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Surgery > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

How long do joint replacements typically last?

A

10-15 years

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2
Q

What are some of the different types of joint replacement?

A
  • Total-> both articular surfaces
  • Hemiarthroplasty
  • Partial joint resurfacing-> only part of surface
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3
Q

What are some of the indications for joint replacement?

A
  • Severe OA
  • Fractures
  • Sepsis
  • Osteonecrosis
  • Tumours
  • RA
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4
Q

How is a total hip replacement performed?

A
  • Head of femur removed + metal/ceramic replacement in with cement or pushed in
  • Acetabulum hollowed + replaced by metal with cement or screw
  • Spacer between new joint
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5
Q

How is a total knee replacement performed?

A
  • Vertical anterior incision
  • Patella rotated out of way
  • Articular surfaces, femur + tibia removed
  • New metal surface in with cement or by pushing
  • Spacer between
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6
Q

How is a total shoulder replacement performed?

A
  • Anterior incision along deltoid + dislocated
  • Head of humerus replaced-> metal ball, stem or screws
  • Glenoid replaced
  • May do reverse-> sphere where glenoid + spacer with cup for humerus
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7
Q

What should be done before total joint replacements?

A
  • Bloods-> include G+S and crossmatch
  • Scans
  • VTE prophylaxis
  • Fasting
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8
Q

What may be done/given during total joint replacements?

A
  • GA or spinal
  • Prophylactic antibiotics
  • May give tranexamic acid-> minimise blood loss
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9
Q

What may be done after total joint replacements (post op care)?

A
  • Analgesia
  • Post op imaging + bloods (eg anaemia)
  • VTE prophylaxis
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10
Q

What usually causes joint replacement infection?

A
  • Staph aureus

- More common in revision surgery

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11
Q

What are the risk factors for developing joint replacement infection?

A
  • Prolonged operation
  • Obesity
  • Diabetes
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12
Q

What are the symptoms of joint replacement infection?

A

Fever, pain, swelling, erythema, warm

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13
Q

How is joint replacement infection diagnosed?

A
  • Clinically
  • X ray
  • Bloods
  • Cultures-> blood +/- synovial
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14
Q

How is joint replacement infection managed?

A
  • Repeat surgery-> irrigation, debridement, replacement

- Antibiotics

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15
Q

What is a compound fracture?

A

Skin broken + fracture exposed to air

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16
Q

What is a stable fracture?

A

Bone sections are in alignment in the fracture

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17
Q

What is a pathological fracture?

A

Fracture due to abnormality in the bone-> tumour, osteoporosis, Paget’s

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18
Q

What are the different types of fracture?

A
  • Transverse
  • Oblique
  • Spiral
  • Segmental
  • Comminuted-> multiple
  • Compression-> vertebral spine
  • Greenstick
  • Buckle-> torus
  • Salter-Harris-> growth plate
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19
Q

What is a Colle’s fracture?

A
  • transverse distal radius fracture

- causes ‘dinner fork deformity’ as distal radius displaces posteriorly

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20
Q

What causes a scaphoid fracture?

A

Fall on outstretched hand

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21
Q

What is a key sign of a scaphoid fracture>

A

Tender anatomical snuffbox

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22
Q

Why can scaphoid fractures be difficult to heal?

A
  • Retrograde blood supply ie from only 1 directed
  • Fracture-> cut off supply
  • Avascular necrosis + non-union
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23
Q

What fractures can be obtained in the ankle?

A
  • Lateral malleolus-> distal fibula

- Medial malleolus-> distal tibia

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24
Q

What is the Weber classification system?

A
  • For lateral malleolus fractures
  • In relation to syndesmosis (fibrous joint) between tibia + fibula
  • More likely to need surgery if disrupted-> affects stability + function
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25
Q

What are the different types of ankle fracture?

A
  • Weber type A-> below ankle + leaves syndesmosis intact
  • Weber type B-> at level of joint so syndesmosis intact or partially torn
  • Weber type C-> above joint to syndesmosis interrupted
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26
Q

What happens with a pelvic ring fracture?

A

If fracture in one place will cause fracture elsewhere

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27
Q

What are the risks with a pelvic ring fracture?

A

Intra-abdominal bleeding from vascular injury or cancellous bone-> shock + death

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28
Q

What cancers commonly cause pathological fractures?

A

PoRTaBLe

  • Prostate
  • Renal
  • Thyroid
  • Breast
  • Lung
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29
Q

How can fragility be assessed?

A
  • History + exam
  • FRAX score-> risk of fragility fracture over next 10 years
  • DEXA scan + T score-> for bone mineral density
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30
Q

What are the side effects of bisphosphonates?

A

Reflux + oeseophageal erosions, atypical fractures, osteonecrosis of the jaw, external auditory canal problems

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31
Q

Why is it important to get 2 images when taking an X-ray for suspected fracture?

A

Because it’s easy to miss things if just one is taken

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32
Q

How are fractures managed?

A
  • Mechanical realignment
  • Closed reduction-> manipulation
  • Surgery
  • Fix bone-> external cast, K wires, intramedullary nails or wires, screws, plates + screws
  • May need trauma meeting + plan if complex
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33
Q

What are the immediate complications of fractures?

A

Damage to structures, haemorrhage, compartment syndrome, fat embolism, VTE

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34
Q

What are the long-term complications of fractures?

A

Delayed union, malunion, non-union, avascular necrosis, infection, instability, stiffness, contractures, arthritis, pain

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35
Q

When do fat embolisms usually occur?

A

24-72 hours after long bone fracture

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36
Q

What is fat embolism?

A

Globule released into circulation + gets lodged in BVs-> obstruction

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37
Q

How can fat embolism be prevented?

A

Early operation to fix fractures

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38
Q

How are fat embolisms managed?

A
  • Supportive

- Monitor for multi-organ failure

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39
Q

What is Gurd’s criteria?

A

For diagnosis of fat embolism

  • Major-> respiratory distress, petechial rash, cerebral involvement
  • Minor-> jaundice, thrombocytopaenia, fever, tachycardia
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40
Q

What are the major risk factors for NOF#?

A

Older, osteoporosis, female

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41
Q

When should surgery be performed in NOF#?

A

Within 48 hours

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42
Q

What is the 30 day mortality for NOF#?

A

5-10%

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43
Q

What is the anatomy of the hip joint?

A
  • Femur (head + neck)
  • Greater trochanter (lateral)
  • Lesser trochanter (medial)
  • Intertrochanteric line
  • Shaft
  • Capsule-> fibrous + attaches to rim of acetabulum + IT line
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44
Q

What is the blood supply to the head of the femur?

A
  • Medial + lateral circumflex femoral arteries

- Join neck proximal to intertrochanteric line

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45
Q

When can avascular necrosis of the femoral head occur?

A

Intra-capsular NOF#-> damage + remove blood supply

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46
Q

What is an intracapsular NOF#?

A

Break in NOF within hip joint capsule-> proximal to intertrochanteric line

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47
Q

What is the Garden classification system?

A

For intracapsular NOF#

  • Grade I-> incomplete fracture + non displaced
  • II-> complete + non-displaced
  • III-> partially displaced
  • IV-> fully displaced
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48
Q

What is a non-displaced intracapsular NOF# and how should it be managed?

A
  • May have intact blood supply

- Internal fixation

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49
Q

What is a displaced intracapsular NOF# and how should it be managed?

A
  • Blood supply disrupted

- Head of femur needs removing + replacing

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50
Q

When is hemi-arthroplasty performed?

A

More risky patients-> co-morbidities or limited mobility

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51
Q

When is total hip replacement performed?

A

Patient is able to walk independently + is fit for surgery

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52
Q

What is extra-capsular NOF# and how is it managed?

A
  • Distal to intertrochanteric line
  • Blood supply intact
  • Don’t need head of femur replacement
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53
Q

What is intertrochanteric NOF# and how is it managed?

A
  • Between lesser + greater trochanters

- Dynamic hip screw-> through head + neck with plate and barrel to outside shaft

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54
Q

What is sub-trochanteric NOF# and how is it managed?

A
  • Distal to lesser trochanter (within 5cm)

- Intramedullary nail

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55
Q

How does NOF# usually present?

A
  • Often 60+ and after fall
  • Pain in groin/hip + can radiate to knee
  • Unable to weight bear
  • Shortened + abducted + externally rotated leg
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56
Q

How is NOF# investigated?

A
  • AP + lateral X ray views
  • Shenton’s line on AP hip disrupted-> curving line formed by medial border of femoral neck
  • CT/MRI when -ve X ray but suspect
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57
Q

When should patients mobilise after surgery to fix NOF#?

A

Immediately-> allow mobilisation + rehabilitation

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58
Q

What is compartment syndrome?

A
  • Increased pressure in fascia compartment
  • Cut off blood flow to compartment
  • Muscles, nerves + BVs surrounded by fascia (fibrous connective tissue sheet)
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59
Q

What causes acute compartment syndrome?

A

Acute injury-> bleeding + tissue swelling

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60
Q

How does acute compartment syndrome present?

A
  • Legs, forearm, feet, thigh, buttocks
  • 5P’s-> pain, paraesthesia, pale, high pressure, paralysis (late)
  • Pain disproportional + worsened by passive muscle stretches
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61
Q

How can you tell the difference between acute compartment syndrome and limb ischaemia?

A
  • Disproportionate pain

- Not pulseless

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62
Q

How is acute compartment syndrome managed?

A
  • Orthopaedic emergency
  • Manometry to measure pressure
  • Escalate, remove dressings, elevate leg to heart
  • Emergency fasciotomy-> within 6 hours
  • Debride any necrotic tissue-> few times over few days
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63
Q

What causes chronic compartment syndrome?

A

Exertion-> pressure rise-> blood flow restricted-> symptoms + resolved at rest

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64
Q

What are the symptoms of chronic compartment syndrome?

A

Pain, numb + paraesthesia on exertion

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65
Q

How is chronic compartment syndrome managed?

A
  • Not emergency
  • Needle manometry
  • Fasciotomy
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66
Q

What bacteria usually causes osteomyelitis?

A

Staph aureus infection

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67
Q

What causes osteomyelitis?

A
  • Inflammation of bone + marrow
  • Haematogenous-> pathogen in blood seeds in bone
  • Direct contamination-> fracture or operation
  • Can be acute or chronic
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68
Q

What are the risk factors for osteomyelitis?

A

Open fracture, operations, diabetes, ulcers, PAD, IVDU, immunosuppression

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69
Q

How does osteomyelitis present?

A

Fever, pain, tenderness, erythema, swelling, systemic symptoms

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70
Q

How is osteomyelitis investigated?

A
  • MRI best
  • Bloods-> inflammatory
  • Cultures of blood + bone
  • X-ray-> periosteal reaction (change to surface), localised osteopenia, destruction
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71
Q

How is acute osteomyelitis managed?

A
  • Surgical debridement
  • 6 weeks of flucloxacillin-> may + rifampicin or fusidic acid in 1st 2 weeks
  • If prosthetic-> may need revision surgery
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72
Q

How is chronic osteomyelitis managed?

A
  • Surgical debridement
  • 3+ months of antibiotics
  • If prosthetic-> may need revision surgery
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73
Q

What is osteosarcoma?

A

A common bone cancer

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74
Q

What is chondrosarcoma?

A

Cartilage cancer

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75
Q

What is Ewing sarcoma?

A

Bone + soft tissue cancer that presents mostly in kids

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76
Q

What is rhabdomyosarcoma?

A

Skeletal muscle cancer

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77
Q

What is sarcoma?

A

Connective tissue cancer

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78
Q

What is leiomyosarcoma?

A

Smooth muscle cancer

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79
Q

What is liposarcoma?

A

Adipose/fat tissue cancer

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80
Q

What is synovial sarcoma?

A

Cancer of soft tissues around joints

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81
Q

What is angiosarcoma?

A

Cancer of blood or lymph vessels

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82
Q

What is Kaposi’s sarcoma?

A
  • Red/purple raised skin lesions
  • Due to HHV 8
  • Often in end stage HIV
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83
Q

How does sarcoma present?

A
  • Growing, painful, large lump

- Swelling and persistent pain

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84
Q

How is sarcoma investigated?

A
  • X ray for bony lumps
  • US for soft tissue lumps
  • CT/MRI-> more detail + look for mets (esp lungs)
  • Biopsy + histology
  • Staging-> TNM or grade 1-4
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85
Q

How is sarcoma managed?

A
  • MDT + specialist centres
  • Surgery
  • Radiotherapy
  • Chemo
  • Palliative
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86
Q

When should acute back pain improve?

A

Within 1-2 weeks

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87
Q

When should sciatica improve?

A

In 4-6 weeks

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88
Q

What are the causes of mechanical back pain?

A
  • Muscle/ligament sprain
  • Facet joint dysfunction
  • SIJ dysfunction
  • Herniated disc
  • Spondylolisthesis-> anterior displacement of vertebrae
  • Scoliosis
  • Degenerative change
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89
Q

What are the potential causes of neck pain?

A
  • Muscle/ligament strain
  • Torticollis-> unilateral stiffness + pain due to spasms
  • Whiplash
  • Cervical spondylosis-> degenerative change
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90
Q

What are the red flag/serious causes of back pain?

A
  • Spinal fracture
  • Spinal infection
  • Cauda equina
  • Spinal stenosis
  • Ankylosing spondylitis-> eg age <40 with morning stiffness
  • Cancer
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91
Q

How does back pain in ankylosing spondylitis present?

A

Stiff in the morning or rest, age <40, gradual onset, night pain

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92
Q

How does back pain in cancer present?

A

Gradual, night pain, weight loss, local tenderness, age 50+ usually

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93
Q

How does cauda equina present?

A
  • Bilateral symptoms, saddle anaesthesia, urinary retention, incontinence, reduced anal tone on PR, back pain
  • LMN signs-> reduced tone + reflexes
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94
Q

How does back pain in infection present?

A

Local tenderness, IVDU, fever

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95
Q

How is back pain investigated?

A
  • Clinical
  • STaRT Back screening tool
  • Xrays + CT-> fractures
  • Emergency MRI in suspected cauda equina
  • Ankylosing spondylitis-> inflammatory markers, XR, MRI
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96
Q

What sign is often present on an X-ray in ankylosing spondylitis?

A

Fused bamboo spine

97
Q

What is the STaRT back pain screening tool?

A
  • Assesses risk of acute turning to chronic back pain
  • Guides intensity of initial interventions
  • 9 questions-> function + psych response to pain
  • Low risk-> <3 for total + psych questions
  • Medium risk
  • High risk-> >3 for both
98
Q

How is acute back pain managed?

A
  • Exclude emergencies
  • Low risk-> self management, analgesia, mobilising
  • Medium/high risk-> physio, group exercise, CBT
  • Analgesia-> NSAIDs 1st line, codeine, benzos
  • Safety-netting for red flags
  • Radiofrequency denervation
99
Q

What causes sciatica?

A

Herniated disc, spondylolisthesis, spinal stenosis

100
Q

What is the anatomy of the sciatic nerve?

A
  • Formed from spinal nerves L4-S3
  • Exists posterior pelvis through greater sciatic foramen
  • Goes through buttocks
  • Goes to back of leg + at knee divides to tibial + common peroneal nerves
101
Q

What does the sciatic nerve supply?

A
  • Sensation-> lateral lower leg + foot

- Motor-> posterior thigh, lower leg + foot

102
Q

How does sciatica present?

A
  • Unilateral pain-> bum to back of thigh + below knee/feet
  • Pain-> electric, shooting, paraesthesia, numbness
  • Motor weakness + reflexes affected
  • Bilateral-> red flag for cauda equina
103
Q

How is the sciatic stretch test performed?

A
  • Lie on back with leg straight
  • Lift leg from ankle with knee extended + hip flexed
  • Dorsiflex ankle
  • Positive test-> sciatica pain in buttocks/posterior thigh due to nerve root irritation + improves when knee flexed
104
Q

How is sciatica managed?

A
  • Acute lower back pain management-> NSAIDs, not opioids if chronic
  • Neuropathic meds-> amitriptyline or duloxetine (NOT gabapentin or pregabalin)
  • Specialist-> epidural steroids, local anaesthetic, radiofrequency denervation, spinal decompression
105
Q

What is the pathophysiology of cauda equina syndrome?

A
  • Nerve roots through spinal canal after SC ends (L2/3)
  • Tapers at end to conus medullaris + roots exit and vertebral level (L3-S5)
  • Compression-> herniated disc, spondylolisthesis, spinal stenosis, tumours, mets, abscess
106
Q

What do the roots of the cauda equina supply?

A
  • Sensation-> perineum, bladder, rectum
  • Motor-> legs, anal + urethral sphincters
  • Parasympathetic-> bladder + rectum
107
Q

How is cauda equina syndrome managed?

A
  • Admission
  • Emergency MRI
  • Lumbar decompression (neurosurgery)
108
Q

What can cauda equina syndrome leave patients with?

A
  • Bladder, bowel and sexual dysfunction
  • Leg weakness
  • Sensory impairment
109
Q

What are the symptoms of metastatic spinal cord compression?

A
  • Similar to cauda equina
  • Back pain worse on coughing + steaining
  • UMN signs
110
Q

How is metastatic spinal cord compression managed?

A
  • Rapid imaging
  • High dose dexamethasone-> reduce swelling
  • Analgesia
  • Surgery
  • Radiotherapy
  • Chemo
111
Q

What is spinal stenosis?

A
  • Narrowing of spinal canal-> compression of cord + nerve roots
  • Usually lumbar
112
Q

What are the types of spinal stenosis?

A
  • Central (canal)
  • Lateral (nerve root canals)
  • Foramina stenosis
113
Q

What is radiculopathy?

A

Compression of nerve roots as exit cord + column

114
Q

What causes spinal stenosis?

A

Congenital, degenerative change, herniated discs, thickened ligamentum flava or posterior longitudinal ligament, spinal fractures, spondylolisthesis, tumours

115
Q

How does spinal stenosis present?

A
  • Gradual onset
  • Mild to severe
  • When stand or walk
  • Improved by rest or bending forward (flex spine + extend canal)
  • Intermittent neurogenic claudication-> lower back pain + buttock/leg pain + leg weakness
116
Q

How is spinal stenosis investigated?

A
  • MRI

- Exclude PAD with ABPI or CT angiogram

117
Q

How is spinal stenosis managed?

A
  • Exercise and weight loss
  • Analgesia
  • Physio
  • Decompression
  • Laminectomy-> remove all/part of lamina (bony) from vertebrae
118
Q

What is trochanteric bursitis?

A
  • Inflammation of bursa over greater trochanter causing pain in outer hip
  • Inflammation-> thickened synovial membrane + fluid production
119
Q

What is a bursa?

A
  • Sac from synovial membrane filled with fluid

- On bony prominences to reduce friction between bones + soft tissues when move

120
Q

What causes trochanteric bursitis?

A
  • Friction-> repetitive movement
  • Trauma
  • Inflammation-> RA
  • Infection-> sepsis
121
Q

How does trochanteric bursitis present?

A
  • Typically middle aged + gradual onset
  • Pain-> lateral thigh, radiate down, ache/burn
  • Worse with activity or standing or sitting cross legged
  • Difficulty sleeping or finding a comfy position
122
Q

What examination findings might be present in trochanteric bursitis?

A
  • Tender + not swollen
  • +ve Trendelenburg
  • Resisted abduction, internal and external rotation-> cause pain
123
Q

How is trochanteric bursitis managed?

A
  • Rest, ice, analgesia, physio, steroids

- Infection-> may need antibiotics

124
Q

What are the menisci in the knee?

A
  • Between femur + tibia
  • Medial + lateral
  • Condyles (rounded bones) don’t match so menisci help femur + tibia fit together
  • Shock absorber + distribute weight
125
Q

What does the patellofemoral joint consist of?

A
  • Patella in trochlea (PF groove)

- Quadriceps tendon-> attached to patella + when contracts causes knee extension

126
Q

How does meniscal tear present?

A
  • Younger-> sports or twisting
  • Older-> minor twist
  • Pain, swelling, stiffness, restricted ROM, locking, giving way, ‘pop’ sound, referred pain to hip/lower back
  • Local tenderness on joint line
  • Positive McMurray’s + Apley grind test-> not used as causes pain
127
Q

What are the Ottawa knee rules?

A

Differentiating between meniscal tear + bone fracture-> does pt need an X ray?

  • 55+
  • Patella tender only
  • Fibular head tender
  • Can’t flex knee to 90 degrees
  • Can’t weight bear for 4 steps
128
Q

How is meniscal tear investigated?

A
  • MRI

- Arthroscopy-> visualise + repair/remove damage

129
Q

How is meniscal tear managed?

A
  • RICE-> rest, ice, compression, elevate
  • NSAIDs
  • Physio
  • Surgery-> arthroscopy + repair/resection
130
Q

What is the main complication of meniscal tear?

A

Osteoarthritis

131
Q

What knee ligament injury is most common?

A

ACL injury

132
Q

Where is the Anterior Cruciate Ligament (ACL)?

A
  • Attaches to anterior part of intercondylar area (between medial + lateral condyles)
  • Originate from lateral aspect of intercondylar notch (groove between 2 femur condyles)
133
Q

Where is the Posterior Cruciate Ligament (PCL)?

A
  • Attaches to posterior part of intercondylar area (between medial + lateral condyles of tibia)
  • Originate from medial aspect of intercondylar notch (groove between 2 femur condyles)
134
Q

How does Anterior Cruciate Ligament (ACL) injury present?

A
  • Twisting injury
  • Pain + swelling
  • Hear a ‘pop’
  • Tibia moves anteriorly-> buckle + weakness
  • Positive anterior draw test + Lachman test
135
Q

How is Anterior Cruciate Ligament (ACL) injury investigated?

A
  • Exam-> anterior draw + Lachman tests
  • Arthroscopy
  • MRI scan
136
Q

How is Anterior Cruciate Ligament (ACL) injury managed?

A
  • Urgent referral
  • RICE
  • NSAIDs
  • Crutches, knee brace
  • Physio
  • Arthroscopic surgery-> reconstructive, new ligament using graft of tendon
137
Q

How is Anterior Cruciate Ligament (ACL) injury managed?

A
  • Urgent referral
  • RICE
  • NSAIDs
  • Crutches, knee brace
  • Physio
  • Arthroscopic surgery-> reconstructive, new ligament using graft of tendon
138
Q

What is Osgood-Schlatter disease?

A

Inflammation to tibial tuberosity where patella ligament inserts

139
Q

What is the pathophysiology of Osgood-Schlatter disease?

A
  • Patella tendon into tibial tuberosity
  • Minor avulsion fractures-> patellar ligament tears away tiny bone pieces
  • Tibial tuberosity grows + visible lump below knee
  • Tender then heals + becomes non-tender
140
Q

How is Anterior Cruciate Ligament (ACL) injury managed?

A
  • Urgent referral
  • RICE
  • NSAIDs
  • Crutches, knee brace
  • Physio
  • Arthroscopic surgery-> reconstructive, new ligament using graft of tendon
141
Q

What is Osgood-Schlatter disease?

A

Inflammation to tibial tuberosity where patella ligament inserts

142
Q

What is the pathophysiology of Osgood-Schlatter disease?

A
  • Patella tendon into tibial tuberosity
  • Minor avulsion fractures-> patellar ligament tears away tiny bone pieces
  • Tibial tuberosity grows + visible lump below knee
  • Tender then heals + becomes non-tender
143
Q

How does Osgood-Schlatter disease present?

A
  • Gradual onset
  • Hard + tender lump at tibial tuberosity
  • Less tender as heals
  • Anterior knee pain-> worse on activity, kneeling + extension
144
Q

How is Osgood-Schlatter disease managed?

A
  • Reduced activity
  • Ice
  • NSAIDs
  • Stretching + physio when settled
  • May need surgery if avulsion fractures
145
Q

What is a Baker’s cyst?

A

Cyst in the popliteal fossa due to degenerative changes in the knee

146
Q

How does Baker’s cyst present?

A
  • Pain, fullness, pressure, lump, swelling, restricted ROM-> popliteal fossa
  • Foucher’s sign-> most apparent when knee extended + less when flex to 45 degrees
  • Oedema-> when compress venous drainage
147
Q

What are some differentials for Baker’s cyst?

A

DVT, abscess, aneurysm, ganglion cyst, lipoma, varicose vein, tumour

148
Q

What are some differentials for Baker’s cyst?

A

DVT, abscess, aneurysm, ganglion cyst, lipoma, varicose vein, tumour

149
Q

What are the complications of Baker’s cyst?

A
  • Rupture-> pain + swollen calf muscle + tissues

- Compartment syndrome

150
Q

How is Baker’s cyst investigated?

A
  • US-> rule out DVT

- MRI-> underlyign pathology

151
Q

What is the Achilles tendon?

A
  • Attached gastrocnemius + soleus to calcaneus (heel) bone

- Flex calf muscles + cause plantarflexion of ankle

152
Q

What is Achilles tendinopathy?

A
  • Damage, swelling, inflammation + reduced function
  • Insertion-> within 2cm of insertion on calceneus
  • Mid portion-> 2-6cm above insertion
153
Q

What antibiotics can cause Achilles tendinopathy?

A

Fluoroquinolones-> ciprofloxacin

154
Q

How does Achilles tendinopathy present?

A
  • Gradual onset pain/ache in tendon/heel
  • Increased with activity
  • Stiff, tender, swollen
  • Nodularity on palpation
155
Q

How is Achilles tendinopathy managed?

A
  • Clinical
  • Exclude tendon rupture-> US + Simmond’s calf squeeze test
  • RICE
  • Analgesia
  • Physio
  • Orthotics
  • Extracorporeal shock-wave therapy
  • Surgery-> remove nodules + adhesions
156
Q

What are the risk factors for achilles tendon rupture?

A
  • Sudden onset injury
  • Sports
  • Existing tendinopathy
  • FH
  • Fluoroquinine antibiotics
  • Systemic steroids
157
Q

How does achilles tendon rupture present?

A
  • Sudden onset pain + snap sound/sensation
  • Feel like hit on back of head
  • Exam-> dorsiflexed, palpable gap, weakness of plantar flexion, unable to stand on tiptoes
  • Positive Simmond’s calf squeeze test
158
Q

What is Simmond’s calf squeeze test?

A
  • Prone/kneel with feet off end of ben
  • Squeeze calf-> should plantar flex
  • Ruptured achilles tendon-> won’t (+ve)
159
Q

How is achilles tendon rupture managed?

A
  • US diagnosis
  • Same day ortho referal
  • Immediate RICE + VTE prophylaxis
  • Non-surgical-> boot, full plantar flexion to neutral, for 6-12 weeks
  • Surgery-> reattach then boot
160
Q

What is plantar fasciitis?

A

Inflammation of plantar fascia-> thick connective tissue attaching to calcaneus + branches out to flexor tendons of toes

161
Q

How does plantar fasciitis present?

A
  • Gradual onset pain in plantar heel

- Worse on-> pressure, walking, standing, palpation

162
Q

How is plantar fasciitis managed?

A
  • RICE
  • Analgesia
  • Physio
  • Steroid injections
  • ECST
  • Surgery
163
Q

What is frozen shoulder?

A

Adhesive capsulitis-> pain + stiffness

164
Q

What causes frozen shoulder?

A
  • Usually middle age + diabetic
  • Primary-> spontaneous
  • Secondary-> trauma, surgery, immobility
165
Q

What is the pathophysiology of frozen shoulder?

A
  • Inflammation + fibrosis of capsule (connective tissue)

- Adhesions bind to capsule-> tighten + restrict movements

166
Q

How does frozen shoulder present?

A
  • 3 phases-> last 1-3 years before resolve but some persist
  • Painful phase-> worse at night
  • Stiff-> active + passive movement (especially external rotation), pain settles
  • Thawing-> gradual improvement + return to normal
167
Q

What are the differentials for frozen shoulder?

A
  • Tendinopathy (eg supraspinatus)
  • ACJ/glenohumeral arthritis
  • Septic joint
  • Inflammation
  • Malignant
  • Injury-> dislocation, fracture, rotator cuff tear
168
Q

What is supraspinatus tendinopathy?

A

Impingement where passes between humeral head + acromion

169
Q

What sign is present in supraspinatus tendinopathy?

A

Empty can test positive

170
Q

What sign is present in ACJ arthritis?

A
  • Scarf test positive
  • Tender palpation
  • Pain at extreme of abduction
171
Q

How is frozen shoulder investigated?

A
  • Clinical
  • X rays look normal
  • Other scans-> thickened joint capsule
172
Q

How is frozen shoulder managed?

A
  • Analgesia
  • Physio
  • Intra-articular steroids
  • Hydrodilation
  • Manipulation under anaesthetic
  • Arthroscopy-> cut adhesions
173
Q

What causes rotator cuff tears?

A
  • Injury of tendons or muscles (partial/full tear)
  • Acute injury
  • Degenerative change
  • Overhead activity
174
Q

What are the 4 muscles of the rotator cuff?

A
  • Supraspinatus
  • Infraspinatus
  • Teres minor
  • Subscapularis
175
Q

What does the supraspinatus do?

A

Abducts the arm

176
Q

What does the infraspinatus do?

A

External rotation

177
Q

What does the teres minor do?

A

External rotation

178
Q

What does subscapularis do?

A

Internal rotation

179
Q

How does rotator cuff tear present?

A
  • