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Orthopaedics Flashcards

1
Q

What is osteogenesis imperfecta?

A

Genetic condition that results in brittle bones that are prone to fracture

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2
Q

What is osteogenesis imperfecta also know as?

A

Brittle bone syndrome

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3
Q

What makes up bone?

A

Collagen framework with mineral inbetween

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4
Q

What part of bone is affected in osteogenesis imperfecta and why is this important?

A

Collagen which maintains the structure of bone

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5
Q

How does osteogenesis imperfecta usually present?

A

Recurrent and inappropriate fractures

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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
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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

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8
Q

What are the medical treatments for osteogenesis imperfecta?

A

Bisphosphonates

Vitamin D supplementation

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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
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10
Q

What causes osteogenesis imperfecta?

A

Autosomal dominant genetic condition causing defects in T1 Collagen genes

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11
Q

WHat is rickets?

A

Condition causing defective bone mineralisation

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12
Q

What happens to bones in rickets?

A

They become soft and deformed

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13
Q

What is rickets known as in adults?

A

Osteomalacia

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14
Q

What causes rickets?

A

Vitamin D or calcium deficiency

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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

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16
Q

What is a rare cause of rickets?

A

Hereditary hypophosphataemic rickets- genetic defects causing low phosphate in blood

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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

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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

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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

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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

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21
Q

What are potential symptoms of rickets?

A 
Lethargy
Bone pain
Swollen wrists
Bone deformity 
Poor growth
Dental problems
Muscle weakness
Fractures
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22
Q

What bone deformities can occur with rickets?

A 
Bowed legs
Knock knees
Rachitic rosary 
Craniotabes
Delayed teeth
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23
Q

What is rachitic rosary?

A

Where the ends of the ribs expand at the costochondral junctions, causing lumps along the chest

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24
Q

What is craniotabes?

A

Soft skull with delayed closure of the sutures and frontal bossing

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25
Q

What investigations are done to diagnose rickets?

A

Serum 25-hydroxyvitamin D

X-ray

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26
Q

What result indicates vitamin D deficiency?

A

<25 nmol/L

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27
Q

What may Xray show in rickets?

A

Osteopenia (radiolucent bones)

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28
Q

What other investigations may indicate rickets?

A

Low serum calcium nad phophate
High serum alkaline phosphatase
High PTH

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29
Q

What other pathology should be looked for when diagnosing rickets/

A 
FBC for iron deficiency anaemia
ESR/ CRP for inflammatory conditions
U&Es for kidney disease
LFTs
TFTs for hypothyroidism
Malabsorption screen
Autoimmune/ rheumatoid tests
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30
Q

How is rickets prevented?

A

If purely breastfeeding, mothers should take vitamin D supplement
Everyone should take vitamin D during winter months

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31
Q

How is rickets treated?

A

With vitamin D dosed depending on age

Calcium supplementation as needed

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32
Q

What are epiphyseal plates?

A

Growth plates found at the ends of long bones in children that allow bones to grow

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33
Q

What are growth plates made up of?

A

Hyaline cartilage sitting between the epiphysis and metaphysis

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34
Q

What to the growth plates during the end of puberty?

A

The epiphysis and metaphysis fuse, and the growth plates become epiphyseal lines

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35
Q

What is the difference between children and adults bones?

A

Children have more cancellous bone whereas adults have more cortical bone, making them more flexible but less strong

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36
Q

What is cancellous bone?

A

Spongy, highly vascular bone in the centre of long bones

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37
Q

What is cortical bone?

A

Compact, hard bone around the outside

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38
Q

Why do fractures heal better the younger you are?

A

Bones in children have very good blood supply

Fractures are more likely to be a clean break in children

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39
Q

What are the different types of fracture?

A 
Buckle
Transverse
Oblique
Spiral
Segmental
Salter-Harris
Comminuted
Greenstick
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40
Q

What is a buckle (/torus) fracture?

