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Zero to Finals: Surgery > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

risk factors for OA?

A
  • obesity
  • ageing
  • occupation
  • trauma
  • female sex
  • FHx
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2
Q

which joints are commonly affected in OA?

A
  • hips
  • knees
  • sacro-iliac joints
  • DIPs
  • CMC (base of thumb)
  • wrist
  • cervical spine (gives spondylosis)
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3
Q

LOSS: X-ray changes seen in OA?

A
  • loss of joint space
  • osteophytes
  • subarticular sclerosis
  • subchondral cysts
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4
Q

presentation of OA?

A
  • joint pain and stiffness
  • worse after use / end of the day
  • bulky enlargement of joints
  • reduced ROM
  • crepitus on passive movement
  • effusion around joint
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5
Q

hand signs seen in OA?

A
  • bouchard’s nodes (PIPs)
  • heberden’s nodes (DIPs)
  • squaring of base of thumb
  • weak grip
  • reduced ROM
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6
Q

how is OA diagnosed?

A

does not require investigations if:

  • age >45
  • typical pain w/ activity
  • no morning stiffness (or <30 mins of morning stiffness)
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7
Q

management of OA?

A
  • weight loss
  • physiotherapy
  • OT
  • orthotics (e.g. knee braces)
  • analgesia
  • joint replacement if severe
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8
Q

analgesic ladder in OA?

A
  1. PO paracetamol + topical NSAIDs
  2. add PO NSAIDs (+PPI)
  3. weak opioids (codeine)

other options:

  • topical capsaicin
  • intra-articular steroids
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9
Q

what is a compound fracture?

A

when skin is broken and the broken bone is exposed to air

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10
Q

what is a stable fracture?

A

when sections of the bone remain in alignment at the fracture

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11
Q

what is a pathological fracture?

A

when a bone breaks due to underlying bone abnormalities

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12
Q

give some causes of pathological fractures

A
  • bony mets
  • osteoporosis
  • paget’s disease of the bone
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13
Q

which cancers commonly metastasise to the bone?

A
  • prostate
  • renal cell carcinomas
  • thyroid
  • breast
  • lung
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14
Q

what is a colle’s fracture?

A

transverse fracture of the distal radius

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15
Q

which fractures are commonly caused by falling onto an outstretched hand (FOOSH)?

A
  • colle’s fracture

- scaphoid fracture

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16
Q

main complication of a pelvic fracture?

A

intra-abdominal bleeding, which can then cause shock / death

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17
Q

common sites for pathological fractures?

A
  • femur

- vertebral bodies

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18
Q

what is a fragility fracture? commonest cause?

A
  • fracture due to weakness of bone

- osteoporosis

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19
Q

what is the FRAX score?

A

risk of fragility fracture within the next 10 years

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20
Q

how can bone mineral density be calculated?

A

using a DEXA scan

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21
Q

which T-score range means there is osteopenia?

A

-1 to -2.5

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22
Q

which T-score range means BMD is normal?

A

more than -1

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23
Q

T-score range indicating osteoporosis?

A

less than -2.5

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24
Q

WHO criteria for severe osteoporosis?

A

T-score < -2.5 AND a fracture

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25
Q

prophylaxis of fragility fractures in osteoporotic pts?

A
  • calcium
  • vitamin D
  • bisphosphonates (e.g. alendronic acid)
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26
Q

key side effects of bisphosphonates?

A
  • reflux, oesophageal erosions
  • atypical fractures (esp femoral)
  • osteonecrosis of the jaw
  • osteonecrosis of external auditory canal
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27
Q

what are the 3 key goals of fracture management?

A
  • pain management
  • mechanical alignment
  • relative stability (so that it can heal)
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28
Q

2 methods of achieving mechanical alignment in fracture management?

A
  • closed reduction (manipulating the limb)

- open reduction (surgery)

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29
Q

complications of a fracture?

A
  • damage to local structures (e.g. tendons, muscle)
  • haemorrhage
  • compartment syndrome
  • fat embolism
  • VTE
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30
Q

presentation of fat embolism syndrome?

A
  • onset is typically 24-72h after a fracture
  • respiratory distress
  • petechial rash
  • cerebral involvement
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31
Q

how can fat embolism syndrome be prevented?

A

by operating early on the fracture

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32
Q

RFs for hip fracture?

A
  • ageing

- osteoporosis

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33
Q

how can hip fractures be classified?

A
  • intra-capsular

- extra-capsular

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34
Q

describe the capsule of the hip joint

A
  • strong fibrous structure
  • surrounds head and neck of femur
  • attaches to rim of acetabulum on pelvis and intertrochanteric line
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35
Q

describe the blood supply to the hip joint

A
  • retrograde blood supply

- supplied by medial and lateral circumflex femoral arteries

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36
Q

when is a hip fracture classed as intra-capsular?

A
  • when there is a break in the femoral neck

- this is proximal to the intertrochanteric line

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37
Q

how can intra-capsular hip fractures be classified?

A

using Garden classification:

  • grade I = incomplete
  • grade IV = fully displaced
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38
Q

main complication of an intra-capsular hip fracture?

A

avascular necrosis

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39
Q

how can non-displaced intra-capsular hip fractures be treated?

A

interval fixation with screws

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40
Q

describe a hemiarthroplasty. which pts get offered this?

A
  • replacing the head of femur but leaving the acetabulum in place
  • pts with limited mobility / lots of comorbidities
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41
Q

describe a total hip replacement. which pts get offered this?

A
  • replacing both head of femur and acetabulum

- pts who are independently mobile and fit for surgery

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42
Q

which is worse: extra-capsular or intra-capsular hip fracture?

A
  • intra-capsular

- in an extra-capsular fracture, the blood supply is left intact, so the head of femur doesn’t need to be replaced

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43
Q

types of extra-capsular hip fracture?

A
  • intertrochanteric

- subtrochanteric

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44
Q

how are intertrochanteric (extra-capsular) hip fractures treated?

A

dynamic sliding hip screw

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45
Q

how are subtrochanteric (extra-capsular) hip fractures treated?

A

intramedullary nail

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46
Q

presentation of a hip fracture?

A
  • typically pts aged >60
  • groin / hip pain
  • might radiate to knee
  • shortened, abducted and externally rotated leg
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47
Q

investigations for a hip fracture?

A
  • initially: X-ray in 2 views (AP and lateral)

- MRI / CT where X-ray is -ve but fracture still strongly suspected

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48
Q

what might be seen on an AP view X-ray in a hip injury? what does this indicate?

A
  • shenton’s line

- indicates #NOF

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49
Q

management of a hip fracture?

A
  • analgesia
  • X-ray in 2 views
  • VTE risk assessment
  • bloods, ECG for pre-op assessment
  • operate within 48h (improves prognosis)
  • orthogeriatrics input
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50
Q

recovery time following a hip replacement surgery?

A

pt should be able to bear weight immediately!

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51
Q

what is compartment syndrome?

A

when the pressure in a fascial compartment is too high

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52
Q

what is acute compartment syndrome? how is it treated?

A
  • surgical emergency usually associated with an acute injury or bleed
  • needs fasciotomy
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53
Q

5Ps: presentation of acute compartment syndrome?

A
  • typically following bone fracture / crush injury
  • pain
  • paraesthesia
  • pale
  • pressure (high)
  • paralysis (late, worrying)
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54
Q

describe the pain felt in acute compartment syndrome. which areas might be affected?

A
  • disproportionate to initial injury (fracture / crush)
  • unresponsive to analgesia
  • worse on passive stretching of muscles
  • legs are most common, but also: forearms, feet, thighs
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55
Q

how can acute compartment syndrome be differentiated from acute limb ischaemia?

A

in compartment syndrome, pulses remain present (whereas there’s pulselessness in ALI)

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56
Q

investigation for acute compartment syndrome?

A

needle manometry (measures pressure in compartment)

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57
Q

initial management of acute compartment syndrome?

A
  • escalate to ortho
  • remove external dressings / bandages
  • elevate leg to heart level
  • maintain good BP, avoid hypotension
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58
Q

definitive management of acute compartment syndrome?

A

emergency fasciotomy

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59
Q

what is chronic compartment syndrome typically associated with?

A

exertion

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60
Q

presentation of chronic compartment syndrome?

A
  • pain
  • numbness
  • paraesthesia
  • typically comes on with exercise
  • goes away with rest
61
Q

investigation and management of chronic compartment syndrome?

