Orthopaedics Flashcards
What are some causes of hip pain in adults?
osteoarthritis
inflammatory arthrits
referred lumbar spine pain
avascular necrosis
pubic symphysis dysfunction
trochanteric bursitis
transient idiopathic osteoporosis
meralgia paraesthetica
what is meralgia paraesthetica?
Caused by compression of lateral cutaneous nerve of thigh
Typically burning sensation over antero-lateral aspect of thigh
features of referred lumbar spine pain?
Femoral nerve compression may cause referred pain in the hip
Femoral nerve stretch test may be positive - lie the patient prone. Extend the hip joint with a straight leg then bend the knee. This stretches the femoral nerve and will cause pain if it is trapped
features of trochanteric bursitis?
Due to repeated movement of the fibroelastic iliotibial band
Pain and tenderness over the lateral side of thigh
Most common in women aged 50-70 years
features of transient idiopathic osteoporosis?
An uncommon condition sometimes seen in the third trimester of pregnancy
Groin pain associated with a limited range of movement in the hip
Patients may be unable to weight bear
ESR may be elevated
Causes of avascular necrosis of the hip?
long-term steroid use
chemotherapy
alcohol excess
trauma
Investigation findings for avascular necrosis of hip?
plain x-ray findings may be normal initially. Osteopenia and microfractures may be seen early on. Collapse of the articular surface may result in the crescent sign
MRI is the investigation of choice. It is more sensitive than radionuclide bone scanning
what is a monteggia fracture?
a fracture of the proximal ulna in association with a dislocation of the proximal head of the radius.
what is a galeazzi fracture?
fracture of the distal radius with an associated dislocation of the distal radioulnar joint
what is a colles fracture?
distal radius fracture with dorsal displacement
what is a smiths fracture?
distal radius fracture with volar displacement
what is a bennetts fracture?
a fracture of the base of the first metacarpal, that extends into the carpometacarpal joint
what is a bartons fracture?
Distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation
Fall onto extended and pronated wrist
Management of AVN of the hip?
Non-operative -> bisphosphonates
Operative -> core decompression +/- bone grafting (relieves bleeding)
rotational osteotomy
free-fibula transfer
THR
total hip resurfacing
hip arthrodesis (can provide pain relief)
Indications for surgical management of AVN of hip?
core decompression and bone graft - early AVN
rotational osteotomy - small lesions <15 degrees
free-fibula transfer - pre/post collapse
total hip resurfacing - small focus of AVN in end disease
how is risk of femoral head collapse estimated?
modified Kerboul angle - add arc of femoral head necrosis on mid sagittal and mid coronary MRI
Low risk <190
mod risk 190-240
high risk >240
Complications of supracondylar humeral fracture?
brachial artery injury
median nerve injury (anterior interosseous branch - deep flexors (FPL, FDP, pronator quadrates))
radial nerve
compartment syndrome
gunstock deformity (cubitus varus)
why is the scaphoid prone to AVN?
Retrograde blood supply
80% from dorsal carpal branch of radial artery
Classification for NOF fractures?
gardner
Classification for supracondylar fractures?
gartland
Classification for scaphoid fractures?
Mayo classification
Classification for perilunate instability?
Mayfield classification
Classification for tibial plateau fracture?
Schatzker
what is out common long bone fracture?
tibial
(also most common long bone open fracture)
What is a pott’s fracture?
bimalleolar fracture
What is a cotton’s fracture?
trimalleolar fracture
what is a pilon fracture?
a fracture of distal tibia involving the articular surface
- excessive axial loading through feet
- falls from height
rude-allgower classification
what is a maisonneuve fracture?
where high twisting injuries disrupt syndesmosis- high fibular fracture
request long length XR if widening of syndesmosis on ankle XR
What is weber classification?
talar shift/fibular fracture
A: below syndesmosis
B: at syndesmosis
C: above syndesmosis
Mx lower back pain?
- self mx, physical exercise
- NSAIDs 1st line + PPI, neuropathic pain agent for sciatica
- exercise programme, radio frequency denervation, epidural injections of LA and steroid
What does positioning patient in the Lloyd Davies position increase risk of?
peroneal nerve neuropraxia
foot drop
What are the clinical features of a fat embolism?
Resp: Early persistent tachycardia
Tachypnoea, dyspnoea, hypoxia usually 72 hours following injury
Pyrexia
Derm: Red/ brown impalpable petechial rash (usually only in 25-50%)
Subconjunctival and oral haemorrhage/ petechiae
CNS: Confusion and agitation
Retinal haemorrhages and intra-arterial fat globules on fundoscopy
what is seen on imaging of a fat embolism?
May be normal
Fat emboli tend to lodge distally and therefore CTPA may not show any vascular occlusion, a ground glass appearance may be seen at the periphery
Treatment of fat embolism?
Prompt fixation of long bone fractures
Some debate regarding benefit Vs. risk of medullary reaming in femoral shaft/ tibial fractures in terms of increasing risk (probably does not).
DVT prophylaxis
General supportive care
What is compartment syndrome most associated with?
supracondylar and tibial shaft fractures
Features of compartment syndrome?
Pain, especially on movement (even passive)
- excessive use of breakthrough analgesia should raise suspicion for compartment syndrome
Parasthesiae
Pallor may be present
Arterial pulsation may still be felt as the necrosis occurs as a result of microvascular compromise
Paralysis of the muscle group may occur
What is Finkelstein test +ve?
pain over radial styloid on forced abduction/flexion of the thumb
= tenosynovitis
Features of De Quervain’s tenosynovitis?
pain on the radial side of the wrist
tenderness over the radial styloid process
abduction of the thumb against resistance is painful
Finkelstein’s test +VE
Mx of De Quervain’s tenosynovitis?
analgesia
steroid injection
immobilisation with a thumb splint (spica) may be effective
surgical treatment is sometimes required
What are some causes of subacromial impingement?
Intrinsic:
Muscular weakness
Shoulder overuse
Degenerative tendinopathy
Extrinsic: Scapular muscle dysfunction
Glenohumeral instability
Anatomical variation
What is subacromial impingement?
anything that reduces subacromial space [supraspinatus]
what is subcoracoid impingement?
narrowing at the coracohumeral interval impinges the ligaments of:
- subscapularis
- the long head of the biceps
- the middle glenohumeral ligament
RF for Achilles tendon disorders?
quinolone use (e.g. ciprofloxacin) is associated with tendon disorders
hypercholesterolaemia (predisposes to tendon xanthomata)
What is cubital tunnel syndrome?
Cubital tunnel syndrome is caused by compression of the ulnar nerve and can present with tingling/numbness of the 4th and 5th finger
Caused by ulna nerve entrapment at the elbow
Causes of carpal tunnel syndrome?
idiopathic
pregnancy
oedema e.g. heart failure
lunate fracture
rheumatoid arthritis
Mx of carpal tunnel?
corticosteroid injection
wrist splints at night
surgical decompression (flexor retinaculum division)
S/S carpal tunnel?
pain/pins and needles in thumb, index, middle finger
unusually the symptoms may ‘ascend’ proximally
patient shakes his hand to obtain relief, classically at night
weakness of thumb abduction (abductor pollicis brevis)
wasting of thenar eminence (NOT hypothenar)
Tinel’s sign: tapping causes paraesthesia
Phalen’s sign: flexion of wrist causes symptoms
What are anterior and posterior shoulder dislocations associated with?
Anterior shoulder dislocation is associated with FOOSH; while posterior shoulder dislocation is more likely associated with seizures and electric shock
what movement is impaired in adhesive capsulitis?
External rotation (on both active and passive movement) is classically impaired
both active and passive movement is affected
associations of adhesive capsulitis?
diabetes
what muscles of the hand does the median nerve supply?
LOAF
lateral two lumbricals
opponens pollicis
abductor pollicis brevis
flexor pollicis brevis
FDP lateral and FCR
What are the contents of the carpal tunnel?
medial nerve
flexor pollicis longus (FPL)
flexor carpi radialis (FCR)
FDP (flexor digitorum profundus)
FDS (flexors digitorum superficialis)
What muscles does the ulnar nerve supply?
hypothenar
medial lumbricals
interossei
adductor pollicis
FDP (medial)
FCU
Associations of Dupuytren’s contracture?
BAD FIBERS
Bent penis(Peyronie’s)
AIDS
DM
FHx (AD)
Idiopathic (MOST COMMON)
Booze
Epilepsy and epilepsy meds (phenytoin)
Reidel’s thyroiditis and other fibromatoses
Smoking
difference between common peroneal nerve palsy and L5 radiculopathy?
Common peroneal nerve lesion can cause weakness of foot dorsiflexion and foot eversion
(in L5 radiculopathy, eversion tends to be spared while inversion is weak and sensory involvement tends to be greater)
Features of common peroneal nerve palsy?
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 anterior tibial and peroneal muscles
What is a Colles fracture?
Fall onto extended outstretched hands
Described as a dinner fork type deformity
What are the 3 typical features of Colles fracture?
Transverse fracture of the radius
2. 1 inch proximal to the radio-carpal joint
3. Dorsal displacement and angulation
What is a Bennett’s fracture?
Intra-articular fracture of the first carpometacarpal joint
Impact on flexed metacarpal, caused by fist fights
X-ray: triangular fragment at ulnar base of metacarpal
What is a Smith’s fracture?
Volar angulation of distal radius fragment (Garden spade deformity)
Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed
What is a Monteggia fracture?
Dislocation of the proximal radioulnar joint in association with an ulna fracture
Fall on outstretched hand with forced pronation
Needs prompt diagnosis to avoid disability
What is a Galaezzi fracture?
Radial shaft fracture with associated dislocation of the distal radioulnar joint
Occur after a fall on the hand with a rotational force superimposed on it.
On examination, there is bruising, swelling and tenderness over the lower end of the forearm.
X Rays reveal the displaced fracture of the radius and a prominent ulnar head due to dislocation of the inferior radio-ulnar joint.
Normal femur neck shaft angle?
130 +/- 7 degrees, and 10 +/- 7 degrees of neck anteversion.
Typical presentation of a NOF fracture?
pain in the hip/groin, a shortened, abducted, externally rotated leg
inability to straight-leg-raise
Best imaging for NOF?
XR first line but if inconclusive:
mri gold standard
(CT if more appropriate)
How are extra capsular NOF fractures classified?
pertrochanteric or subtrochanteric (within 5cm distal to the lesser trochanter)
Causes of avascular necrosis?
P ancreatitis
L upus
A lcohol
S teroids
T rauma
I diopathic, infection
C aisson disease, collagen vascular disease
R adiation, rheumatoid arthritis
A myloid
G aucher disease
S ickle cell disease
What is the best classification for open fractures?
Gustillo and Anderson
Clinical features of perthes?
Males 4x’s greater than females
Age between 2-12 years (the younger the age of onset, the better the prognosis)
Limp
Hip pain
Bilateral in 20%
What staging system is used for Perthes?
Catterall staging
Diagnosis of perthes?
Plain x-ray, Technetium bone scan or magnetic resonance imaging if normal x-ray and symptoms persist.
Mx 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 Scheuermann’s disease?
Epiphysitis of the vertebral joints is the main pathological process
Predominantly affects adolescents
Symptoms include back pain and stiffness
Xray and clinical features of scheuermann’s ?
X-ray :epiphyseal plate disturbance and anterior wedging
Clinical features: progressive kyphosis (at least 3 vertebrae must be involved)
what is scoliosis?
curvature of the spine in the coronal plane
Types of structural scoliosis?
idiopathic, congential and neuromuscular
Three categories of spina bifida?
myelomeningocele, spina bifida occulta and meningocele
What is Spondylolysis?
Congenital or acquired deficiency of the pars interarticularis of the neural arch of a particular vertebral body, usually affects L4/ L5
- maybe be asymptomatic
- affects 5% of population
What is Spondylolisthesis?
-One vertebra is displaced relative to its immediate inferior vertebral body
- can be due to stress fracture or spondylolysis
Traumatic cases may show the classic ‘Scotty Dog’ appearance on plain films
Mx of spondylolisthesis?
spinal decompression and stabilisation
Early and late evidence of avascular necrosis on X-ray?
Early: area appearing as being more radio-opaque due to hyperaemia and resorption of the neighboring area.
Late: Radiolucency and subchondral collapse