A

Compression/ impact fracture- when one side of the bone bends, raising a buckle without breaking the other side of the bone

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41
Q

Which fractures are children much more likely to get than adults?

A

Greenstick fracture
Buckle fracture
Salter-Harris fracture

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42
Q

Why are children more likely to get a buckle fracture ?

A

Due to less strength against compression

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43
Q

What is a Salter-Harris fracture?

A

A growth plate fracture

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44
Q

What is a segmental fracture?

A

When the bone is broken in at least two places, leaving a segment of bone completely separated

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45
Q

What is a comminuted fracture?

A

Bone that is broken in to three or more pieces

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46
Q

What is a greenstick fracture?

A

Where only one side of the bone breaks whilst the other side stays intact

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47
Q

Why are greenstick fractures more common in children?

A

Because their bones are softer and more flexible so the bone bends and cracks instead of breaking into separate pieces

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48
Q

How are growth plate fractures classified?

A

Salter-Harris classification

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49
Q

What are the 5 types of Growth plate fracture? (SALTR pneumonic)

A 
1= Straight across
2= Above
3= beLow 
4= Through
5= cRush
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50
Q

Which type of growth plate fracture is more likely to disturb growth?

A

The higher the salter-harris grade, the more likely

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51
Q

What is the first principle in fracture management?

A

Mechanical alignment of the fracture

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52
Q

What are the two types of fracture alignment?

A 
Closed reduction (manipulation of joint) 
Open reduction (surgery)
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53
Q

What is the second principle of fracture management?

A

Providing relative stability to allow healing

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54
Q

What are the different ways of fixing the bone to allow for healing?

A 
External casts
K wires
Intramedullary wires
Intramedullary nails
Screws
Plate & screws
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55
Q

What are the steps in pain management in children with fractures?

A

Step 1= Paracetamol or Ibuprofen

Step 2= Morphine

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56
Q

What pain relief is not used in children and why?

A

Codeine and tramadol due to unpredictability in their metabolism
Aspirin is contraindicated due to Reye’s syndrome

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57
Q

How may a child with hip pain present?

A 
Limp 
Refusal to walk 
Refusal to weight bear
Inability to walk
Pain
Swollen/ tender joint
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58
Q

What are the differential diagnoses of limp in 0-4 year old?

A

Septic arthritis
Developmental dysplasia of the hip
Transient sinovitis

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59
Q

What are the key differential diagnoses of limp in 5-10 year olds?

A

Septic arthritis
Transient sinovitis
Perthes disease

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60
Q

What are the key differential diagnoses of limp in 10-16 year olds?

A

Septic arthritis
Slipper upper femoral epiphysis
Juvenile idiopathic arthritis

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61
Q

What are the red flags for hip pain?

A 
Child <3 
Fever
Waking at night
Weight loss
Anorexia
Night sweats
Fatigue
Persistent pain
Stiffness in the morning
Swollen/ red joint
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62
Q

What is the criteria for urgent referall for assessment in a limping child?

A 
<3
>9 with restricted/ painful hip
Not able to weight bear
Evidence of neurovascular compromise
Severe pain/ agitation
Red flags 
Suspicion of abuse
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63
Q

What investigations may be useful to diagnose the cause of a limp?

A 
Blood tests (CRP/ ESR) 
XRays
USS
Joint aspiration
MRI
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64
Q

In what age range is septic arthritis most common?

A

Children <4

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65
Q

Why is septic arthritis an emergency?

A

It can quickly begin to destroy the joint and cause serious systemic illness

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66
Q

What is the mortality of septic arthritis?

A

10%

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67
Q

What is the most common cause of septic arthritis?

A

Joint replacement

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68
Q

How does septic arthritis present?

A

Hot, painful, swollen joint
Refusal to weight bear
Stiffness, reduced ROM
Systemic features

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69
Q

What are the commonly affected joints in septic arthritis?

A

Knee or hip

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70
Q

What is the most common causative organism of septic arthritis?

A

Staph aureus

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71
Q

What other bacteria may cause septic arthritis?

