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Surgery > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

Describe the term arthritides.

A

Umbrella term for conditions causing inflammation and degradation of the joint which can include non-inflammatory (OA), inflammatory seropositive (RA) or inflammatory seronegative (psoriatic; crystal arthropathy; reactive; ankylosing spondylitis; enterohepatic arthritis)

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2
Q

How can arthritides be broadly classified?

A
  • Degenerative: Osteoarthritis (OA)

* Inflammatory: Rheumatoid Arthritis (RA); Ankylosing spondylitis; Crystal arthropathies; Psoriatic Arthropathy

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3
Q

Outline the difference between articular and peri-articular pain.

A
  • Articular pain = true joint pain
  • Periarticular pain = pain in structures around a joint – e.g. tendonitis; bursitis; enthesitis
  • Referred pain = pain referred from a distant site of pathology
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4
Q

State 4 structures present at a joint.

A
  • Bone
  • Joint capsule
  • Tendon
  • Ligament and enthesis
  • Articular cartilage
  • Bursa
  • Synovium
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5
Q

Describe Osteoarthritis.

A

Degenerative joint disorder, a type of arthritide, caused by inflammation of the whole joint resulting in degradation of the articular cartilage, synovium and subchondral bone characterised by symptoms of joint pain, functional difficulties.

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6
Q

State 3 RFs for OA.

A
  • Advanced age: > 50 years
  • Female sex
  • Genetic factors
  • Obesity
  • Knee malalignment: Varus thrust
  • Physically demanding sport
  • Occupation
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7
Q

How may osteoarthritis present?

A

• Joint pain: worse on movement; better on rest
• Functional difficulties: post-rest stiffness (‘gelling’)
• Swelling
- Heberden’s Nodes (DIP); Bouchard’s Nodes
Note: Heberden’s Nodes&raquo_space;> Bouchard’s Nodes (common)
• Stiffness: Morning stiffness

• Antalgic gait
• Crepitus
• Effusion
• Bony deformities: Bouchard’s nodes (PIP)/Heberden’s nodes (DIP)
• Reduced range of movement
• Malalignment: genu valgum (knock-knees); genu varum (bow-legs)
Note: Varus thrust (worsening varus alignment when weight-bearing) = worsened medial knee OA

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8
Q

Which finger swellings are more present in OA? Describe what joints are typically affected.

A

Heberden’s Nodes - swelling of the DIP

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9
Q

What are the 4 radiographic signs seen in OA on XR.

A

Mnemonic: LOSS

  • Loss of joint space (JSN)
  • Osteophyte (bony spurs)
  • Subchondral sclerosis (hardening of bone)
  • Subchondral cysts (fluid filled spaces)
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10
Q

What Grading System may be used to objectively measure OA on XR.

Outline the grades.

A

Kellgren-Lawrence Grading System

Grade 0 = no OA

Grade 1 = doubtful JSN and possible OPs

Grade 2 = OPs and possible JSN

Grade 3 = multiple OPs, definite JSN, cystic areas with sclerotic walls and possible bony contour deformity

Grade 4 = large OPs, multiple sclerotic areas and deformity of bone contour

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11
Q

A XR-knee shows definite JSN loss and multiple OPs, what grade of KL is this?

A

Grade 3

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12
Q

An XR-Hip shows doubtful JSN but some possible osteophytes. What KL grade is this?

A

Grade 1

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13
Q

An XR-Knee shows definite osteophytes and possible JSN, it is unclear. What KL grade is this?

A

Grade 2

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14
Q

An XR-Hip shows multiple large osteophytes, definite JSN and severe sclerosis.

What KL Grade is this?

A

Grade 4

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15
Q

How do you manage patient with OA?

A

Supportive: education/ weight loss/ self-management/ exercise

Medical: analgesia (paracetamol/diclofenac/tramadol/co-codamol); Methylprednisolone IA

Surgery: Total knee arthroplasty

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16
Q

Describe septic arthritis?

A

Infection of ≥ 1 joints caused by a pathogen either through direct inoculation or via haematogenous spread which is characterised by joint pain, fever and potential haemodynamic instability

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17
Q

State 3 pathogens that may cause Septic Arthritis.

A
  • S. aureus
  • N. gonorrhoea
  • N. meningitidis
  • M. tuberculosis
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18
Q

State 3 RFs for Septic Arthritis.

A
  • Pre-existing joint disease – RA/OA
  • Prosthetic joint
  • IVDU
  • Immunosuppressed
  • Diabetes mellitus
  • PMHx of IA corticosteroid injections/surgery
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19
Q

What investigations would confirm a suspected case of septic arthritis?

A

• Arthrocentesis + Gram stain + White cell count: Pathogen present; Urate or pyrophosphate crystals may be present; Normal (≤ 3000 WCC/mm3)/ Inflammatory fluid (> 3000WCC/mm3)/ Septic fluid (up to 75 000 WCC/mm3)
-> Send to lab for urgent processing; Act on clinical suspicion at the time
• FBC: Leukocytosis perhaps
• CRP: Elevated
• Swab + Culture (Urethra/Cervix/Anorectum): Positive for gonococcal infection

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20
Q

How would you manage a patient with septic arthritis of a native joint?

A

• ABX: Ceftriaxone (Meningococcal)/ Ceftriaxone + Azithromycin (Gonococcal)/ ∑ Rifampicin + Isoniazid + Pyrazinamide + Ethambutol (TB)/ Vancomycin (Gram Positive)
±
• Surgery: Joint aspiration
±
• Analgesia: Paracetamol/ Ibuprofen/ Diclofenac

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21
Q

How do you manage a case of septic arthritis in a prosthetic joint without systemic involvement?

A

ABX
+
• Surgery: Arthrocentesis/Joint replacement
±
• Analgesia: Paracetamol/ Ibuprofen/ Diclofenac

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22
Q

Describe osteomyelitis.

A

Infection of the bone caused by pathogen (commonly Staphylococcus spp.) transmitted by hematogenous spread or direct inoculation involving a single bone

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23
Q

How may osteomyelitis present?

A
  • Pain: at site of infection
  • Fever
  • Malaise
  • Fatigue
  • Inflammation
  • Erythema
  • Reduced range of movement
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24
Q

What would an XR of a bone with osteomyelitis show?

A

• XR: Osteopenia; Bone destruction; Periosteal reaction; Cavities; Involucrum (thick sheath of periosteal bone surrounding sequestrum); Sequestrum (necrotic bone fragment); Cloacae (opening of involucrum)

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25
Q

What is the involucrum in osteomyelitis?

A

Periosteal thickened sheath of bone surrounding sequestrum

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26
Q

What is the sequestrum in osteomyelitis?

A

Necrotic bone fragment

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27
Q

What is the cloacae in osteomyelitis?

A

Opening of the involucrum - the thick sheath of periosteal bone

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28
Q

How would you manage osteomyelitis?

A

• Supportive: Analgesia/ Immobilisation/ Mobilisation/ Specialist referral
+
• ABX: Vancomycin; Pip/Taz

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29
Q

What is a soft tissue sarcoma?

A

Umbrella term for solid tumour of connective tissue (mesenchymal) which presents as soft-tissue swelling and diagnosed upon biopsy. Two main categories are sarcoma of bone or sarcoma of soft tissues.

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30
Q

What are the clinical features of a soft tissue sarcoma?

A
  • Mass: no pain
  • Weight loss
  • Fatigue
  • Anorexia
  • Other Sx related to System affected: GI bleed; Rash; Acute abdomen
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31
Q

How may you manage a soft tissue sarcoma?

A
  • MDT Referral: Surgical excision + radiotherapy + chemotherapy
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32
Q

What is an Ewing Sarcoma?

A

malignant bone tumour from neuroectodermal cells often present in the diaphyses of long bones and the pelvis present in young adults

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33
Q

Outline the clinical features of Ewing Sarcoma.

A
  • Diaphyses of long bones and pelvis
  • B symptoms
  • Pain
  • Hyperthermia
  • Swelling after trauma (presents following trauma)
  • In M and young adults
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34
Q

How may you manage an Ewing Sarcoma?

A 
-	Surgery: Resection 
\+
-	Chemotherapy
\+
-	Radiotherapy
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35
Q

Describe what an Osteosarcoma is?

A

malignant, osteoid tumour from mesenchymal stem cells (Obs) in periosteum commonly in the metaphyses of long bones (femur and tibia) of young adults with progressive swelling and pain limiting ROM and gait

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36
Q

What is the term for the radiological feature showing a periosteal damage which lifts off the periosteum without replacement, leaving a triangular gap?

What bone cancer is this seen in?

A

Codman Triangle

Osteosarcoma

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37
Q

How do you manage Osteosarcoma?

A
  • Surgery: Resection
    +
  • Chemotherapy
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38
Q

What is a chondrosarcoma?

A

malignant tumour arising from mesenchymal cells producing cartilage

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39
Q

What is the benign precursor to a chondrosarcoma?

A

Osteochondroma

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40
Q

How may a Chondrosarcoma present?

A
  • Deep, dull pain
  • Localised swelling
  • Pathological fractures
  • NV disturbance
  • In 50+ y/o
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41
Q

What are the key radiological findings shown in a Chondrosarcoma.

