3 tears might be able to be managed conservatively as they have a very rich blood supply
Medial tears 2/3 tears may need a meniscectomy as poor supply of blood
147
What is Osgood-Schlatter's disease?
Tibial tuberosty apophysitis and patellar tendonitis
148
Can Osgood-Schlatter's disease be bilateral?
Yes, it is in 25-50%
149
How is Osgood-Schlatter's disease diagnosed?
Clinical diagnosis + XR
150
What would an X ray show in Osgood-Schlatter's disease?
Fragmentation of tibial tubercle and overlying soft tissue swelling
151
What are the signs and symptoms of osgood schlatter's?
Knee pain after exercise with gradual onset
Localised tenderness and swelling over the tibial tuberosity
Hamstring tightness
152
How should Osgood-Schlatter's disease be managed?
Analgesia, ice packs
| Reassure --> should resolve at end of growth spurt
153
What is meralgia paraesthetica?
Syndrome of paraesthesia/ anaesthesia in distribution of the lateral femoral cutaneous nerve
154
In what age group does meralgia paraesthetica typically develop?
30-40y
155
What are the signs and symptoms of meralgia paraesthetica?
Upper lateral thigh burning, tingling, coldness or shooting pain
NO MOTOR WEAKNESS
Symptoms usually aggravated by standing and relieved by sitting
156
How can you reproduce symptoms of meralgia paraesthetica on examination?
Deep palpation beneath ASIS
157
What is the main symptom of chondromalacia patellae?
Patellar aching after prolonged sitting or climing stairs
158
How can you investigate for chondromalacia patellae?
Clarke's test
| Pain on patellofemoral compression
159
What would be seen on XR in chondromalacia patellae?
Normal film
160
How can symptoms of chondromalacia patellae be improved?
Vastus medialis strengthening
161
What is a 'Baker's cyst'?
Popliteal extensions of the gastrocnemius-semimembranosus bursa (not a true 'cyst')
162
If Baker's cysts are secondary, what are they likely to be secondary to?
Osteoarthritis
163
What are the signs and symptoms of Baker's cysts?
Swelling in popliteal fossa
164
What is the mainstay of management for low ankle sprain?
RICE (rest, ice, compression, elevation)
165
Which prescription drug is highly associated with achilles tendon rupture?
Quinolones (eg ciprofloxacin)
166
What is Simmond's triad?
100% sensitive in combination for picking up an Achilles' tendon rupture
- Thomas test does not elicit plantarflexion
- Angle of declination (greater dorsiflexion of injured foot)
- Gap in tendon path
167
Which type of imaging is diagnostic of Achiles tendon rupture?
USS
168
What are the signs and symptoms of Morton's neuroma?
'Walking on a marble'
Shooting pain in the ball of the foot
Numb toes
169
Where is the most common site of Morton's neuroma?
Between 3rd and 4th tarsal bones
170
What form of imaging can confirm a diagnosis of Morton's neuroma?
USS
171
What is the management of Morton's neuroma?
Orthotics --> steroid injections --> surgical resection
172
What is plantar fasciitis?
Inflammation of the plantar aponeurosis
173
What would make plantar fasciitis better or worse?
Exercise makes it better
| Inactivity makes it worse
174
What is the management for plantar fasciitis?
```
Orthotics
Physiotherapy
Analgesia
Steroid injection
Refer to orthopaedics
```
175
What is the proper name for a bunion?
Halux valgus
176
How can bunions be managed conservatively?
Bunion pads
| Plastic wedge between great and 2nd toes
177
What surgery can be used to fix bunions?
Metatarsal osteotomy
178
What are the signs and symptoms of charcot foot?
```
Deformity
Debris
Density change
Destruction
Dislocation
```
179
What are the signs and symptoms of cervical spondylosis?
Neck pain and headaches
180
What are the signs and symptoms of lumbar spine stenosis?
```
Back pain that is worse when standing
Leaning forward relieves it
Neuropathic pain
Neurogenic claudication
Preserved distal pulses
```
181
What is the most common pathogen implicated in discitis?
Staph aureus
182
What is the most common pathogen implicated in iliopsoas abscess?
Staph aureus
183
What is the difference between the investigation of choice for discitis vs iliopsoas abscess?
Discitis: MRI (if S aureus --> echo)
| Iliopsoas abscess: CT
184
What is the difference between the management of choice for discitis vs iliopsoas abscess?
Discitis: IV Abx
| Iliopsoas abscess: Abx and percutaneous drain
185
What is Brown-Sequard syndrome?
Hemisected spinal cord
186
What are the signs and symptoms of Brown-Sequard syndrome?
Ipsilateral paralysis
Ipsilateral loss of proprioception & fine touch
Contralateral loss of pain & temperature
187
What is the management of developmental dysplasia of the hip in a child <6 months old?
Pavlik harness for 6 months
188
What is Perthes' disease?
Avascular necrosis of the proximal femoral epiphysis from interruption of supply --> revascularisation and reossification over 18-36 months
189
What test can you perform on examination to test for Perthes?
Roll test
| Roll affected hip internally and externally --> guarding or spasm
190
Recall the management protocol for Perthes disease
If <6 years: analgesia, traction, crutches, physio to improve ROM
If >6 years: pelvic/ femoral osteotomy
191
What is SCFE?
