Orthopaedics Flashcards
What is the diaphysis?
The shaft
What are the risk factors of OA?
Increasing age
Female gender (twice as common)
Obesity
Developmental dysplasia of the hip
What are the features of OA of the hip?
chronic history of groin ache following exercise and relieved by rest
red flag features suggesting an alternative cause include rest pain, night pain and morning stiffness > 2 hours
the Oxford Hip Score is widely used to assess severity
What should you give to patients with lower back pain?
NSAIDS are now recommended first-line for patients with back pain. This follows studies that show paracetamol monotherapy is relatively ineffective for back pain
proton pump inhibitors should be co-prescribed for patients over the age of 45 years who are given NSAIDs
NICE guidelines on neuropathic pain should be followed for patients with sciatica
What stabilises the ankle joint.
Tibiofibular syndesmosis
The syndesmosis is an essential part of the ankle jointand its stability, preventing splaying of the tibia and the fibula
What Ix would you want to do for a person with suspected ankle fracture?
Bedside tests- observations, BM, pregnancy test, ECG
Blood tests - FBC, U and Es and LFTS (prophylactic anticoagulation), clotting screen if someone is on anticoags to see what their clotting time is before surgery
Imaging- ankle XR (weight beading when possible, AP and lateral and mortise views), ankle CT is used in complex fractures
Special tests
What is a talar shift?
Widening of the medial clear space
It is associated an increased risk of post traumatic arhritis
It may not be evident on non weight bearing films
Talar shift is a clear sign of instability
What is the classification system used for ankle fractures?
Weber classification, based on the level of the fibular fracture in relation to the syndesmosis.
What is weber A, B, C Classifications?
A= below the level of syndesmosis B= at the syndesmosis C= above the level of syndesmosis
What is a maisonneuve fracture?
It is where there is ankle injury but the energy may pass upward and fracture the fibula, therefore in an ankle fracture you should always examine the knee with potential xray depending on clinical findings
What is the management of weber A fracture?
Weight bear with walking boot
How do you treat weber B fractures?
May need surgical fixation, although some will be appropriate for cast immobilisation
What do you do for a weber C fracture?
ORIF
What is close contact casting?
May be used as an alternative to surgical fixation
What would your approach be to an ankle fracture?
Analgesia- conscious sedation, opiates, gas and air
Reduce and cast (backslab)
Backslab allows the ankle to swell at the front
Re assess and check neurovascular status
Repeat xray
NBM (if really unstable and you think they will be going to theatre and elevate)
Senior review
When may you consider closed contact casting?
In patients who are elderly or co-morbid (e.g. diabetes mellitus, peripheral neuropathy) closed contact casting (CCC) should be considered for definitive management. Complications associated with surgery (e.g. infection) are eliminated though there appears to be a higher risk of mal-union with CCC.
What is a colles fracture?
An extra articular fracture of the metaphsyeal region of the radius with dorsal angulation of the distal fragment and impaction
What normally causes a colles fracture?
Fall onto outstretched hand (FOOSH)
What is a Smiths fracture?
This is reverse of Colles, refers to fracture of the distal radius with volar angulation of the distal fragment. Tends to be inherently less stable than fractures with dorsal angulation
What are the presentation of wrist fractures?
Fractures of the distal radius are acute injuries, patients will present with pain, swelling and reduced function of the affected joint.
Symptoms
Pain
Reduced range of movement
Signs
Boney tenderness
Swelling
Deformity
All patients should have a full assessment (and documentation) of the limbs neurovascular status. Complete a full-body assessment for associated injuries.
What investigations do you need to do for Colles?
The diagnosis of a wrist fracture may be made clinically and confirmed by a wrist radiograph.
Bedside
Observations
Urine dip
ECG
Bloods
FBC U&Es CRP Bone profile Vitamin D Group & save Clotting screen Imaging
Wrist X-ray: PA and lateral films.
CT: allows accurate delineation of the extent of the fracture and any intra-articular involvement (not routinely required).
MRI: allows assessment of soft tissue injuries (not routinely required).
How do you manage wrist fracture?