A

Calcifications, Osteolysis, Endosteal scalloping

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42
Q

How do you manage a Chondrosarcoma?

A 
-	Surgery: Resection
\+
-	Chemotherapy
\+
-	Radiotherapy
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43
Q

Describe a Scoliosis.

A

A lateral curvature of the spine (and also a rotational deformity) which can be idiopathic or secondary to neuromuscular disease, tumour, skeletal dysplasia or infection. Painful scoliosis needs investigation (MRI for tumours, infections).

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44
Q

What are the clinical features of Scoliosis?

A
  • Shoulder asymmetry

- Asymmetry

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45
Q

What is the term for the angle used to quantify the curvature in the spine?

A

Cobb Angle

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46
Q

What is the threshold for spinal curvature to label a spine scoliotic?

A

Cobb angle > 10º

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47
Q

How do you manage Scoliosis?

A

Cobb angle ≤45º
- Supportive: Exercise; Physiotherapy
± (20º 45º)
- Surgery: Arthrodesis

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48
Q

What is a spondylolisthesis?

A

Slipping of one vertebra over another and usually occurs at L4/L5 and L5/S1. Associated with increased body weight or increased sporting activity.

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49
Q

How may a spondylolisthesis present?

A
  • Lower back pain
  • Radiculopathy
  • Flat back- due to muscle spasm
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50
Q

How may a spondylolisthesis be managed?

A
  • Minor- physio

* Severe- stabilisation

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51
Q

What is mechanical back pain?

A

Recurrent relapsing and remitting back pain with no focal neurological symptoms, relieved by rest and in the absence of red flag symptoms

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52
Q

How may mechanical back pain be managed?

A

Supportive: simple analgesia; exercise; physiotherapy

Medical: Ibuprofen/Paracetamol; Co-codamol; Tramadol

Surgical: Spinal stabilisation; Decompression

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53
Q

What portion of the intervertebral disc is damaged in an acute disc tear?

A

Tear in AF with protruding NP

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54
Q

What augments the pain in an acute disc tear?

A

Movement

Coughing

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55
Q

What effect will coughing have on the pain in an acute disc tear?

A

Worsens - raised intrathoracic pressure on disc

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56
Q

How may an acute disc tear be managed?

A

Analgesia and Physio

Surgery - stabilisation (discectomy and corpectomy with metallic cage, compressible or non-compressible)

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57
Q

What is Sciatica?

A

Disc material impinging on exiting spinal nerve root resulting in pain and altered motor/sensation in a dermatomal distribution

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58
Q

What clinical finds would be present if there is impingement at L3/L4 vertebral level?

A

L4 nerve affected

Pain down to the medial ankle (L4 dermatome)

Reduced quad power (extensor thigh compartment)

Reduced patellar tendon reflex

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59
Q

What clinical finds would be present if there is impingement at L4/L5 vertebral level?

A

L5 nerve affected

Pain affecting dorsum of foot and anterolateral leg.

Reduced power of EHL, EHL and TA (all supplied by deep peroneal nerve

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60
Q

What clinical finds would be present if there is impingement at L5/S1 vertebral level?

A

S1 nerve affected

Pain to the sole of the foot

Reduced plantarflexion and reduced ankle jerk tendon reflex

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61
Q

Which nerves does the Sciatic nerve give rise to?

A

Divides into:
Common fibular nerve
Sural nerve
Tibial nerve

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62
Q

Which nerves form the Sural Nerve?

A

Medial cutaneous branch of Tibial nerve and Lateral cutaneous branch from Common Peroneal Nerve

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63
Q

What is Bony Nerve Root Entrapment?

A

OA of facet joints leading to osteophyte formation hence impingement of exiting nerve roots

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64
Q

How is OA of facet joints managed?

A

Supportive - rest; exercise

Medical - analgesia

Surgery - decompression

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65
Q

Define spinal stenosis.

A

Reduced space within spinal canal which may compress multiple nerve roots

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66
Q

How may neurological claudication differ to vascular claudication?

A

Cause is neurological, not due to endothelial damage and subsequent atherosclerotic changes
Distance differs
Pain is burning
Pain is less severe walking up hill and bending forwards
Pedal pulses preserved

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67
Q

How may a spinal stenosis present?

A
  • LBP: Neuropathic; insidious and duration; radiates down leg
  • Claudication: neurogenic claudication; weakness in thighs; bend over to relieve; stooped posture;
  • Leg weakness
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68
Q

How may spinal stenosis be treated?

A
  • Physiotherapy
  • Weight loss
  • MRI evidence of stenosis may make patients candidates for
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69
Q

Define Cauda Equina syndrome.

A

Large central disc prolapse compressing all nerve roots of the cauda equina (below L2) resulting in altered perineal sensation, defeacation, urination and back pain

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70
Q

How may Cauda Equina present?

A
  • Bilateral leg pain
  • Paraesthesia or numbness- around sitting area and perineum
  • Urinary retention
  • Faecal incontinence and constipation
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71
Q

What investigation is required to diagnose Cauda Equina Syndrome?

A

• Urgent MRI to determine level of disc prolapse

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72
Q

How is Cauda Equina treated?

A

Surgical management - urgent discectomy

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73
Q

Define an Osteoporotic crush fracture.

A

With severe osteoporosis, spontaneous crush fractures of the vertebral body can occur

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74
Q

How may an Osteoporotic crush fracture be treated?

A

Conservative - analgesia and rest

Surgery - Vertebroplasty

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75
Q

Define Cervical Spondylosis.

A

This is a reduction in H20 content of the intervertebral discs leading to increased load on facet joints and accelerated OA.

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76
Q

Define Cervical Disc Prolapse.

A

erve root compression can cause shooting neuralgic pain in a dermatomal distribution with weakness and loss of reflexes. Typically involves the lower nerve root e.g. C5/C6 prolapse- C6 spinal nerve affected.

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77
Q

Give 3 conditions in which cervical spine instability may occur.

A

RA

Down Syndrome

Previous Injury

Chiari Malformation

Connective Tissue Diseases e.g. Ehler-Dahnloss Syndrome

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78
Q

What form of cervical spine instability may patients with Down Syndrome experience?

A

Atlanto-occipital instability - potential for subluxation

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79
Q

Define shoulder impingement.

A

This is when the tendons of the rotator cuff (predominantly supraspinous) are compressed in the sub acromial space.

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80
Q

State 3 causes of shoulder impingement.

A

Subacromial bursitis
AC OA
Hooked acromion rotator cuff tear

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81
Q

What are the clinical features of Shoulder Impingement?

A
  • Painful arc between 60 and 120 degrees
  • Pain radiates to deltoid and upper limb
  • Tenderness may be felt below lateral edge of the acromion
  • Hawkins kennedy test (Internal rotation of flexed shoulder) recreates the pain
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82
Q

How may you differentiate between shoulder impingement and a rotator cuff pathology?

A

Shoulder impingement may not be painful when movement is passive as the tendon is not engaged if muscle is not actively contracting

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83
Q

How may you manage a shoulder impingement?

A
  • NSAIDs, analgesia and physio
  • Subacromial steroid injection (up to three times)
  • If it still doesn’t improve subarcomial decompression surgery is an option
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84
Q

Define a rotator cuff tear.

A

The tendons of the rotator cuff muscles (subscapularis, supraspinatous, infraspinatous and teres minor) can tear with minimal force. Classic Hx of sudden jerking motion in a patient >40 with subsequent pain and weakness. Tears can be partial or full thickness.

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85
Q

A jobe’s test is used to …

A

Test supraspinatus muscle

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86
Q

What does the painful arc test for?

A

Supraspinatus impingement

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87
Q

What does external rotation against resistance test for?

A

Infraspinatus and teres minor

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88
Q

The Gerber’s lift-off test examines which muscle?

A

Subscapularis

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89
Q

The Scarf test examines the function of…

A

The AC Joint

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90
Q

What is the gold standard imaging to diagnose a rotator cuff tear?

A

MRI

or US if metal work in the body

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91
Q

How would you manage a rotator cuff injury?

A

Supportive: analgesia; physiotherapy

Medical: Steroid injection

Surgical: Subacromial decompression

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92
Q

Define adhesive capsulitis?

Outline the 3 phases

A

Progressive pain and stiffness of the shoulder with global reduction in movement.

3 phases:

  • Painful phase (2-9 mo)
  • Frozen phase (4-12 mo)
  • Thawing phase
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93
Q

How is frozen shoulder syndrome diagnosed?

A

Clinical diagnosis - potential XR-Shoulder to exclude any other pathology

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94
Q

How may adhesive capsulitis be managed?

A

Supportive: analgesia; physiotherapy; steroid injections

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95
Q

What is Acute Calcific Tendonitis?

A

Calcium deposition in a tendon causing acute onset severe shoulder pain which is exacerbated by activity

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96
Q

How may Acute Calcific Tendonitis be diagnosed?

A

XR-Shoulder - calcific area shown on superior aspect of greater tuberosity

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97
Q

How is acute calcific tendonitis managed?

A

Subacromial steroid injection

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98
Q

Define shoulder instability.