A
  • needle manometry

- may offer fasciotomy

62
Q

what is osteomyelitis?

A

bacterial infection of the bone and bone marrow

63
Q

how can ostemyelitis occur?

A
  • haematogenous spread of a bacterium

- direct contamination (e.g. from a fracture / surgery)

64
Q

commonest causative organism of osteomyelitis?

A

staph aureus

65
Q

RFs for osteomyelitis?

A
  • open fractures
  • orthopaedic surgery, esp with prosthetic joints
  • PAD
  • IVDU
  • immunosuppression
66
Q

presentation of osteomyelitis?

A
  • fever
  • pain
  • tenderness
  • erythema
  • swelling
  • lethargy
  • nausea
  • muscle aches
67
Q

investigations for osteomyelitis?

A
  • X-ray
  • MRI (gold standard)
  • bloods
  • blood cultures
  • bone cultures
68
Q

signs on X-ray in osteomyelitis?

A
  • NAD early on
  • periosteal reaction
  • localised osteopenia
  • bone destruction
69
Q

which bloods are relevant in osteomyelitis?

A
  • WCC

- inflamm markers (CRP, ESR)

70
Q

management of osteomyelitis?

A
  • surgical debridement of infected bone / tissue

- ABx

71
Q

ABx of choice in acute osteomyelitis? how long is the course of these?

A
  • flucloxacillin for 6w
  • may add on rifampicin / fusidic acid after week 2
  • clindamycin if pen allergic
72
Q

ABx of choice in osteomyelitis caused by MRSA?

A

either: vancomycin or teicoplanin

73
Q

how long are ABx taken for in chronic osteomyelitis?

A

3+ months

74
Q

management of osteomyelitis caused by an infected prosthetic joint?

A

complete revision surgery (replacing the joint again)

75
Q

what are the 3 types of bone sarcoma?

A
  • osteosarcoma
  • chondrosarcoma
  • ewing sarcoma
76
Q

which organism causes kaposi’s sarcoma? which condition is this associated with?

A
  • HHV 8

- end-stage HIV (it is an AIDS-defining illness)

77
Q

commonest type of bone Ca?

A

osteosarcoma

78
Q

presentation of sarcoma?

A
  • soft tissue lump which is growing / painful
  • bone-swelling
  • persistent bone pain
79
Q

investigations for sarcoma?

A
  • X-ray if bony lump / bone pain
  • USS if soft tissue lump
  • CT / MRI to visualise and look for spread
  • biopsy and histology
80
Q

which CT scan is particularly important in sarcoma? why?

A
  • CT thorax

- lungs are most common place for it to spread to

81
Q

management of sarcoma?

A
  • MDT care
  • surgical resection
  • radiotherapy
  • chemo
  • palliative
82
Q

what is sciatica?

A

irritation of the sciatic nerve

83
Q

how long does acute lower back pain last?

A

should improve within 1-2 weeks

84
Q

average recovery time after sciatica?

A

4-6 weeks

85
Q

causes of mechanical back pain?

A
  • muscle / ligament sprain
  • facet joint dysfunction
  • sacroiliac joint dysfunction
  • herniated disc
  • spondylolisthesis
  • scoliosis
  • degenerative changes
86
Q

causes of neck pain?

A
  • muscle / ligament strain
  • torticollis
  • whiplash
  • cervical spondylosis
87
Q

describe torticollis

A
  • waking up with unilateral neck stiffness

- caused by muscle spasm

88
Q

red flag causes of back pain?

A
  • spinal fracture
  • cauda equina
  • spinal stenosis
  • ankylosing spondylitis
  • spinal infection
89
Q

causes of back pain not directly related to the spine?

A
  • pneumonia
  • ruptured aortic aneurysm
  • renal stones
  • pyelonephritis
  • pancreatitis
  • prostatitis
  • PID
  • endometriosis
90
Q

which nerves make up the sciatic nerve?

A

L4 - S3

91
Q

presentation of sciatica?

A
  • unilateral buttock pain
  • shoots down the leg, “electric shock” like
  • pins and needles
  • numbness
  • motor weakness
  • loss of reflexes
92
Q

main causes of sciatica?

