Orthopaedics Flashcards
1
Q
What is osteogenesis imperfecta?
A
Genetic condition that results in brittle bones that are prone to fracture
2
Q
What is osteogenesis imperfecta also know as?
A
Brittle bone syndrome
3
Q
What makes up bone?
A
Collagen framework with mineral inbetween
4
Q
What part of bone is affected in osteogenesis imperfecta and why is this important?
A
Collagen which maintains the structure of bone
5
Q
How does osteogenesis imperfecta usually present?
A
Recurrent and inappropriate fractures
6
Q
What are some features associated with osteogenesis imperfecta?
A
Hypermobility Blue/ grey sclera Triangular face Short stature Deafness Dental problems Bone deformities (bowed legs, scoliosis) Joint/ bone pain
7
Q
How is osteogenesis imperfecta diagnosed?
A
Clinically
X-rays can diagnose fractures and bone deformities
Genetic testing is possible but not routinely done
8
Q
What are the medical treatments for osteogenesis imperfecta?
A
Bisphosphonates
Vitamin D supplementation
9
Q
What further actions can be taken to manage osteogenesis imperfecta?
A
MDT PT OT Paediatrician input Orthopaedic surgeons to manage fractures Specialist nurses Social workers
10
Q
What causes osteogenesis imperfecta?
A
Autosomal dominant genetic condition causing defects in T1 Collagen genes
11
Q
WHat is rickets?
A
Condition causing defective bone mineralisation
12
Q
What happens to bones in rickets?
A
They become soft and deformed
13
Q
What is rickets known as in adults?
A
Osteomalacia
14
Q
What causes rickets?
A
Vitamin D or calcium deficiency
15
Q
How do we acquire vitamin D?
A
In the body in response to sunlight
Obtained through foods such as eggs, oily fish or fortified cereals
16
Q
What is a rare cause of rickets?
A
Hereditary hypophosphataemic rickets- genetic defects causing low phosphate in blood
17
Q
What causes vitamin D deficiency?
A
Not enough UV radiation (worse for those with darker skin)
Not enough in diet
Malabsorption disorders
Chronic kidney disease
18
Q
What is the action of vitamin D?
A
Causes calcium and phosphate absorption in the intestines and kidneys
Regulates bone turnover
Promotes bone reabsorption to boost serum calcium level
19
Q
Why do inadequate vitamin D levels lead to defective bone mineralisation?
A
Leads to a lack of calcium and phosphate in the blood, both of which are needed for the construction of bone
20
Q
What does low calcium lead to?
A
Secondary hyperparathyroidism, where the parathyroid gland tries to raise the calcium level by secreting PTH. This stimulated increased reabsorption of calcium from the bones
21
Q
What are potential symptoms of rickets?
A
Lethargy Bone pain Swollen wrists Bone deformity Poor growth Dental problems Muscle weakness Fractures
22
Q
What bone deformities can occur with rickets?
A
Bowed legs Knock knees Rachitic rosary Craniotabes Delayed teeth
23
Q
What is rachitic rosary?
A
Where the ends of the ribs expand at the costochondral junctions, causing lumps along the chest
24
Q
What is craniotabes?
A
Soft skull with delayed closure of the sutures and frontal bossing
25
What investigations are done to diagnose rickets?
Serum 25-hydroxyvitamin D
| X-ray
26
What result indicates vitamin D deficiency?
<25 nmol/L
27
What may Xray show in rickets?
Osteopenia (radiolucent bones)
28
What other investigations may indicate rickets?
Low serum calcium nad phophate
High serum alkaline phosphatase
High PTH
29
What other pathology should be looked for when diagnosing rickets/
```
FBC for iron deficiency anaemia
ESR/ CRP for inflammatory conditions
U&Es for kidney disease
LFTs
TFTs for hypothyroidism
Malabsorption screen
Autoimmune/ rheumatoid tests
```
30
How is rickets prevented?