A

Shoulder disclocation/subluxation - often antero-inferiorly (90%)

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99
Q

What radiological sign is observed in a posterior shoulder dislocation?

A

Lightbulb sign

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100
Q

How may a shoulder subluxation be managed?

A

Analgesia
Reduction

Immobilise in a sling

If recurrent - surgery e.g. Bankart Repair

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101
Q

Define Tennis Elbow.

A

Lateral epicondylitis whereby the lateral epicondyle is inflamed due to RSI causing micro tears in the common extensor origin

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102
Q

How may Tennis Elbow present?

A
  • Painful and tender lateral epicondyle

* Pain on resisted middle finger and wrist extension

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103
Q

How is Tennis Elbow managed?

A
  • Usually self limiting- period of rest from activities that exacerbate the pain
  • Physio
  • NSAIDs
  • Steroid injections
  • Brace use
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104
Q

What is Golfers Elbow?

A

RSI due to overuse causing micro tears in the common flexor origin at the median epicondyle

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105
Q

How is Golfers Elbow managed?

A
  • Physio

- NSAIDs

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106
Q

Define Carpal Tunnel Syndrome.

A

Median nerve compression when travelling through the wrist

The carpal tunnel is formed from the carpal bones and the flexor retinaculum. 10 structures pass through the carpal tunnel, four tendons of the flexor digitorum superficialis, four tendons of the flexor digitorum profundus, one tendon from the flexor pollicus longus and the median nerve. Any change in the carpal tunnel can cause compression of the median nerve.

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107
Q

State 3 causes of Carpal Tunnel Syndrome.

A 
Pregnancy 
RA
Wrist Fractures 
Acromegaly
Neoplasm
Idiopathic
Diabetes
Oedema 
Scar tissue
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108
Q

Outline the clinical features of carpal tunnel syndrome.

A
  • Paraesthesia in the median nerve supplied area- the thumb, index and half of middle finger.
  • Weakness of the thumb
  • Muscle wasting of the thenar eminence.
  • Tinels test- can reproduce symptoms by percussing over the median nerve.
  • Phalens test- reproduce symptoms by holding the wrists hyperflexed
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109
Q

How may Carpal Tunnel Syndrome be managed?

A
  • Non-operative- wrist splints at night to prevent flexion. Corticosteroid injection
  • Carpal tunnel decompression- division of the transverse carpal ligament.
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110
Q

Define Cubital Tunnel Syndrome.

A

This is compression of the ulnar nerve at the medial epicondyle. Can be due to tightness in the Osbornes fascia or tightness in the intermuscular septum where the nerve passes through two heads of flexor carpi ulnaris

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111
Q

What is Osborne’s Fascia?

A

Ligamentous tissue connecting Olecranon and Lateral Epicondyle - forming the cubital retinaculum

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112
Q

How may Cubital Tunnel Syndrome Present?

A
  • Paraesthesia in the ulnar supplied areas- the little and ring finger plus half of the middle finger.
  • Weakness of ulnar nerve supplied muscles

• Positive tinels test over cubital tunnel

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113
Q

What investigations may you order for Carpal Tunnel Syndrome?

A 
FBC
TFTs
U+Es
Ca2+
HbA1c

Nerve conduction studies- slowed conduction

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114
Q

How may you manage Cubital Tunnel Syndrome?

A

Surgical decompression

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115
Q

Define Dupuytrens Contracture.

A

A proliferative connective tissue disease where the palmar fascia undergoes hyperplasia with normal fascial bands producing nodules and cords progressing to contractures at the MCP and PIP joints.

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116
Q

What cell type is responsible for Dupuytren’s contracture?

A

Abnormal Collagen produced by myofibroblast cells

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117
Q

State 3 RFs for Dupuytrens Contracture.

A

FHx
Alcoholism
Diabetic

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118
Q

How may Dupuytren’s contracture present?

A
  • Puckered skin
  • Palpable nodules
  • Ring and little finger most commonly affected
  • Half of cases are bilateral
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119
Q

How may Dupuytren’s Contracture be managed?

A
  • Mild contractures may be tolerated
  • Surgery for contractures interfering with function. Fasciotomy- division of the cords. Fasciectomy- removal of diseased fascia.
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120
Q

Explain a trigger finger.

A

Tendonitis in a flexor tendon to a digit can result in nodular enlargement of the affected tendon- usually distal to a fascial pulley over the metacarpal neck (the A1 pulley). Movement of the finger produces a clicking sensation as the nodule catches then passes underneath the pulley, it cant go back to extension without help. Finger may lock in a flexed position. Most commonly affecting middle and ring finger.

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121
Q

Which fingers are most commonly affected in Trigger Finger?

A

Middle and Ring Finger

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122
Q

How may Trigger Finger be treated?

A
  • Steroid injection around the tendon within the sheath

* Surgery in recurrent and persistent cases

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123
Q

Define a Ganglion cyst.

A

These are common mucinous filled cysts found adjacent to a tendon or synovial joint

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124
Q

What are the clinical features of a ganglion cyst?

A

Firm, smooth and rubbery

Transilluminates

Not painful

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125
Q

How may a Ganglion Cyst be managed?

A

Needle aspiration

Surgical excision

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126
Q

Where may a Giant Cell Tumour of the Tendon Sheath be found?

What colour are they and why?

A

In the palmar surface of the hand.

Containing MGCs and heamosidirin gives them a brown appearance

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127
Q

What two questions must you always ask in a history?

A

Locking - functional locking or mechanical locking

Giving way

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128
Q

Rupture of which meniscus is more common and why?

A

Medial > Lateral due to Medial being more fixed and less mobile

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129
Q

What is the usual MOA of a meniscus injury?

A

Twisting injury on a planted foot

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130
Q

What are the clinical features of a meniscal injury?

A
  • Pain localising to the medial or lateral compartment
  • Joint effusion and swelling occurring a day or so after
  • Locking and mechanical symptoms
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131
Q

How may you clinically suspect a meniscal tear?

A

McMurray test

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132
Q

What is the gold standard imaging test for a meniscal injury?

A

MRI

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133
Q

How may you manage meniscal injury?

A

Supportive: physio; analgesia; movement

Surgical: Repair; Partial meniscectomy

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134
Q

Define ACL rupture.

A

The anterior cruciate ligament runs from the medial anterior tibia to the lateral posterior femoral condyle. It prevents the femur from sliding posteriorly on the tibia (or the tibia sliding anteriorly on the femur).

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135
Q

Where does the ACL originate and insert?

A

posteromedial corner of lateral femoral condyle to the anterior intercondyloid eminence of the tibia

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136
Q

What is the function of the ACL?

A

Prevent anterior tibial translocation

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137
Q

Which MOA may cause an ACL rupture?

A

MOA- high impact twisting injury (e.g. turning the upper body on a planted foot)

Valgus moment at knee and adduction moment at hip upon landing

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138
Q

What are the clinical features of an ACL rupture?

A
  • Audible pop
  • Haemarthrosis (seen clinically as swelling)
  • Deep knee pain
  • Rotational instability

• Positive anterior draw test- trying to pull the tibia forward when the knee is flexed and planted. Positive if there is excessive anterior translation.

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139
Q

What is the gold standard imaging for an ACL rupture?

A

MRI

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140
Q

How may an ACL rupture be managed?

A
  • Non-operative techniques for those with poor demand e.g. those not involved in sports
  • Arthroscopic anterior cruciate repair with hamstring or patellar tendon graft- symptomatic knee instability. Professional sportsmen.
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141
Q

Which triad is commonly affected during a high-velocity pivot/ high-velocity lateral blow (valgus moment) of the knee?

A

ACL

MCL

Medial meniscus

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142
Q

What is the blood supply of the ACL?

A

Middle Geniculate Artery

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143
Q

What is the innervation of the ACL?

A

Posterior articular nerve (branch of Tibial nerve)

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144
Q

What fracture is pathognomonic of an ACL injury?

A

Segond Fracture - avulsion fracture of the proximal lateral tibia

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145
Q

What is the management for an ACL injury?

A

Non-operative: physio; lifestyle modifications

Operative: ACL repair

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146
Q

Define a PCL rupture.

A

High velocity/force causing posterior tibial translation when the knee is flexed resulting in tearing of the fibres

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147
Q

What is the origin and insertion of the PCL?

A

Anterolateral aspect of medial femoral condyle to posterior aspect of medial tibia plateau

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148
Q

Outline the clinical features of a PCL injury?

A
  • Knee pain
  • Swelling- can range from mild to severe
  • Instability
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149
Q

How may you manage a PCL injury?

A
  • Isolated PCL rupture is only repaired if there is severe laxity or recurrent instability with frequent hyperextension or feeling unstable going down stairs
  • PCL construction is usually performed if there is multiple ligamentous injury.
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150
Q

What is the MOA of a MCL injury?

A

Excessive valgus stress on the knee

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151
Q

Clinical features of a MCL injury?

A
  • Laxity
  • Pain on valgus stress
  • Tenderness over insertion of the MCL
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152
Q

Management of an MCL injury?

A
  • Acute tears are treated with hinged knee braces

* Chronic instability can be treated operatively with MCL tightening or reconstruction

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153
Q

How may you grade an MCL injury?