A

Neisseria gonorrhoea
Group A streptococcus (Streptococcus pyogenes)
Haemophilus influenza
E. coli

72
Q

What are the differential diagnoses of septic arthritis?

A

Transient sinovitis
Perthes disease
Slipped upper femoral epiphysis
JIA

73
Q

How is septic arthritis diagnosed?

A

Joint aspiration for gram staining, crystal microscopy, culture and antibiotic sensitivities

74
Q

How is septic arthritis treated?

A

Empirical IV antibiotics until sensitivities are known

75
Q

How long are antibiotics usually continued after septic arthritis is confirmed?

A

3-6 weeks

76
Q

What may be needed to clear the infection in severe cases?

A

Surgical drainage and washout of the joint

77
Q

What is the most common cause of hip pain in children aged 3-10?

A

Transient synovitis

78
Q

What is transient synovitis?

A

Temporary irritation and inflammation in the synovial membrane of the hip

79
Q

What is transient synovitis often associated with?

A

Viral upper respiratory tract infection

80
Q

How does transient synovitis usually present?

A 
Within a few weeks of viral illness
Limp
Refusal to weight bear
Groin/ hip pain
Mild low grade fever
81
Q

How is transient synovitis managed?

A

Symptomatic with simple analgesia

Give clear safety net advice

82
Q

How is transient synovitis diagnosed?

A

Rule out septic arthritis

83
Q

What is the prognosis of transient synovitis?

A

Usually significant improvement in 24-48 hours
Symptoms resolve within 1-2 weeks
Recurs in 20% patients

84
Q

What is Perthes disease?

A

Disruption of blood flow to the femoral head, causing avascular necrosis to the bone

85
Q

What part of the femur is affected in Perthes disease?

A

The epiphysis of the femoral head

86
Q

What age range is affected by Perthes disease?

A

4-12 years (most commonly 5-8 year old boys)

87
Q

What is the cause of Perthes disease?

A

Idiopathic

88
Q

What happens over time with Perthes disease?

A

There is revascularisation or neovascularisation and remodeling of the femoral head

89
Q

What is the main complication of Perthes disease ?

A

Soft, deformed femoral head, leading to early hip osteoarthritis

90
Q

How does Perthes present?

A 
Slow onset of:
Hip pain
Limp
Restricted hip movements
Referred knee pain
91
Q

What is the initial investigation of choice in Perthes disease?

A

Xray

92
Q

What other investigations may be done to diagnose Perthes?

A

Blood tests (should be normal)
Technetium bone scan
MRI scan

93
Q

How is Perthes disease managed?

A

Conservative: maintain healthy alignment and reduce risk of damage (bed rest, crutches ect)
PT
Regular Xrays
Surgery in extreme cases

94
Q

What should you think of if there is hip pain and a history of minor trauma?

A

SUFE

95
Q

What is SUFE?

A

Slipped upper femoral ephiphysis

96
Q

What is SUFE also known as?

A

Slipped capital femoral epiphysis (SCFE)

97
Q

What happens in SUFE?

A

The head of the femur is displaced along the growth plate

98
Q

In which patients is SUFE more common?

A

Boys 8-15

More common in obese children

99
Q

Does SUFE tend to present earlier or later in girls?

A

Earlier

100
Q

What is the typical presentation of SUFE?

A

Adolescent, obese male undergoing a growth spurt and a history of minor trauma

101
Q

What are the presenting symptoms of SUFE?

A

Vague
Hip, groin, thigh or knee pain
Restricted ROM
Painful limp

102
Q

What will the patient be like on examination of SUFE?

A

Prefer to keep hip in external rotation

Restricted internal rotation

103
Q

What is the investigation of choice in SUFE?

A

Xray

104
Q

How is SUFE managed?

A

Surgery to return femoral head to correct position and fix it in place

105
Q

What is osteomyelitis?

A

Infection in the bone and bone marrow

106
Q

Where does osteomyelitis typically occur?