Slipped Capital Femoral Epiphysis
| Displaced of epiphysis of femoral head postero-inferiorly
192
What are the 2 main key examination findings in SCFE?
Loss of internal rotation of a flexed hip
| Trendelenburg gait positive
193
How is SCFE managed?
Percutaneous internal fixation at growth plate
194
Which prognostic scoring systems are useful in osteoporosis?
FRAX
QFracture
Estimate a patient's 10 year risk of developing a fragility fracture
195
Recall the treatment indications for bisphosphonates
- Fragility fracture + age >75
| - Fragility fracture + T score 65y and on/ about to start longterm steroids
196
When should you give immediate bisphosophonates to patients who are on or about to start longterm steroids?
- If they are over 65
| - If under 65 then do a DEXA - give bisphosphonates if score -1 or less
197
What treatments should you give alongside bisphosphonates?
Always vitamin D
| Calcium supplements IF low levels
198
What are some contraindications to bisphosphonates?
eGFR <30
Severe GORD
Recurrent gastric ulcer
199
Recall the instructions for administration of PO bisphosphonates
Take on empty stomach in the morning
Full glass of water
Stay upright for 30 minutes
200
If PO bisphosphonates are not tolerated, what alternative is there?
Annual IV zoledronate
201
What is the 2nd line for bisphosphonates if they are not contra-indicated?
SC denosumab
202
Recall some abnormalities that might be seen in the hands in osteoarthritis?
Heberden's nodes (DIPJ)
| Bouchard's nodes (PIPJ)
203
What are the 4 indications of osteoarthritis on X ray?
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
204
Recall some options for managing osteoarthritis
Wt loss
Physiotherapy
1st line: PO paracetamol w/ topical NSAID
2nd line: PO NSAIDs + PPI or weak opioids or capsaicin cream
3rd line: intra-articular corticosteroids
Surgical: joint replacement
205
Recall some immediate, early and late complications of T knee replacements
Immediate: vascular/ nerve injury
Early: DVT, prosthesis infection
Late: Loosening, instability from los ACL
206
What is osteochondritis?
Idiopathic condition in which bony centres of paediatric bones become temporarily softened due to osteonecrosis
207
What would be seen on X ray in osteochondritis?
Increased density/ sclerosis --> patchy appearance
208
What is the management for osteochondritis dissecans?
Arthroscopic removal
209
What is pre-patellar bursitis?
It's an infection of the potential space in front of the patella
210
What should you ask about in the history if you are querying pre-patellar bursitis?
History of kneeling (eg builders)
211
How should pre-patelllar bursitis be managed?
Analgesia, compression, aspiration
212
Recall the risk factors for septic arthritis, and split them into modifiable and non-modifiable
Modifiable:
crystal arthropathies
Non-modifiable:
Age >90, rheumatoid arthritis, chronic renal failure, prosthetic joints
213
What investigations should be done to investigate septic arthritis?
XR
USS and MC&S joint aspirate
Bloods
Blood cultures
214
How should septic arthritis be managed?
IV antibiotics
| Joint washout
215
What is the investigation of choice in suspected osteomyelitis?
MRI
216
What is the management for osteomyelitis?
IV antibiotics and radical debridement to living bone
217
What is the most likely pathogen in a prosthetic joint infection within 6 weeks of infection and after that?
<6 weeks: S. aureus
| >6 weeks: S. epidermidis
218
What are the 2 main types of non-neoplastic bone tumours?
Fibrous dysplasia
| Simple bone cyst
219
Which bone tumour produces a 'shepherd's crook deformity' on X ray?
Fibrous dysplasia
220
Recall the names of 3 types of benign cartilaginous neoplasms
Osteochondroma
Endochondroma
Chondroblastoma
221
What is the most common benign bone tumour?
Osteochondroma
222
What is the most likely location of an osteochondroma?
Knee
223
What is a chondrosarcoma?
A malignant cartilaginous neoplasm
224
What are the most common sites of chondrosarcomas?
Pelvis
| Axial skeleton
225
Which form of tumour produces the appearance of 'popcorn calcification' on x ray?
Chondrosarcoma
226
Recall the 4 main different types of benign bone-forming neoplasms
Osteoma
Osteoid osteoma
Osteoblastoma
Osteoclastoma (giant cell tumour)
227
Which bone tumour typically produces severe nocturnal pain in young adults?
Osteoid osteoma
228
Which bone tumour produces a 'soap bubble' appearance on X ray?
Giant cell tumour/ osteoclastoma
229
What are the 2 main forms of malignant bone-forming neoplasms?
Osteosarcoma
| Ewing's sarcoma
230
What is the most common malignant primary bone tumour?
Osteosarcoma
231
Which bone tumour is associated with onion-skinning of the periosteum on X ray?
Ewing's sarcoma
232
In which dermatomes is sensation lost in Erb's palsy?
C5 C6
233
In which dermatomes is sensation lost in Klumpke's?
C8 T1
234
What muscle groups would be paralysed in Erb's palsy?
Abductors and external rotators --> waiter's tip
235
What muscle groups would be paralysed in Klumpke's?
Small muscles of hand --> claw hand