A

Grade 1 = minor sprain, high signal seen medial to ligament

Grade 2 = high signal medial to ligament and at ligament with slight tear

Grade 3 = complete disruption of the ligament

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154
Q

What is the origin and insertion of the MCL?

A

Medial aspect of distal femur to medial aspect of distal tibia

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155
Q

What is the origin and insertion of the LCL?

A

Lateral femoral condyle to fibular head

156
Q

What are the clinical finds of a LCL tear?

A
  • Marked instability on rotational movements
  • Can have common peroneal nerve injury presenting with foot drop
  • Vascular injury also common- affecting popliteal artery intimal
157
Q

How may an LCL injury be managed?

A

Non-operative: physio; analgesia

Operative: reconstruction

158
Q

Define an osteochondral lesion.

A

These are bony or cartilaginous injuries that can occur after direct blows to the knee or impaction of the articular surfaces. Any ongoing knee pain and effusion warrants further investigation.

159
Q

How may you investigate a potential osteochondral lesion?

A
  • X-ray
  • MRI
  • Arthroscopy
160
Q

How may you manage an Osteochondral lesion?

A

Non-operative: Rest; NSAIDs; Physiotherapy; Exercise; Weight reduction

Operative: Surgery

  • Debridement
  • Mosaicplasty
  • Chrondroplasty
  • Microfracture

4cm is the threshold for debridement/microfracture/mosaicplasty vs MACI/ACI

161
Q

What classification system may be used for an osteochondral lesion?

What components does it involve?

A

Outerbridge Scoring System

Grade 0 = normal

Grade 1 = softening and swelling (via probe)

Grade 2 = Partial thickness defect (<1.5cm)

Grade 3 = deep fissures of subchondral bone (>1.5cm diameter)

Grade 4 = exposed subchondral bone

162
Q

What are the clinical features of an extensor mechanism rupture?

A
  • Inability to straight leg raise
  • Palpable gap in extensor tendon
  • X-rays will show patellar shift. If the patellar is high a patellar tendon rupture has occurred, if low a quadriceps tendon rupture has occurred.
  • Ultrasound can determine extent of partial tears
163
Q

What investigations may you order in an extensor mechanism rupture? What will they show?

A
  • X-rays will show patellar shift. If the patellar is high a patellar tendon rupture has occurred, if low a quadriceps tendon rupture has occurred.
  • Ultrasound can determine extent of partial tears
164
Q

How may you manage an extensor mechanism rupture?

A

• Surgical tendon-tendon repair

165
Q

What are the clinical features of Patellofemoral Dysfunction?

A
  • Anterior knee pain
  • Worse on downhill
  • Grinding or clicking sensation in the front of the knee
  • Stiffness after prolonged sitting resulting in pseudolocking
166
Q

How may you manage patellofemoral dysfunction?

A
  • Physiotherapy aimed at rebalancing quads

* Surgery is a last resort releasing the lateral retinaculum

167
Q

Why is vastus medialis weakness a cause of patellofemoral dysfunction?

A

The pull of the quadriceps tendon pulls the patellar in a slight lateral direction. In some people excessive lateral forces produces anterior knee pain as the patella is compressed against the distal wall of the lateral femoral trochlear.

168
Q

How may patellar instability be managed?

A

Treat with physio. If recurrently dislocates-need to reconstruct medial patellofemoral lig.

169
Q

How is ankle OA managed?

A

Non-operative: NSAIDs; Analgesia; Exercise; Weight loss

Operative: Ankle arthroplasty; Arthrodesis

170
Q

Describe a Hallux Valgus.

A

This is medial deviation of the MTP joint but lateral deviation of the toe itself. Aetiology is poorly understood however familial component.

171
Q

What are the clinical features of a hallux valgus?

A
  • May be painful due to joint malalignment or rubbing on shoes
  • Ulceration and skin breakdown may occur from rubbing of toes
172
Q

Define Hallux Rigidus.

A

This is OA of the first MTP joint.

173
Q

How can Hallux Rigidus be managed?

A
  • Conservative- A metal bar can be inserted into the sole of the shoe
  • Surgical treatment- arthrodesis- fusion should alleviate pain with no motion (however little sacrifice as it doesn’t move much anyway
174
Q

Define a Mortons Neuroma.

A

Swollen and irritated plantar (medial and lateral) nerves become swollen and inflamed, this is called a neuroma. Patients complain of burning pain and tingling radiaiting to the affected toes. More likely in women wearing high heels. Commonly found between the 3rd and 4th metatarsals.

175
Q

What are the clinical features of a Mortons Neuroma?

A

Relief when removing shoes
Pain at the 3rd and 4th metatarsals (3rd webspace)
May be loss of sensation in the affected web space
Squeezing forefoot over MTPs may illicit pain

Mulder’s test (squeezing metatarsals = click)

176
Q

What imaging may you order for a suspected Morton’s Neuroma?

A

US - hypoechoic mass parallel to metatarsal bones

XR - rule out pathology

MRI - rule out pathology

177
Q

How do you manage a Morton’s Neuroma?

A

Non-operative: wider shoes; steroid injection

Operative: neurectomy

178
Q

What investigation may you order in a suspected metatarsal stress fracture?

A
  • X-ray- may not show fracture until around 3 weeks as callus will grow.
  • DEXA bone scan can be useful in diagnosis
179
Q

How would you manage a metatarsal stress fracture?

A

• Prolonged rest for 6-12 weeks- rigid soled boot

180
Q

How may Achilles Tendonopathy present?

A

Pain at the distal posterior leg; worse on activity; better on rest; tender on palpation

181
Q

Which medications can increase the risk of Achilles tendon rupture?

A

Ciprofloxacin
Quinolones
Steroids

182
Q

How do you manage Achilles Tendinopathy?

A

Treatment of tendonitis is rest, physio, use of heel raise to offload the tendon, splint or boot use. Usually self limiting

183
Q

How may Achilles Rupture present?

A
  • Sudden pain- like being kicked in the back of the leg
  • Popping noise
  • Difficulty weight bearing
  • Weakness of plantarflexion
  • Squeezing calf produces no plantarflexion
  • Palpable gap
184
Q

How would you manage Achilles Tendon Rupture?

A
  • Non-operative has the same affects as operative at the 6 month period. Manage with serial plaster casts with foot in full equinous position (ankle plantarflexed- closes the gap).
  • Surgical repair has lots of non-healing complications- suture repair. Need plaster cast for 8 weeks.
185
Q

Describe plantar fasciitis.

A

Repetitive stress/overload condition of the foot. Pain with walking on the instep of the foot (the origin of the plantar fascia). Localised tenderness on palpation of the calcaneal tuberosity.

186
Q

How may plantar fasciitis present?

A

Pain localised to calcaneal tuberosity (base of heel)

Worse when walking

Feels tight

187
Q

How do you manage plantar fasciitis?

A
  • Conservatively- rest, cushioning heel pads, Achilles and plantar fascia stretching exervises
  • Corticosteroid injections may alleviate symptoms. Can take up to two years to resolve.
188
Q

How do you manage Pes Cavus?

A

Treated with soft tissue release and tendon transfer.

189
Q

How do you manage claw and hammer toes?

A

Management- can be painful so corn sleeves and support is conservative.

Surgical options include tenotomy (removal of overactive tendon), arthrodesis or amputation.

190
Q

Outline the difference between a claw and hammer toe.

A
  • Claw toe- hyperextension at MTP and hyperflexion at DIP

* Hammer toe- hyperextension at MTP and hyperextension at DIP

191
Q

Outline the process for interpreting an XR of bone.

A
  • Details: Name, DOB; Date; Anatomical location and view (AP/PA/Lat)
  • RPE: Rotation; Picture; Exposure
  • Alignment and joint space
  • Bone texture: density and trabeculae
  • Cortices: Trace the cortex for lesion (location, shape, pieces, displacement)
  • Soft tissue: ligament/cartilage; soft tissue
192
Q

Outline the management of a fracture.

A 
•	Supportive: A-E assessment; admission; XR (2 planes); catastrophic haemorrhage management; Splintage; dressing + prophylactic ABX 
\+
•	Analgesia: Morphine/ Entonox 
\+
•	Definitive treatment: 
If stable --> Cast/splint/traction

If unstable –> Surgical fixation

193
Q

Outline the classification system for Paediatric Fractures at the Growth Plate.

A

Type 1 = transverse through physis – separating epiphysis and metaphysis
Type 2 = transverse through physis and metaphysis – separating triangular section of metaphysis
Type 3 = transverse fracture of physis and epiphysis
Type 4 = fracture through everything – metaphysis, physis and epiphysis
Type 5 = fracture characterised by impaction and disruption

Mnemonic: SALTeR
Straight across joint
Above joint
Lower
Through Everything
Rammed
194
Q

What classification system is used to assess a patient’s physiological status prior to surgery?

195
Q

Outline the ASA classification.

A
  • I = normal healthy patient
  • II = Mild systemic disease
  • III = Severe systemic disease
  • IV = Severe systemic disease + threat to life
  • V = Requires operation to survive
  • VI – Brain-dead patient whose organs removed for donor purposes
196
Q

How may you classify peripheral nerve injury?