If purely breastfeeding, mothers should take vitamin D supplement
Everyone should take vitamin D during winter months
31
How is rickets treated?
With vitamin D dosed depending on age
| Calcium supplementation as needed
32
What are epiphyseal plates?
Growth plates found at the ends of long bones in children that allow bones to grow
33
What are growth plates made up of?
Hyaline cartilage sitting between the epiphysis and metaphysis
34
What to the growth plates during the end of puberty?
The epiphysis and metaphysis fuse, and the growth plates become epiphyseal lines
35
What is the difference between children and adults bones?
Children have more cancellous bone whereas adults have more cortical bone, making them more flexible but less strong
36
What is cancellous bone?
Spongy, highly vascular bone in the centre of long bones
37
What is cortical bone?
Compact, hard bone around the outside
38
Why do fractures heal better the younger you are?
Bones in children have very good blood supply
| Fractures are more likely to be a clean break in children
39
What are the different types of fracture?
```
Buckle
Transverse
Oblique
Spiral
Segmental
Salter-Harris
Comminuted
Greenstick
```
40
What is a buckle (/torus) fracture?
Compression/ impact fracture- when one side of the bone bends, raising a buckle without breaking the other side of the bone
41
Which fractures are children much more likely to get than adults?
Greenstick fracture
Buckle fracture
Salter-Harris fracture
42
Why are children more likely to get a buckle fracture ?
Due to less strength against compression
43
What is a Salter-Harris fracture?
A growth plate fracture
44
What is a segmental fracture?
When the bone is broken in at least two places, leaving a segment of bone completely separated
45
What is a comminuted fracture?
Bone that is broken in to three or more pieces
46
What is a greenstick fracture?
Where only one side of the bone breaks whilst the other side stays intact
47
Why are greenstick fractures more common in children?
Because their bones are softer and more flexible so the bone bends and cracks instead of breaking into separate pieces
48
How are growth plate fractures classified?
Salter-Harris classification
49
What are the 5 types of Growth plate fracture? (SALTR pneumonic)
```
1= Straight across
2= Above
3= beLow
4= Through
5= cRush
```
50
Which type of growth plate fracture is more likely to disturb growth?
The higher the salter-harris grade, the more likely
51
What is the first principle in fracture management?
Mechanical alignment of the fracture
52
What are the two types of fracture alignment?
```
Closed reduction (manipulation of joint)
Open reduction (surgery)
```
53
What is the second principle of fracture management?
Providing relative stability to allow healing
54
What are the different ways of fixing the bone to allow for healing?
```
External casts
K wires
Intramedullary wires
Intramedullary nails
Screws
Plate & screws
```
55
What are the steps in pain management in children with fractures?
Step 1= Paracetamol or Ibuprofen
| Step 2= Morphine
56
What pain relief is not used in children and why?
Codeine and tramadol due to unpredictability in their metabolism
Aspirin is contraindicated due to Reye's syndrome
57
How may a child with hip pain present?
```
Limp
Refusal to walk
Refusal to weight bear
Inability to walk
Pain
Swollen/ tender joint
```
58
What are the differential diagnoses of limp in 0-4 year old?
Septic arthritis
Developmental dysplasia of the hip
Transient sinovitis
59
What are the key differential diagnoses of limp in 5-10 year olds?
Septic arthritis
Transient sinovitis
Perthes disease
60
What are the key differential diagnoses of limp in 10-16 year olds?
Septic arthritis
Slipper upper femoral epiphysis
Juvenile idiopathic arthritis
61
What are the red flags for hip pain?
```
Child <3
Fever
Waking at night
Weight loss
Anorexia
Night sweats
Fatigue
Persistent pain
Stiffness in the morning
Swollen/ red joint
```
62
What is the criteria for urgent referall for assessment in a limping child?
```
<3
>9 with restricted/ painful hip
Not able to weight bear
Evidence of neurovascular compromise
Severe pain/ agitation
Red flags
Suspicion of abuse
```
63
What investigations may be useful to diagnose the cause of a limp?
```
Blood tests (CRP/ ESR)
XRays
USS
Joint aspiration
MRI
```
64
In what age range is septic arthritis most common?
Children <4
65
Why is septic arthritis an emergency?
It can quickly begin to destroy the joint and cause serious systemic illness
66
What is the mortality of septic arthritis?
10%
67
What is the most common cause of septic arthritis?
Joint replacement
68
How does septic arthritis present?
Hot, painful, swollen joint
Refusal to weight bear
Stiffness, reduced ROM
Systemic features
69
What are the commonly affected joints in septic arthritis?
Knee or hip
70
What is the most common causative organism of septic arthritis?
Staph aureus
71
What other bacteria may cause septic arthritis?
Neisseria gonorrhoea
Group A streptococcus (Streptococcus pyogenes)
Haemophilus influenza
E. coli
72
What are the differential diagnoses of septic arthritis?
Transient sinovitis
Perthes disease
Slipped upper femoral epiphysis
JIA
73
How is septic arthritis diagnosed?
Joint aspiration for gram staining, crystal microscopy, culture and antibiotic sensitivities
74
How is septic arthritis treated?
Empirical IV antibiotics until sensitivities are known
75
How long are antibiotics usually continued after septic arthritis is confirmed?
3-6 weeks
76
What may be needed to clear the infection in severe cases?
Surgical drainage and washout of the joint
77
What is the most common cause of hip pain in children aged 3-10?
Transient synovitis
78
What is transient synovitis?
Temporary irritation and inflammation in the synovial membrane of the hip
79
What is transient synovitis often associated with?
Viral upper respiratory tract infection
80
How does transient synovitis usually present?
```
Within a few weeks of viral illness
Limp
Refusal to weight bear
Groin/ hip pain
Mild low grade fever
```
81
How is transient synovitis managed?
Symptomatic with simple analgesia
| Give clear safety net advice
82
How is transient synovitis diagnosed?
Rule out septic arthritis
83
What is the prognosis of transient synovitis?
Usually significant improvement in 24-48 hours
Symptoms resolve within 1-2 weeks
Recurs in 20% patients
84
What is Perthes disease?
Disruption of blood flow to the femoral head, causing avascular necrosis to the bone
85
What part of the femur is affected in Perthes disease?
The epiphysis of the femoral head
86
What age range is affected by Perthes disease?
4-12 years (most commonly 5-8 year old boys)
87
What is the cause of Perthes disease?
Idiopathic
88
What happens over time with Perthes disease?
There is revascularisation or neovascularisation and remodeling of the femoral head
89
What is the main complication of Perthes disease ?
Soft, deformed femoral head, leading to early hip osteoarthritis
90
How does Perthes present?
```
Slow onset of:
Hip pain
Limp
Restricted hip movements
Referred knee pain
```
91
What is the initial investigation of choice in Perthes disease?
Xray
92
What other investigations may be done to diagnose Perthes?
Blood tests (should be normal)
Technetium bone scan
MRI scan
93
How is Perthes disease managed?
Conservative: maintain healthy alignment and reduce risk of damage (bed rest, crutches ect)
PT
Regular Xrays
Surgery in extreme cases
94
What should you think of if there is hip pain and a history of minor trauma?
SUFE
95
What is SUFE?
Slipped upper femoral ephiphysis
96
What is SUFE also known as?
Slipped capital femoral epiphysis (SCFE)
97
What happens in SUFE?
The head of the femur is displaced along the growth plate
98
In which patients is SUFE more common?
Boys 8-15
| More common in obese children
99
Does SUFE tend to present earlier or later in girls?
Earlier
100
What is the typical presentation of SUFE?
Adolescent, obese male undergoing a growth spurt and a history of minor trauma
101
What are the presenting symptoms of SUFE?
Vague
Hip, groin, thigh or knee pain
Restricted ROM
Painful limp
102
What will the patient be like on examination of SUFE?
Prefer to keep hip in external rotation
| Restricted internal rotation
103
What is the investigation of choice in SUFE?
Xray
104
How is SUFE managed?
Surgery to return femoral head to correct position and fix it in place
105
What is osteomyelitis?
Infection in the bone and bone marrow
106
Where does osteomyelitis typically occur?
Metaphysis of the long bones
107
What is the most common causative organism of osteomyelitis?
Staph aureus
108
What is chronic osteomyelitis?
Deep seated, slow growing infection with slowly developing symptoms
109
How can osteomyelitis occur?
Either by direct infiltration into the bone (open fracture) , or infection travelling to the bone through the blood
110
In which patients is osteomyelitis more common?
Boys and children <10
111
What factors increase the risk of osteomyelitis?
```
Open bone fracture
Orthopaedic surgery
Immunocompromised
Sickle cell anaemia
HIV
TB
```
112
How does osteomyelitis present?
```
Refusal to weight bear
Pain
Swelling
Tenderness
Acute= fever
```
113
What investigations are done into osteomyelitis?
Xrays
MRI
Inflammatory markers and WCC
Blood culture
114
How is osteomyelitis managed?
Extensive antibiotic therapy
| May need surgery for drainage and debridement
115
What is the initial vs gold standard investigation for osteomyelitis?
Initial= osteomyelitis
| Gold standard= MRI
116
What is osteosarcoma?
Type of bone cancer
117
In what age range does osteosarcoma usually present?
10-20 year olds
118
What is the most commonly affected bone in osteosarcoma?
Femur
| tibia and humerus
119
What is the main presenting feature of osteosarcoma?
Persistent bone pain (particularly worse at night time)
120
What other symptoms may be present in osteosarcoma?
Bone swelling
Palpable mass
Restricted joint movements
121
How is osteosarcoma diagnosed?
Urgent Xray
122
What will Xray show with osteosarcoma?
Poorly defined lesion
Destruction of normal bone
Fluffy appearance
Periosteal reaction= 'sun-burst' appearance
123
What other tests are done into osteosarcoma?
```
Blood tests
CT
MRI
Bone scan
PET scan
Bone biopsy
```
124
What may blood test show with osteosarcoma?
Raised ALP
125
How is osteosarcoma managed?
Surgical resection of lesion (often with limp amputation)
| Adjuvant chemotherapy
126
What are the main complications of osteosarcoma?
Pathological bone fractures
| Metastasis
127
What is talipes?
Clubfoot- a fixed abnormal ankle position
128
When does talipes present?
At birth or at newborn examination
129
What is talipes equinovarus?
The ankle in plantar flexion and supination
130
What is talipes calcaneovalgus?
The ankle in dorsiflexion and pronation
131
How is talipes treated?
Ponseti method
| May require surgery
132
What is the Ponseti method?
Foot manipulation and application of a cast to return foot to normal position
Will also need achilles tenotomy
After treatment brace is used to hold foot in correct position until 4
133
What is positional talipes?
Where the resting position of the ankle is in plantar flexion and supination, but there is no structural bone issue
134
How is positional talipes managed?
Referral to physiotherapist for simple exercises
135
What is developmental dysplasia of the hip?
Condition where there is a structural abnormality in the hips caused by abnormal development of the fetal bones during pregnancy
136
What does developmental dysplasia lead to?
Instability in the hips and a tendency for subluxation or dislocation
May persist into adulthood with abnormal gait and early degeneration
137
When is DDH picked up?
At NIPE or later when child presents with hip assymetry or limp
138
What are the risk factors for DDH?
First degree family history
Breech presentation
Multiple pregnancy
139
Where is DDH screened for?
NIPE at birth and 6-8 weeks
140
What examination findings may suggest DDH?
Different leg lengths
Restricted hip abductino
Significant bilateral restriction
Difference in flexed knee level clunking on special tests
141
What two special tests are used to check for DDH?
Ortolani test
| Barlow test
142
What is the Ortolani test?
Gentle pressure used to abduct babies hips to see if they will dislocate anteriorly
143
What is the Barlow test?
Gentle pressure placed on knees through femur to see if the femoral head will dislocate posteriorly
144
What is done is clunking is found on NIPE?
USS
145
How is DDH managed if the baby is <6 months?
Pavlik harness
146
What is the Pavlik harness?
Harness kept on permanently that hold the femoral head in the correct position to allow the hip socket to develop into a normal shape
147
At what stage is the Pavlik harness removed?
6-8 weeks
148
When would surgery be used for DDH?
When the harness fails or diagnosis if after 6 months
149
What is achondroplasia?
Type of skeletal dysplasia
150
What is achondroplasia the most common cause of?
Dwarfism
151
What is the achondroplasia gene?
FGFR3 gene on chromosome 4
152
What causes achondroplasia?
Sporadic or inherited mutation of FGFR3 gene
153
What is the inheritance pattern of achondroplasia?
Autosomal dominant
154
What does inheritance of two achondroplasia genes cause?
Death in neonatal period
155
What do mutations in the FGFR3 gene cause?
Abnormal function of the epiphyseal plates, restricting the bone growth in lenght
156
What is the average height of a patient with achondroplasia ?
4 feet
157
What parts of the body are most affected by achondroplasia?
Limbs- particularly proximal limbs (femur and humerus)
158
What are the features of achondroplasia ?
```
Short stature
Short digits
Bow legs
Disproportionate skill
Foramen magnum stenosis
```
159
Why do patients with achondroplasia have a disproportionate skull?
Different ares of the skull grow by different methods, some of which are more affected than others
160
What other conditions is achondroplasia associated with?
```
Recurrent otitis media
Kyphoscoliosis
Spinal stenosis
Obstructive sleep apnoea
Obesity
Cervical cord compression/ hydrocephalus (due to foramen magnum stenosis)
```
161
Why do you get foramen magnum stenosis in achondroplasia?
The skull base grows and fuses via endochondral ossification which is affected by achondroplasia
162
What is the management of achondroplasia?
MDT
163
What is the prognosis of achondroplasia?
Normal life expectancy
164
What is Osgood-Schlatter disease?
Condition that causes pain and swelling below the knee joint
165
What causes Osgood-Schlatter disease?
Inflammation of the tibial tuberosity
166
Where on the tibial tuberosity does the inflammation occur?
Where the patella ligament inserts
167
In what age range does Osgood-Schlatter disease typically occur?
Patients aged 10-15
| More common in males
168
Where does the patella tendon insert?
At the tibial tuberosity, whcih is at the epiphyseal plate
169
Why does inflammation occur in Osgood-Schlatter disease?
Due to stress from movement at the same time as growth in the epiphyseal plate
170
Why do you get a visible lump in Osgood-Schlatter disease?
There are multiple avulsion fraction where the patella ligament pulls away tiny pieces of bone, leading to a growth of the tibial tuberosity
171
What are avulsion fractures?
When a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone
172
What happens to the lump in Osgood-Schlatter disease?
It it initially tender but eventually becomes hard and non-tender
173
How does Osgood-Schlatter disease present?
Gradual onset of:
Visible/ palpable hard and tender lump at tibial tuberosity
Pain in anterior knee, exacerbated by activity
174
How is Osgood-Schlatter disease managed?
Reduction in activity
ICE
NSAIDS
175
What is the prognosis of Osgood-Schlatter disease?
Symptoms will fully resolve but patient will be left with hard boney lump
176
What is the rare complication of Osgood-Schlatter disease?
Full avulsion fracture- tibial tuberosity is separated from rest of tibia