Under 65- surgery will typically be considered. If closed reduction is possible then K wire fixation is generally preferred to ORIF
Over 65- in more elderly pts, non operative management will be considered as definitive management, where there is instability, significant deformity or neurological compromise then surgery will be considered.
What are the complications of wrist fracture?
Early
Median nerve neuropathy Ulnar nerve neuropathy Extensor pollicis longus or flexor pollicis longus rupture Compartment syndrome Medium to late
Osteoarthritis Non-union / mal-union Complex regional pain syndrome Metalwork infection Metalwork irritation
What does cauda equia normally present with?
Compression of the cauda equina (L1-S5) of the spinal nerves
It usually presents with bilateral leg weakness and paraesthesia
Also associated with bladder and bowel dysfunction
What does lumbar disc herniation present with?
Lumbar disc herniation is incorrect this usually presents with reduced power and sensation in the affected leg. This is due to nerve root compression compressing both motor and sensory nerve fibres. A positive straight leg raise test is indicative of the condition.
The sciatic nerve divides into the tibial and common peroneal nerves
Injury often occurs at the neck of the fibula
What are the characteristics of a common peroneal nerve lesion?
Most characteristic feature is foot drop
Other features..
- weakness of foot dorsiflexion
- weakness of foot eversion
- weakness of extensor hallucis longus
- sensory loss over the dorsum of the foot and the lower lateral part of the leg
- wasting of the anteror tibial and peroneal muscles
What are the clinical features of degenerative disc disease?
Depemds on the region and severity
Potential signs include local spinal tenderness of contracted parasoinal muscles, hypomobility, painful extension of back or neck
All cases require a complete neurological exam
When the disc degeneration progresses to cause instability, the pain may become more severe and include radicular leg pain or paraesthesia. Pain may be reproduced by passively raising the extended leg (positive Lasegue sign).
Further disease progression may demonstrate signs of worsening muscle tenderness, stiffness, reduced movement (particularly lumbar region), and scoliosis.
Pain after replacement?
Osteomyelitis
Dislocation of the prosthesis
Loosening of the prosthesis
What is the name for bunion?
Hallux valgus
What are the symptoms of hallux valgus caused by?
Pressure on the medial aspect of the first metetarsal head
What is cervical spondylosis?
Osteophytes in the vertebral foramen
Causes of limp in child?
< 4years old
NAI Juvenile idiopathic arthritis Transient synovitis (after an illness) NAI Leukaemia
Causes of hip pain in child 4-10 years?
Perthes
Osteomyelitis
SA
Leukaemia
Hip pain in 10-16 years?
Slipped femoral epiphysis
Avulsion fractures
Osteomyelitis/ septic arthritis
What would you see on Xray of perthes?
Flattening of the femoral head
What is the management of perthes?
To keep the femoral head within the acetabulum: cast, braces
If less than 6 years: observation
Older: surgical management with moderate results
Operate on severe deformities
What is enthesopathy?
Disorder or tendon/ ligament insertion
What is tendosynovitis?
Tendon sheath synovitis
What are the features of epicondylitis?
Gradual Onset pain
Pain is worse with activity and relieved by rest
What is lateral epicondylitis?
What are the risk factors?
What are the signs on examination?
What is the management?
Also called tennis elbow
It is inflammation of the lateral epicondyle
Pain worse with movement, gradual onset, normal passive ROM
Risk factors= obesity, smoking, carpal tunnel, tendionpathies
On examination you get pain with resisted wrist extension (cozens test) and supination
Treatment= NSAIDS, splints, physio
Medical= steroid injection if tx resistant
Surgical option= release incision
What is medical epicondylitis?
What are the risk factors?
What are the signs on examination?
What is the management?
Inflammation of the common flexor pronator tendon and ulnar collateral ligament
Risk factors= manual work and sports
Pain with wrist flexion and pronation +/- carpal tunnel
What is de quervains tenosynovitis?
Where is the pain?
What is the treatment?
Inflammation of the synovial sheaths of thumb tendons (external pollicus brevis and abductor pollicus longus)
The pain is worse of thumb flexion and ulnar deviation (finkelsteins test)
Swelling around sytloid process of radius
Management is with Rest, splinting, NSAIDS
Localised corticosteroid injections
Surgical release of tendon tunnel, if sx persist
When do you refer tendor tears?
Only refer for imaging/ secondary care if no improvement if 12 weeks or traumatic injury
What are the risk factors for frozen shoulder
What are the stages
What is the treatment
Risk factors= Female Diabetes >40yrs Following surgery/injury Thyroid Immobility
Stages
Pain then freezing then resolution (resolves in 1.5 to two years)
NSAIDS and physio +/- steroid injections
What are the causes of impingement syndrome?
What is the management?
Causes= subacromial bursitis, suprasoinatus tendonitis, acromioclaviculae arthritis
Management is with NSAIDs, physio, steroid injections, and removing bony tissues
What is the treatment of biceps tendon rupture?
It depends if the pt is young and active
If young and active then you can do surgery
If old or not active then you can do RICE
What are the two types of patellar bursitis, how do you treat?
Infrapatellar = clergymans knee Suprapatellar= housemaids knee
Avoid kneeling, incision and drainage if infected
What is plantar fasciitis?
How does it present?
Overuse injury causing inflammation of the plantar fascia
Stabbing pain under heal (worse wirh first steps after prolonged resting)
Associated w/ prolonged standing/running, poor trainers/ hard ground, flat feet, obesity, middle aged + female
What does subcalcaneal bursitis present with?
What is the treatment?
A dull ache under the heel which worsens throughout the day
Again treatment is RICE, NSAIDS, comfortable footwear and orthoptics
What is associated with an ACL tear?
Medial meniscus damage
What are the causes of meniscal damage of the knee
How do you diagnose it?
Degenerative tears
Acute tears due to twisting injury
Diagnosis is with mcmurrays test, may do an x ray to rule out fracture and osteoarthritis, MRI is diagnostic
What is the management of meniscal problems?
Arthroscopic repair (if sx are serious or it is a younger patient) Conservative tx (if degenerative tear/OA)- activity modification, physio, NSAIDS
How do you diagnose ligamental damage to knee?
ACL/PCL= replacement with hamstring or patellar tendon graft (dont tend to heal on their own)
Collateral ligaments= immobilisation with knee brace and phsyio
What are the red flags of back pain that require MRI?
New onset in <22y/o or >55 years Constant night pain Progressive motor weakness Thoracic back pain Saddle anaesthesia Bladder or bowel incontinence Recent infection Hx of trauma or cancer
What is radiculopathy, what are the sx?
What is myelopathy, what are the sx!?
Radiculopathy is where the nerve roots are pinched as they exit the spine
Causes pain, paraesthesia, weakness in a dermatomal distribution
You also get LMN signs (hyporeflexia, hypotonia)
Myelopathy is where the spinal cord is compressed and it causes pain, paraestgesia, weakness BILATERALLy and other neurological symptoms
You get UMN signs (hypereflexia, hypertonia, spasticity)
What is cervical spondylosis?
Cervical radiculopathy which is caused by age related degenerative changes to the spine
It is caused by osteophyte development which pinch nerve roots as they leave the spinal canal
What are the symptoms of spondylosis?
How do you diagnose it?
What is the management?
Pain in neck (radiating down as a dull ache or toothache) —> brachial neuralgia
Tingling and numbness in one dermatome
+/- weakness in one arm
Usually a clinical diagnosis
Management is mostly self limiting (6-12 weeks), rest, physio, Analgesia (NSAIDS or neuropathic - TCAS), hard collar for immobilisation
What nerve would be damaged in a humeral fracture?
Radial nerve
How do you treat acromioclavicular joint dislocation?
Surgical fixation
What is the most likely presentation of arterial embolus?
Pain out of keeping with clinical findingsb
What nerve is damaged if there is paraesthesia of the whole dorsum of foot?
Superficial fibular
What nerve is compromised if you have paraesthesia of the first web space?
Deep peroneal
What do you see in posterior dislocation of the hip?
Leg shortening and internal rotation
What is the most common cause of osteomyelitis?
How do you treat it?
Staph aureus
Need to do MRI to Ix
Management is fluclox for 6 weeks
What is meralgia paraesthetica?
Compression of lateral cutaneous nerve
Get burning sensation of antero lateral aspect of thigh