A

Seddon Classification

197
Q

What are the basic types of peripheral nerve injury?

A

1) Stretch related: traction force&raquo_space;
2) Compression
3) Laceration

198
Q

What are the two types of bone healing?

A 
Primary: perfect opposition (0.1mm) and <2% strain; direct attempt by cortex to re-establish, without the formation of fracture callous. 
Cutting cones (osteoclasts) cross fracture to generate cavities which are filled by Obs to re-establish osteon bridges and remodel into lamellar bone

Secondary: imperfect opposition and 2-10% strain resulting in injury, haemorrhage, inflammation and soft callus with mineralisation and remodelling

199
Q

Outline the stages of secondary bone healing.

A

Injury: Traumatic fracture

Inflammation: haematoma forms, flooding with HSCs. HSCs secrete GFs; Macrophages, neutrophils and platelets secrete PDGF, TNF-a, TGF-ß, IL-1,6,10 and 12

Fibroblasts and mesenchymal cells migrate to fracture site

Repair: Primary callous forms within 2 weeks; mechanical environment drives differentiation with stable environment yielding osteoblastic lineage of cells. Endochondral ossification converts soft callus to hard callus of woven bone. Transition from type II (cartilage) collagen to type I (bone) collagen

Remodelling: chondrocytes undergo terminal differentiation via Ihh, PTHrP, FGF and BMP with type X collagen expressed by hypertrophic chondrocytes. Proteases degrade ECM and cartilaginous calcification occurs at junction between maturing chondrocytes - expression of TGF-ß, IGF, collagen I, V and XI.

Chondrocytes become apoptotic and VEGF production results in angiogenesis.

Newly formed bone remodelled via organised osteoblastic/osteoclastic activity

Bone is shaped through Wolff’s law and Piezoelectric charges (tension = electropositive with osteoclasts cf compression = electronegative with osteoblasts)

200
Q

How may variables influencing fracture healing be categorised? Give 2 examples of each.

A

Internal vs External

Internal:

  • Blood supply
  • Head injury
  • Mechanical factors: stability; location; degree of loss; pattern

External:

  • LIPUS (accelerates fracture healing and increases callus strength)
  • Bone stimulators
  • COX2
  • Radiation
  • Smoking
  • Diabetes mellitus
  • HIV (TNF-a deficiency, poor intraosseous circulation, poor nutritional intake)
  • NSAIDs
  • Quinolones (chondrotoxic)
201
Q

What mode of bone healing does a compression plate encourage?

A

Compression plate

202
Q

What is a nonunion fracture?

A

Failure to heal by 6 months

203
Q

What are the types of non-union fracture?

A

Septic

Hypertrophic (abundant callous without bridging bone)

Atrophic nonunion (inadequate immobilisation and blood supply)

Oligotrophic nonunion (inadequate reduction with fracture fragment displacement)

204
Q

What is the term for a fracture caused by a ruptured ACL?

Describe this type of fracture.

A

Segund fracture

Avulsion fracture of the proximal lateral tibia

205
Q

What classification system is used in Chondral Lesions?

A

Outerbridge Classification

206
Q

What classification system can be used to grade severity of hip OA.

A

Kellgren-Lawrence Scale

Grade 0 = normal

Grade 1 = possible JSN and subtle osteophytes

Grade 2 = definite JSN and defined osteophytes

Grade 3 = marked JSN, multiple small osteophytes, some sclerosis and subchondral bone cysts

Grade 4 = gross JSN, large osteophytes and increased deformity of femoral head and acetabulum

207
Q

What is the MOA of a steroid injection indicated in OA?

A

Steroid (e.g. Triamcinolone) reduces COX and LOX to prevent biosynthesis of PGEs and leukotrienes thus anti-inflammatory effects.

Steroids inhibit macrophage and leukocyte migration site by reducing dilation and permeability thus reduced oedema, erythema and pruritus

Inhibits NF-kappa-S to reduce cytokine production of IL-6, IL-8, MCP-1 and COX-2.

208
Q

What ASA classification is a healthy patient?

209
Q

What ASA classification is a patient with moderate systemic disease that is well-controlled?

210
Q

What ASA classification is a patient with severe disease limiting activity?

211
Q

What ASA classification is a patient who is brain-dead?

212
Q

What classification is a patient who has severe disease that threatens their life?

213
Q

What ASA classification is a patient who requires the operation urgently, unable to survive 24 hours without an operation?

214
Q

What is a Femoroacetabular Impingement?

A

extra bone grows along one or both of the bones that form the hip joint — giving the bones an irregular shape

215
Q

What are the types of Femoroacetabular Impingement?

A

3 types: Pincer, CAM and Combined

Pincer: extra bone extends out over rim of acetabulum which may crush acetabulum

Cam: femoral head is not round, unable to rotate smoothly within the acetabulum which grinds cartilage inside the acetabulum.

Combined: Pincer and CAM deformity present

216
Q

What are the guidelines regarding diagnosis of OA?

A

Clinical diagnosis may be made if patient is >45 years old, has typical pain and has no morning stiffness >30 minutes

217
Q

How is OA managed?

A

Conservative: patient education; weight loss; physiotherapy; OT; orthotics; topical capsaicin
+
Medical: Oral Analgesia; Opiates; IA injections

±
Surgery: TO; HA; TKR

218
Q

What are the potential adverse effects of NSAIDs?

A

Peptic ulcers
Gastritis

AKI
Worsening CKD

HTN
HF
MI
Stroke

Exacerbate asthma

219
Q

What is the average life span of a replaced joint?

A

10-15 years

220
Q

Outline a Total Hip Replacement.

A

Usually, a lateral incision over the outer aspect of the hip is used. The hip joint is dislocated (separated) to give access to both articular surfaces.

The head of the femur is removed. A metal or ceramic replacement head of femur, on a metal stem, is used to replace it. The stem can either be cemented into the shaft of the femur or carefully pushed into the shaft to make a tight enough fit to hold it securely in place. Uncemented stems have a rough surface that holds them tightly in place.

The acetabulum (socket) of the pelvis is hollowed out and replaced by a metal socket, which is cemented or screwed into place. A spacer is used between the new head and socket to complete the new artificial joint.

221
Q

Outline the process of a Total Knee Replacement.

A

Usually, a vertical, anterior incision is made down the front of the knee. The patella is rotated out of the way to allow access to the knee joint.

The articular surfaces (the cartilage and some of the bone) of the femur and tibia are removed. A new metal surface replaces these. They can be either cemented or pushed tightly into place.

A spacer is added between the new articular surfaces of the femur and tibia to complete the new artificial joint.

222
Q

Outline a total shoulder replacement.

A

Usually, an anterior incision is made down the front of the shoulder, along the deltoid. The shoulder joint is dislocated (separated) to give access to both articular surfaces.

The head of the humerus is removed and replaced with a metal or ceramic ball. This replacement head is attached to the humerus either by a metal stem or screws (stemless).

The glenoid (socket) is hollowed out and replaced by a metal socket. This completes the artificial shoulder joint.

223
Q

Describe a Reverse Total Shoulder Replacement.

A

A reverse total shoulder replacement involves adding a sphere in place of the glenoid (socket) and a spacer with a cup to replace the head of the humerus. This reverses the normal ball-in-cup structure of the shoulder joint, but the joint function remains the same.

224
Q

How long is the post-operative VTE prophylaxis for an elective hip replacement?

225
Q

How long is the post-operative VTE prophylaxis for an elective knee replacement?

226
Q

what percentage of prosthetic joints become infected?

227
Q

What is the most common pathogen to cause a prosthetic joint infection?

228
Q

How can you describe a fracture?

A

1) Describe the radiograph

2) Type of fracture (complete vs Incomplete vs Salter-Harris)
- Transverse
- Oblique
- Spiral
- Comminuted

  • Bowing
  • Buckle
  • Greenstick

3) Site: Anatomical location and part of bone or bony Location
- Diaphysis
- Metaphysis
- Epiphysis

4) Is it displaced? 
Angulation (axis of bone altered)
Translation (fractured bones move away)
Rotation (rotated on its axis) 
Impaction

5) Joint involvement

229
Q

A fracture to the distal radius resulting in dorsal angulation is termed?

What is the most common MOI for this?

A

Colle’s Fracture - dinner fork deformity following FOOSH

230
Q

A fracture of the distal radius resulting in volar displacement is termed?

What is the commonest MOI?

A

Smith’s Fracture

231
Q

A fracture which is involving the intra-articular surface of the distal radius is called?

A

Barton Fracture

232
Q

What investigation would you wish to conduct in a suspected wrist fracture?

A

Wrist radiograph - PA and lateral (always 2 views)

233
Q

How do you manage a non-displaced radius fracture?

A

Goal is to restore normal anatomical alignment, encouraging healing and preserved functionality

Tx depends on site, type and features of fracture

Acute:
- Analgesia

Non-displaced
Supportive: Analgesia; Immobilisation (splint/cast); Elevation using broad-arm sling; check for compartment syndrome; check for safeguarding
±
Immobilisation: Below-wrist cast (4-6wks) with 3 point fixation
–> Soft cast for Greenstick fractures

234
Q

How do you manage a closed displaced radius fracture?