A

Metaphysis of the long bones

107
Q

What is the most common causative organism of osteomyelitis?

A

Staph aureus

108
Q

What is chronic osteomyelitis?

A

Deep seated, slow growing infection with slowly developing symptoms

109
Q

How can osteomyelitis occur?

A

Either by direct infiltration into the bone (open fracture) , or infection travelling to the bone through the blood

110
Q

In which patients is osteomyelitis more common?

A

Boys and children <10

111
Q

What factors increase the risk of osteomyelitis?

A 
Open bone fracture
Orthopaedic surgery
Immunocompromised
Sickle cell anaemia
HIV
TB
112
Q

How does osteomyelitis present?

A 
Refusal to weight bear
Pain
Swelling
Tenderness
Acute= fever
113
Q

What investigations are done into osteomyelitis?

A

Xrays
MRI
Inflammatory markers and WCC
Blood culture

114
Q

How is osteomyelitis managed?

A

Extensive antibiotic therapy

May need surgery for drainage and debridement

115
Q

What is the initial vs gold standard investigation for osteomyelitis?

A

Initial= osteomyelitis

Gold standard= MRI

116
Q

What is osteosarcoma?

A

Type of bone cancer

117
Q

In what age range does osteosarcoma usually present?

A

10-20 year olds

118
Q

What is the most commonly affected bone in osteosarcoma?

A

Femur

tibia and humerus

119
Q

What is the main presenting feature of osteosarcoma?

A

Persistent bone pain (particularly worse at night time)

120
Q

What other symptoms may be present in osteosarcoma?

A

Bone swelling
Palpable mass
Restricted joint movements

121
Q

How is osteosarcoma diagnosed?

A

Urgent Xray

122
Q

What will Xray show with osteosarcoma?

A

Poorly defined lesion
Destruction of normal bone
Fluffy appearance
Periosteal reaction= ‘sun-burst’ appearance

123
Q

What other tests are done into osteosarcoma?

A 
Blood tests
CT
MRI
Bone scan 
PET scan
Bone biopsy
124
Q

What may blood test show with osteosarcoma?

A

Raised ALP

125
Q

How is osteosarcoma managed?

A

Surgical resection of lesion (often with limp amputation)

Adjuvant chemotherapy

126
Q

What are the main complications of osteosarcoma?

A

Pathological bone fractures

Metastasis

127
Q

What is talipes?

A

Clubfoot- a fixed abnormal ankle position

128
Q

When does talipes present?

A

At birth or at newborn examination

129
Q

What is talipes equinovarus?

A

The ankle in plantar flexion and supination

130
Q

What is talipes calcaneovalgus?

A

The ankle in dorsiflexion and pronation

131
Q

How is talipes treated?

A

Ponseti method

May require surgery

132
Q

What is the Ponseti method?

A

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
Q

What is positional talipes?

A

Where the resting position of the ankle is in plantar flexion and supination, but there is no structural bone issue

134
Q

How is positional talipes managed?

A

Referral to physiotherapist for simple exercises

135
Q

What is developmental dysplasia of the hip?

A

Condition where there is a structural abnormality in the hips caused by abnormal development of the fetal bones during pregnancy

136
Q

What does developmental dysplasia lead to?

A

Instability in the hips and a tendency for subluxation or dislocation
May persist into adulthood with abnormal gait and early degeneration

137
Q

When is DDH picked up?

A

At NIPE or later when child presents with hip assymetry or limp

138
Q

What are the risk factors for DDH?

A

First degree family history
Breech presentation
Multiple pregnancy

139
Q

Where is DDH screened for?

A

NIPE at birth and 6-8 weeks

140
Q

What examination findings may suggest DDH?

A

Different leg lengths
Restricted hip abductino
Significant bilateral restriction
Difference in flexed knee level clunking on special tests

141
Q

What two special tests are used to check for DDH?

A

Ortolani test

Barlow test

142
Q

What is the Ortolani test?

A

Gentle pressure used to abduct babies hips to see if they will dislocate anteriorly

143
Q

What is the Barlow test?

A

Gentle pressure placed on knees through femur to see if the femoral head will dislocate posteriorly

144
Q

What is done is clunking is found on NIPE?

A

USS

145
Q

How is DDH managed if the baby is <6 months?

A

Pavlik harness

146
Q

What is the Pavlik harness?

A

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
Q

At what stage is the Pavlik harness removed?

A

6-8 weeks

148
Q

When would surgery be used for DDH?

A

When the harness fails or diagnosis if after 6 months

149
Q

What is achondroplasia?

A

Type of skeletal dysplasia

150
Q

What is achondroplasia the most common cause of?

A

Dwarfism

151
Q

What is the achondroplasia gene?

A

FGFR3 gene on chromosome 4

152
Q

What causes achondroplasia?

A

Sporadic or inherited mutation of FGFR3 gene

153
Q

What is the inheritance pattern of achondroplasia?

A

Autosomal dominant

154
Q

What does inheritance of two achondroplasia genes cause?

A

Death in neonatal period

155
Q

What do mutations in the FGFR3 gene cause?

A

Abnormal function of the epiphyseal plates, restricting the bone growth in lenght

156
Q

What is the average height of a patient with achondroplasia ?

A

4 feet

157
Q

What parts of the body are most affected by achondroplasia?

A

Limbs- particularly proximal limbs (femur and humerus)

158
Q

What are the features of achondroplasia ?

A 
Short stature
Short digits
Bow legs
Disproportionate skill
Foramen magnum stenosis
159
Q

Why do patients with achondroplasia have a disproportionate skull?

A

Different ares of the skull grow by different methods, some of which are more affected than others

160
Q

What other conditions is achondroplasia associated with?

A 
Recurrent otitis media
Kyphoscoliosis
Spinal stenosis
Obstructive sleep apnoea
Obesity
Cervical cord compression/ hydrocephalus (due to foramen magnum stenosis)
161
Q

Why do you get foramen magnum stenosis in achondroplasia?

A

The skull base grows and fuses via endochondral ossification which is affected by achondroplasia

162
Q

What is the management of achondroplasia?

A

MDT

163
Q

What is the prognosis of achondroplasia?

A

Normal life expectancy

164
Q

What is Osgood-Schlatter disease?

A

Condition that causes pain and swelling below the knee joint

165
Q

What causes Osgood-Schlatter disease?

A

Inflammation of the tibial tuberosity

166
Q

Where on the tibial tuberosity does the inflammation occur?

A

Where the patella ligament inserts

167
Q

In what age range does Osgood-Schlatter disease typically occur?

A

Patients aged 10-15

More common in males

168
Q

Where does the patella tendon insert?

A

At the tibial tuberosity, whcih is at the epiphyseal plate

169
Q

Why does inflammation occur in Osgood-Schlatter disease?

A

Due to stress from movement at the same time as growth in the epiphyseal plate

170
Q

Why do you get a visible lump in Osgood-Schlatter disease?

A

There are multiple avulsion fraction where the patella ligament pulls away tiny pieces of bone, leading to a growth of the tibial tuberosity

171
Q

What are avulsion fractures?

A

When a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone

172
Q

What happens to the lump in Osgood-Schlatter disease?

A

It it initially tender but eventually becomes hard and non-tender

173
Q

How does Osgood-Schlatter disease present?

A

Gradual onset of:
Visible/ palpable hard and tender lump at tibial tuberosity
Pain in anterior knee, exacerbated by activity

174
Q

How is Osgood-Schlatter disease managed?

A

Reduction in activity
ICE
NSAIDS

175
Q

What is the prognosis of Osgood-Schlatter disease?

A

Symptoms will fully resolve but patient will be left with hard boney lump

176
Q

What is the rare complication of Osgood-Schlatter disease?

A

Full avulsion fracture- tibial tuberosity is separated from rest of tibia

Paeds (18 decks)

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