A

things that compress the lumbosacral nerve:

  • herniated disc
  • spondylolisthesis
  • spinal stenosis
93
Q

what is spondylolisthesis?

A

when one vertebra is out of alignment with the rest

94
Q

why is bilateral sciatica a red flag?

A

could indicate cauda equina syndrome

95
Q

findings O/E in back pain? what could each of these indicate?

A
  • localised tenderness (spinal fracture, Ca)
  • bilateral motor / sensory loss (cauda equina)
  • bladder distension (cauda equina)
  • reduced anal tone on PR (cauda equina)
96
Q

what test can be performed to diagnose sciatica?

A

sciatic stretch test

97
Q

describe the sciatic stretch test

A
  • pt lies on their back with leg straight
  • lift one leg from ankle to 90 degs
  • then dorsiflex ankle
  • if sciatic pain felt, then there’s sciatica
  • symptoms improve on flexing knee
98
Q

main cancers that metastasise to bone?

A
  • prostate
  • kidney
  • thyroid
  • breast
  • lung
99
Q

investigations for spinal fractures?

A

X-ray / CT spine

100
Q

investigation for suspected cauda equina?

A

emergency MRI (within hrs of presentaion)

101
Q

investigations for suspected ankylosing spondylitis?

A
  • inflamm markers (CRP, ESR)
  • X-ray of spine and sacrum
  • MRI spine
102
Q

key finding on X-ray in late-stage ankylosing spondylitis?

A
  • “bamboo spine”

- everything is fused together

103
Q

finding on MRI spine in early stages of ankylosing spondylitis?

A

bone marrow oedema

104
Q

analgesic ladder for lower back pain?

A
  • NSAIDs (first line)
  • codeine
  • BDZs (diazepam) for spasms
  • specifically avoid opioids and neuropathic agents
105
Q

management of sciatica?

A
  • initially same as acute lower back pain
  • either amitriptyline or duloxetine (NOT gabapentin)
  • epidural corticosteroid injections
  • radiofrequency denervation
  • spinal decompression
106
Q

pathophysiology of cauda equina syndrome?

A

compression of nerve roots at L2 - L3

107
Q

causes of cauda equina syndrome?

A
  • herniated disc
  • tumours (primary or mets)
  • spondylolisthesis
  • abscess
  • trauma
108
Q

red flags for cauda equina syndrome?

A

LMN signs:

  • saddle anaesthesia
  • loss of sensation in bladder and rectum
  • urinary retention / incontinence
  • faecal incontinence
  • bilateral sciatica
  • bilateral / severe motor weakness
  • reduced anal tone on PR
109
Q

management of cauda equina syndrome?

A
  • immediate hosp admission
  • emergency MRI spine
  • neurosurg referral (for lumbar decompression)
110
Q

key features of metastatic spinal cord compression to differentiate it from cauda equina syndrome?

A
  • UMN signs instead of LMN

- back pain that is worse on coughing or straining

111
Q

management of metastatic spinal cord compression?

A
  • high-dose dexamethasone
  • analgesia
  • surgery
  • radio
  • chemo
112
Q

pathophysiology of spinal stenosis?

A

narrowing of spinal canal causing compression on spinal cord and nerve roots

113
Q

typical age group affected by spinal stenosis?

A

pts aged 60+

114
Q

causes of spinal stenosis?

A
  • congenital
  • degenerative changes
  • herniated disc
  • spinal fracture
  • spondylolisthesis
115
Q

presentation of spinal stenosis?

A
  • cauda equina syndrome if severe
  • lower back pain
  • buttock, leg pain
  • leg weakness
116
Q

investigations for spinal stenosis?

A
  • MRI = first line

- ABI to r/o PAD

117
Q

management of spinal stenosis?

A
  • weight loss if needed
  • analgesia
  • physio
  • decompression surgery
118
Q

which nerve is affected in meralgia paraesthetica?

A

lateral femoral cutaneous nerve

119
Q

presentation of meralgia paraesthetica?

A
  • NO motor symptoms!!!
  • burning
  • numbness
  • pins and needles
  • cold sensations
  • localised hair loss
    … all on upper outer thigh region
120
Q

which action worsens the pain felt in meralgia paraesthetica?

A

hip extension

121
Q

presentation of trochanteric bursitis? (incl. O/E)

A
  • middle-aged pt with outer hip pain
  • radiates down thigh
  • no swelling
  • positive trendelenburg test
  • pain on resisted abduction
122
Q

what are the 4 ligaments of the knee?

A
  • anterior cruciate
  • posterior cruciate
  • lateral collateral
  • medial collateral
123
Q

presentation of a meniscal tear?

A
  • young pt who heard a “pop” after doing a twisty movement
  • pain, referred to hip / back
  • swelling
  • stiffness, reduced ROM
  • knee locking
  • knee “gives way”
124
Q

tests done O/E for suspected meniscal tear?

A
  • mcmurray’s test

- apley grind test

125
Q

according to the ottawa rules, which pts require a knee x-ray (after a knee injury)?

A

high suspicion of bony fracture in these cases:

  • aged 55+
  • patellar tenderness
  • fibular head tenderness
  • can’t flex past 90 degs
  • can’t weigh bear
126
Q

investigation for meniscal tear?

A
  • MRI knee

- arthroscopy of knee = gold standard

127
Q

management of meniscal tear?

A
  • conservative
  • NSAIDs for pain relief
  • keyhole (arthroscopic) surgery
128
Q

RICE: conservative management of meniscal tears?

A
  • rest
  • ice
  • compression
  • elevation
129
Q

demographic affected by osgood-schlatter disease?

A

pts aged 10-15 years old

130
Q

pathophysiology of osgood-schlatter disease?

A

inflamed tibial tuberosity, where patellar tendon goes in

131
Q

presentation of osgood-schlatter disease?

A
  • unilateral, gradual onset knee pain

- visible / palpable lump at tibial tuberosity (permanent!)

132
Q

management of osgood-schlatter disease?

A
  • rest
  • ice
  • NSAIDs
133
Q

where do baker’s cysts present?

A

popliteal fossa

134
Q

conditions associated with baker’s cysts?

A
  • meniscal tears
  • OA
  • RA
  • knee injuries
135
Q

presentation of baker’s cyst?

A
  • pain / discomfort / pressure in popliteal fossa
  • palpable lump
  • reduced ROM if large
136
Q

differentials for a lump in the popliteal fossa?

A
  • baker’s cyst
  • DVT
  • abscess
  • popliteal artery aneurysm
  • ganglion cyst
  • lipoma
  • varicose vein
  • tumour
137
Q

investigation for baker’s cyst?

A

USS knee

138
Q

which bone does the achilles tendon attach to?

A

calcaneus bone

139
Q

RFs for achilles tendinopathy?

A
  • sports (basketball, tennis, athletics)
  • RA, ank spon
  • DM
  • high cholesterol
  • fluoroquinolones (cipro, levofloxacin)
140
Q

presentation of achilles tendinopathy?

A
  • pain / stiffness in achilles tendon
  • brought on by activity
  • nodule on palpation
  • swelling
141
Q

management of achilles tendinopathy?

A
  • exclude tendon rupture using simmonds calf squeeze test
  • conservative (rest, ice, anaglesia)
  • physio
  • orthotics (shoe insoles)
  • extracorporeal shock-wave therapy (ESWT)
  • surgery to remove nodules
142
Q

presentation of achilles tendon rupture?

A
  • sudden onset achilles / calf pain
  • snapping sound / sensation
  • feeling like someone hit them in the back of the leg :(
  • positive simmonds calf squeeze test (no plantar flexion)
143
Q

how is achilles tendon rupture diagnosed?

A

on USS

144
Q

management of achilles tendon rupture?

A
  • urgent review by ortho
  • rest, immobilisation, ice, elevation, pain relief
  • VTE prophylaxis
  • non-surgical (boot)
  • surgical (tendon reattachment)
145
Q

presentation of plantar fasciitis?

A
  • pain in heel of foot
  • worse with pressure (walking, standing for a long time)
  • tender on palpation
146
Q

management of plantar fasciitis?

A
  • rest
  • ice
  • NSAIDs
  • physio
147
Q

how can the extent of deformity in a bunion be assessed?

A

weight-bearing X-ray

148
Q

commonest cause of shoulder pain and stiffness?

A

adhesive capsulitis

Zero to Finals: Surgery (7 decks)

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