A

Supportive: Analgesia; Closed reduction + immobilisation (below elbow cast 4-6 weeks); check for compartment syndrome; review fracture within 72 hours (if IA) or 7 days if (EA)

235
Q

How do you manage an open displaced fracture of the radius?

A 
Supportive: Analgesia; Consider tetanus status; re-align and splint limb (A+E); check for compartment syndrome
\+
Medical: Co-amoxiclav
\+
Surgery: ORIF (0/12/24 rule)

operate immediately if contaminated

Open in 12 hours if high velocity injury and non-contaminated

Open in 24 hours for all other open displaced fractures

236
Q

What are the complications of a distal radial fracture?

A

Neuropathy: median or ulnar nerve
Extensor pollicis longus/ flexor pollicis longus rupture
Compartment syndrome

OA 
Non-union
Complex regional pain syndrome 
Metal work infection 
Metal work irritation
237
Q

What classification system can be sued to describe lateral malleolus fractures?

Outline it

A

Weber classification - describes fracture in relation to the distal syndesmosis between tibia and fibula (tibiofibular syndesmosis)

A = below the ankle joint, syndesmosis in tact

B = level of ankle joint; synsesmosis intact or partially torn

C = above the ankle joint, syndesmosis disrupted

238
Q

Which ligaments make up the deltoid ligament of the ankle?

A

Consists of superficial and deep part

Superficial portion:
Tibionavicular
Tibiocalcaneal
Superficial posterior tibiotalar ligament

Deep:
Anterior tibiotalar
Deep posterior tibiotalar ligament

239
Q

What makes up the lateral collateral ligament?

A

ATFL
Calcaneofibular ligament
PTFL

240
Q

What MOI tends to cause a weber type B ankle fracture?

A

Eversion ankle - can cause medial malleolus or deltoid ligament fracture - unstable

241
Q

What MOI tends to cause a weber type A ankle fracture?

242
Q

What is a Maisonneuve fracture?

A

Sometimes considered a high Weber C, should not be missed! On occasion the energy from an ankle injury will pass through the ankle and syndesmosis and exit at the proximal fibula. This implies the energy has ruptured the syndesmosis resulting in an unstable ankle.

Always check for knee / proximal fibula pain. It may also be suspected after seeing widening of the mortise without obvious fracture on ankle views.

243
Q

Which rules are used to help determine whether or not an ankle injury requires radiographic assessment?

Outline them

A

Ottawa ankle rules

Bony tenderness at lateral malleolus

Bony tenderness at medial malleolus

Inability to weight bear

244
Q

What views should you order in an ankle injury?

A

AP, mortise and lateral

245
Q

Why do you order a mortise view?

A

Evaluate talar shift (widening of medial clear space) - suggests instability with damage to syndesmosis

246
Q

How is a Weber A fracture managed?

A

Supportive: Analgesia; RICE; Fx clinic FU; immobilisation with moon boot

247
Q

How are Weber B and C fractures managed?

A

Supportive: Analgesia; reduce and cast (knee below backstab); VTE prophylaxis

± Instability
Surgery: ORIF

248
Q

What are the most common cancers that metastasise to the bone?

A 
Prostate 
Breast
Liver
Thyroid
Kidney 
Lung
249
Q

What is a pathological fracture?

A

Fracture of bone secondary to underlying disease, in the absence of trauma

250
Q

48 hours after a fracture, a patient presents with shortness of breath, a petechial rash and some confusion. They have a fever and their heart rate is elevated.

What are your potential differentials?

A

Sepsis

Fat embolism syndrome (use Gurd’s major criteria)

251
Q

Outline the blood supply to the femoral head.

A

Foveal artery (epiphysis supply in embryological development) -> ligamentum teres

Retinacular vessels - lateral and medial circumflex arteries

252
Q

How do you classify a hip fracture?

A

Intra-articular or extra-articular relative to the inter-trochanteric line

253
Q

How can you classify an intra-capsular fracture of the Hip?

Outline them

A

Garden’s Classification

Type 1 = incomplete, impacted in valgus

Type 2 = complete, undisplaced

Type 3 = complete, partially displaced

Type 4 = complete, completely displaced

254
Q

State 5 RFs for a hip fracture.

A 
Increasing age 
OP
Steroids
Smoking 
Pathological fractures 
Excess alcohol
Low muscle mass
255
Q

How can you categorise falls broadly?

A

Mechanical - slips and trips

Precipitated - MI, stroke, UTI etc etc

256
Q

What lines can be used to assess the pelvis and hips on an AP XR-Pelvis?

A

Shenton’s line = curved line along superior ramus

Hilgenreiner’s line = straight line between triradiate cartilages (forming acetabulum)

Perkin’s line = straight line perpendicular to Hilgenreiner’s line at acetabulum

257
Q

What is the surgical management of a subtrochanteric fracture?

A

Intermedullary nail

258
Q

What is the surgical management of an intertrochanteric fracture?

259
Q

What are the NICE guidelines regarding surgical management of a hip fracture?

A

Operate within 48 hours of fracture

260
Q

What is the clinical presentation of Compartment Syndrome?

A

P – Pain “disproportionate” to the underlying injury, worsened by passive stretching of the muscles
P – Paresthesia
P – Pale
P – Pressure (high)
P – Paralysis (a late and worrying feature)

Note: Pulseless is not a feature - differentiating it from ALI

261
Q

What is the management of a Compartment Syndrome?

A

Surgical: Fasciotomy

262
Q

What pathogen most commonly causes Osteomyelitis?

263
Q

What are the RFs for Osteomyelitis?

A

Open fractures
Orthopaedic operations, particularly with prosthetic joints
Diabetes, particularly with diabetic foot ulcers
Peripheral arterial disease
IV drug use
Immunosuppression

264
Q

Which pathogen is more commonly associated with Osteomyelitis in IV drug uses?

A

P aeruginosa

265
Q

Which pathogen is more commonly associated with Osteomyelitis with Sickle Cell Anaemia?

A

Salmonella spp.

266
Q

Which pathogen is more commonly associated with Osteomyelitis with ulcers?

A

Polymicrobial

267
Q

What radiographic features may you see in Osteomyelitis?

A

Sequestrum: dead piece of bone separated due to necrosis from surrounding bone

Involucrum: new growth of periosteal bone

Cloaca: opening in involucres allowing internal necrotic bone and pus to discharge out

268
Q

How do you manage an Osteomyelitis?

A

A-E; Stabilisation
+
Medical: Co-amoxiclav; Ceftriaxone + Vancomycin

± Surgery (abscess/neuro deficit/failed ABX)
- Debridement

269
Q

What are the red flags of back pain?

A

<40

Morning stiffness

Fever

Weight loss

Night sweats

Saddle anaesthesia

Urinary urinary retention

Incontinence

Bilateral neuro signs

Bony tenderness

270
Q

What are the nerve roots of the Sciatic Nerve?

271
Q

What are the main causes of sciatica?

A 
Herniated disc
Facet joint hypertrophy
OA 
Spondylolisthesis 
Spinal stenosis
272
Q

What are the main cancers that metastasise to bone?

A 
Thyroid
Lung
Kidney
Breast
Prostate
273
Q

What is the medical management for chronic sciatica?

A

Amitryptiline

or

Duloxetine

± epidural CSI

274
Q

What are the red flags of Cauda Equina?

A

Saddle anaesthesia (loss of sensation in the perineum – around the genitals and anus)
Loss of sensation in the bladder and rectum (not knowing when they are full)
Urinary retention or incontinence
Faecal incontinence
Bilateral sciatica
Bilateral or severe motor weakness in the legs
Reduced anal tone on PR examination

275
Q

What are the causes of Cauda Equina Syndrome?

A

Herniated disc (the most common cause)

Tumours, particularly metastasis

Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)

Abscess (infection)

Trauma

276
Q

What are the causes of spinal stenosis?

A

Congenital

Degenerative changes

Herniated discs

Thickening of posterior longitudinal ligament

Spinal fractures

Spondylolisthesis

Tumours

277
Q

A 57 year old patient presents with leg weakness and leg pain every time they walk excessively. They have had lower back pain for the last 20 years.

They have a PMHx of Obesity; T2DM; Lap Cholecystectomy.

Their ABPI is normal.

What is your diagnosis?

A

Central spinal stenosis

278
Q

What is the management of central spinal stenosis?

A

Supportive: exercise; weight loss; analgesia; physiotherapy

±
Surgery: Laminectomy

279
Q

What type of neuropathy is Meralgia Paraesthetica?

A

Mononeuropathy of a sensory nerve

280
Q

What are the nerve roots of the lateral femoral cutaneous nerve?

281
Q

A 24 year old girl presents with a strange sensation of burning and numbness on the outer aspect of her thigh. She says she has experienced this for 3/52. The feeling is made worse by walking, improving when sat down.

There is no pain. She is generally well.

O/E no skin colour changes, tender to palpation; painful extension of the hip.

What is your diagnosis?

A

Meralgia paraesthetica

282
Q

A 24 year old girl presents with a strange sensation of burning and numbness on the outer aspect of her thigh. She says she has experienced this for 3/52. The feeling is made worse by walking, improving when sat down.

There is no pain. She is generally well.

O/E no skin colour changes, tender to palpation; painful extension of the hip.

What is your management?

A

Supportive: Rest; Looser clothing; weight loss; Physiotherapy
+
Medical: Analgesia; CSI

±
Surgery: Decompression/Transection/Resection

283
Q

A patient stands on their left leg whilst their right foot is lifted off the ground. The hip is seen to drop.

What sign is this?

Explain which muscle is affected.

A

Trendelenburg Sign

When standing, the contralateral gluteus medius stabilises the pelvis. Therefore when standing on the L leg, the L gluteus medius is weak, failing to stabilise the R pelvis

284
Q

How long does it take to recover from trochanteric bursitis?

A

6-9 months

285
Q

What clinical test is used to rule in or out a meniscal injury?

A

McMurray’s Test - lay supine and flex knee with internal/external rotation whilst extending the leg at the knee.

Pain on internal rotation and varus deformity = lateral meniscus

Pain on external rotation and valgus deformity = medial meniscus

286
Q

What rules may be used to decide if a patient needs a XR-Knee in an acute knee injury?

A

Age 55 <

Patella tenderness

Fibular head tenderness

Cannot flex knee to 90 degrees

Cannot weight bear

287
Q

What is the management of a meniscal injury?

A

Supportive: RICE; NSAIDs; Physiotherapy
+
Surgery: Arthroscopy with repair or resection

288
Q

Where do the ACL and PCL originate and insert?

A

Mnemonic: “LAMP”

ACL - lateral intercondylar area –> anterior intercondylar area of tibia

PCL - medial intercondylar area –> posterior intercondylar area of tibia

289
Q

How is the ACL injured?

A

MOI is twisting

290
Q

What is the MOI of PCL rupture?

A

Blunt trauma from posterior - e.g. car accident

291
Q

What is the gold-standard to diagnose an ACL injury?

292
Q

What type of fracture may be observed in an ACL rupture?

A

Segund fracture - avulsion fracture of tibial plateau

293
Q

What type of fracture may be observed in an posterolateral ligamentous rupture?

A

Arcuate sign - avulsion fracture of proximal fibula

294
Q

What is the name of the accessory ossicle found in the lateral head of gastrocnemius?

295
Q

Which ligaments make up the posterolateral ligamentous complex?

A

LCL
Arcuate Ligament
Popliteofemoral ligament

296
Q

What is the management for a knee ligament injury?

A

Supportive: RICE; NSAIDs; Mobilisation
±
Surgery: Arthroscopic surgery grafting

297
Q

What patient group is Osgood-Schlatter disease more common in?

A

10-15 years old

Males

Active

298
Q

What is the pathophysiology of Osgood-Schlatter Disease?

A

The patella tendon inserts into the tibial tuberosity. In patients with Osgood-Schlatter disease, multiple minor avulsion fractures occur where the patella ligament pulls away tiny pieces of the bone. This leads to growth of the tibial tuberosity, causing a visible lump below the knee. Initially, this lump is tender due to inflammation. As the bone heals and inflammation settles, the lump becomes hard and non-tender.

299
Q

What is the management of Osgood-Schlatter disease?

A

Supportive: RICE; limitation in activity; NSAIDs

300
Q

What are the borders of the Popliteal fossa?

A

Semimembranosus + Semitendinosis

Biceps femoris

Medial + Lateral Gastrocnemius

301
Q

What are Baker’s Cysts associated with?

A

Degenerative changes in the knee

Meniscal tears (an important underlying cause)
Osteoarthritis
Knee injuries
Inflammatory arthritis (e.g., rheumatoid arthritis)

302
Q

What is a Foucher’s Sign?

A

Baker’s cyst disappearing

The lump will get smaller or disappear when the knee is flexed to 45 degrees

303
Q

A lump is found in the Popliteal fossa, what are your differentials?

A 
DVT 
Abscess
Baker's Cyst
Ganglion cyst 
Lipoma
Tumour
304
Q

What is the management for a Baker’s Cyst?

A

Supportive: Reduce exacerbations; NSAIDs; Physiotherapy
±
Intervention: US-guided aspiration; CSI

305
Q

State 3 RFs for Achille’s Tendinopathy.

A

Sports that stress the Achilles (e.g., basketball, tennis and track athletics)
Inflammatory conditions (e.g., rheumatoid arthritis and ankylosing spondylitis)
Diabetes
Raised cholesterol
Fluoroquinolone antibiotics (e.g., ciprofloxacin and levofloxacin)

306
Q

What test is clinical diagnostic of Achille’s Tendinopathy?

A

Simmond’s calf squeeze test

307
Q

What imaging is used to visualise an Achille’s Tendinopathy?

308
Q

What is the management of Achille’s Tendinopathy?

A

Supportive: RICE; weight loss; eccentric exercises; ESWT
±
Surgery: Removing nodules/adhesions

309
Q

How may an Achille’s Tendon rupture present?

A

MOI: force/snapping/pain

Dorsiflexed
Calor/Dolor/Pallor/Tumor
Palpable gap
Tenderness

Weakness in plantarflexion
Positive Simmonds’ calf squeeze test

310
Q

What imaging modality is used in a suspected Achille’s Tendinopathy?

A

US-Achille’s Tendon

311
Q

How do you manage an Achille’s Tendinopathy?

A

Supportive: RICE; Analgesia; moon boot (6-12 healing); physiotherapy

±
Surgery: Gastrocnemius recession; Debridement and Repair

312
Q

A patient presents with gradual onset of pain at the heel. The pain is worse with pressure, better with rest.

It appears tender on palpation.

What is the diagnosis?

How would you manage this?

A

Plantar Fasciitis

Supportive: RICE; Analgesia; Physio

313
Q

A patient presents with gradual onset of pain at the heel. The pain is worse with pressure, better with rest.

It appears tender on palpation. The entire plantar aspect of heel seems sore, worse when barefoot.

US-Foot shows reduced fat.

What is the diagnosis?

How would you manage this?

A

Fat pad atrophy

Supportive: RICE; weight loss; comfortable shoes

314
Q

A 45 year old patient presents with a pain in their foot. The pain is between the 3rd and 4th metatarsal as they point towards it.

The pain is accompanied by a sensation of a lump in the shoe. They have a burning and numb feeling in the toes.

Squeezing the metatarsals elicits pain, as does deep pressure.

A click is felt when using two sites to force the metatarsals against the lesion.

What is your diagnosis?

What is the name of this sign for the audible click heard?

How do you manage this?

A

Morton’s Neuroma

Mulder’s Sign

Supportive: adapt activities; Analgesia; insoles; weight loss
±
Surgery: Excision

315
Q

What joint is affected by a bunion?

316
Q

What is the definitive treatment for a Hallux valgus?

A

Surgery: Bunienectomy

317
Q

A fluid aspirat of the MTP joint shows needle shaped crystals which are negatively birefringent of polarised light.

What is your diagnosis?

How can you manage this?

A

Gout

Acute: 
NSAIDs 
or 
Colchicine 
or 
Steroids

Chronic:
Allopurinol
/
Febuxostat

318
Q

What are the phases of Adhesive Capsulitis?

A

Painful –> Stiff –> Thawing

319
Q

Outline the pathophysiology of adhesive capsulitis.

A

In adhesive capsulitis, inflammation and fibrosis in the joint capsule lead to adhesions (scar tissue). The adhesions bind the capsule and cause it to tighten around the joint, restrict movement in the joint

320
Q

What is the management for Adhesive Capsulitis?

A

Supportive: Analgesia; Exercise; IA-injections

321
Q

Where do the rotator cuff muscles insert onto the humerus?

A

Mnemonic: SITS

Greater tubercle:

Supraspinatus: superior facet of greater tubercle

Infraspinatus: middle facet of greater tubercle

Teres minor: Inferior facet of the greater tubercle

Lesser tubercle: Subscapularis

322
Q

What imaging modality can be used to diagnose a rotator cuff tear?

A

US-Shoulder

or

MRI-Shoulder

323
Q

How do you manage a rotator cuff tear?

A

Supportive: RICE; Analgesia; Physiotherapy
±
Surgery: Arthroscopic rotator cuff repair

324
Q

What is the most common type of GH dislocation?

A

Anterior (90%)

324
Q

What is the most common type of GH dislocation?

A

Anterior (90%)

325
Q

What is the MOI for a shoulder dislocation?

A

Humerus moves posteriorly when arm abducted and extended at shoulder

326
Q

What is an anterior tear of the labrum called?

A

Bankart lesion

327
Q

Following a shoulder dislocation, an XR-Shoulder shows a compression fracture of the posterolateral part of the humeral head.

What is this called?

A

Hill-Sachs lesion

328
Q

What nerve palsy may occur following an anterior shoulder dislocation?

A

Axillary nerve damage

329
Q

What imaging may you conduct in a shoulder anterior dislocation?

A

XR-Shoulder

MRI-Shoulder

Arthroscopy

330
Q

How do you manage a shoulder dislocation?

A

Acute: Analgesia; Closed reduction; Post-reduction XR-Shoulder; broad arm sling

331
Q

What surgical repair can be done to correct a Bankart lesion?

A

Latarhet procedure

332
Q

What are the causes of olecranon bursitis?

A

RSI
Trauma
Inflammatory conditions
Infection

333
Q

What investigation should be conducted in a suspected olecranon bursitis?

What may the different constituencies indicate?

A

Aspiration of fluid

Pus = infection

Straw-coloured = normal

Blood-stained = trauma or inflammation

Milky = gout/pseudogout

334
Q

How do you manage an olecranon bursitis?

A

Supportive: RICE; Analgesia; Support; Aspiration; CSI

± Infection suspected
- ABX

335
Q

Lateral epicondylitis is called?

A

Tennis elbow

336
Q

Medial epicondylitis is called?

A

Golfer’s elbow

337
Q

How can you test clinically for lateral epicondylitis?

A

Cozen’s test: elbow extended, make fist and pronate with radial deviation = pain = positive

338
Q

How can you clinically test for Medial Epicondylitis?

A

Golfer’s elbow test: elbow extender, forearm supinated and wrist extended

339
Q

How do you manage a medial epicondylitis?

A

Supportive: RICE; Analgesia; Physio; Orthotics; CSI; ESWT

340
Q

Which two tendons are affected in DeQuervain’s Tenosyvitis?

A

APL tendon

EPB tendon

341
Q

What is the pathophysiology of DeQuervain’s Tenosynovitis?

A

APL abducts thumb and wrist.

EPB extends the thumb but also abducts thumb and wrist.

Tendon sheaths can become inflamed due to RSI which cause swelling of tendon sheath, catching the extensor retinaculum

342
Q

How can you clinically test for DeQuervain’s Tenosynovitis?

A

Finkelstein’s test: patient arm on table with wrist over edge, adduct wrist over edge = pain

Eichoff’s test: patient makes fist then wrist adducted = pain

343
Q

What is the management of DeQuervain’s tenosynovitis?

A

Supportive: RICE; Analgesia; Physiotherapy; CSI

344
Q

What is the pathophysiology of Trigger Finger?

A

Flexor tendons pass through sheaths along the lengths o the fingers but thickening of the sheath causes the tendon to catch when the finger is flexed and extended.

A1 pulley at the MCP joint most commonly affected

345
Q

What is the management of a trigger finger?

A

Supportive: Rest; Analgesia; Splinting; CSI
±
Surgery: A1 pulley release

346
Q

Outline the pathophysiology of Dupuytren’s contracture.

A

Palmar fascia becomes thicker and tighter, developing nodules which pulls the fingers into flexure - causing a contracture

347
Q

Give 5 RFs for Dupuytren’s Contracture.

A 
Age 
FHx (AD inheritance)
Male 
Manual labour 
DM (1 > 2)
Epilepsy 
Smoking
Alcohol
348
Q

How can you clinically test for a Dupuytren’s contracture?

A

table-top test is a straightforward test for Dupuytren’s contracture. The patient tries to position their hands flat on a table. If the hand cannot rest completely flat, the test is positive, indicating Dupuytren’s contracture

349
Q

What is the management of a Dupuytren’s Contracture?

A

Surgery: Needle fasciotomy; Limited fasciectomy; Dermofasciectomy

350
Q

Which nerve is affected in Carpal Tunnel Syndrome?

A

Palmar digital cutaneous branch of median nerve

351
Q

Give 5 RFs for Carpal Tunnel Syndrome.

A 
Idiopathic 
RSI 
Diabetes
Pregnancy
Acromegaly
Hypothyroidism
Obesity
Perimenopause 
Rheumatoid arthritis
352
Q

How may you clinically test for Carpal Tunnel Syndrome?

A

Tinnel’s test: Tap location of median nerve = numbness and paraesthesia

Phalen’s Test: fully flex wrist and hold in position by putting backs of hands together = numbness and paraesthesia

353
Q

What questionnaire may be used in the diagnosis of Carpal Tunnel Syndrome?

A

Kamath and Stothard questionnaire

  • Symptoms at night
  • Trick movements
  • Little finger affected (less likely diagnosis)
354
Q

What is the gold standard for diagnosis of CTS?

A

Nerve conduction studies - reduced electrical current/signal

355
Q

How is CTS managed?

A

Supportive: Orthoses; Rest; CSI
±
Surgery: Carpal Tunnel Release

356
Q

What are the clinical features of a ganglion?

A

Range in size from 0.5 to 5cm or more (most are 2cm or less)
Firm and non-tender on palpation
Well-circumscribed
Transilluminates (shining a torch into the cyst causes the whole lump to light up)

357
Q

How are Ganglion cysts managed?

A

Supportive: Watch and wait (50% resolve spontaneously)
±
Intervention: Needle aspiration; Surgical excision

358
Q

What is anaemia?

A

Reduced Hb concentration

359
Q

What are the criteria for Anaemia?

State this for M, F and pregnant women.

360
Q

Outline the knee Ottawa rules.

A 
> 55 years old 
Patella tenderness 
Head of the fibula tenderness 
Cannot flex knee 90 degrees 
Cannot weight bear
361
Q

How may you classify pelvic fractures?

Give the broad description.

A

Young-Burgess Classification of Pelvic Fracture

Split into three categories of Anterior Posterior Classification (APC), Lateral Compression (LC) and Vertical Shear (VS)

362
Q

Outline the criteria in the Young-Burgess classification of pelvic fractures.

A

APC I: Symphysis > 2.5cm

APC II: Symphysis > 2.5cm; anterior SI diastasis; Posterior SI ligaments in tact; Disruption of SS and ST ligaments

APC III: SI dislocation; disruption of SS and ST ligaments
-> Related to vascular injury

LC I: Oblique or transverse ramus fracture + anterior sacral ala compression

LC II: Rami fracture + ipsilateral posterior ilium fracture dislocation

LC III: ipsilateral lateral compression and contralateral APC (windswept pelvis)

Vertical shear: Posterior and superior directed force

363
Q

What are the cautions to consider in a haematoma block?

A

Do not inject an open fracture - require washout/debridement (I+D)

Do not use more than 15mL lidocaine - toxicity

Do not repeat injections - concern about compartment syndrome

364
Q

What are the radiographic features of a Charcot joint?

A

Mnemonic: 5Ds

Density change (subchondral osteopenia or sclerosis)
Destruction (osseous fragmentation and resorption)
Debris (IA loose bodies)
Distension (joint effusion)
Disorganisation
Dislocation

365
Q

What is the difference between Charcot Foot and Charcot-Marie-Tooth (CMT) disease?

A

Charcot Foot = charcot neuropathy due to impaired sensation (secondary to Diabetes), bones become weak and breakdown

CMT = inherited disorders of peripheral neuropathy with high arches and curled toes resulting in change shape due to atrophy.

Foot drop
Pes Cavus 
Hammer toes 
Distal muscle weakness
Distal muscle atrophy 
Hyporeflexia 
Stork leg deformity
366
Q

A loss of vibration and proprioception indicates which of the following?

A. Dorsal column lesion

B. Spinothalamic tract lesion

C. Osteomyelitis

D. Infarction of spinal cord

367
Q

Loss of pain, sensation and temperature is suggestive of what spinal disorder?

A

Spinothalamic tract lesion

368
Q

In osteomyelitis of secondary to TB, what region of the spinal cord is affected?

369
Q

What is Brown-Sequard syndrome?

A

Hemisection of the spinal cord

Ipsilateral paralysis and proprioception with loss of fine discrimination

Contralateral loss of pain and temperature

370
Q

What myotome is involved in elbow flexion?

371
Q

What myotome is involved in elbow extension?

372
Q

What myotome is involved in wrist extension?

373
Q

What myotome is involved in finger flexion?

374
Q

What myotome is involved in finger abduction?

375
Q

What myotome is involved in hip flexion?

376
Q

What myotome is involved in knee extension?

377
Q

Which myotome is involved in knee flexion?

378
Q

What myotome is involved in ankle dorsiflexion?

379
Q

What myotome is involved in toe extension?

380
Q

What myotome is involved in plantarflexion?

381
Q

What are the two types of femoracetabular impingement?

A

Pincer lesion (acetabulum covers more of hip joint)

CAM lesion (loss of head sphericity at head-neck junction)

Mixed (combination of CAM and pincer)

382
Q

State a hypothesis for the aetiology of Femoroacetabular impingement.

A

Critical development theory of the proximal femoral physics

10-14 boys
8-12 girls

Repetitive injury causes strain on the physio and subsequent deformity

383
Q

What is the most common site of deformity in a CAM deformity?

A

Abnormal osseous prominence most significant anterior and lateral aspects of femoral neck

384
Q

What is the pathophysiology of a CAM lesion?

A

Anterior and lateral aspects of the femoral neck tend to bear osseous prominence.

An irregularly shaped femoral head rotates within acetabulum during motion which contacts the anterosuperior aspect of the acetabulum resulting in delamination of the articular cartilage. Furthermore, the acetabular labrum is degenerated

Surgery (10 decks)

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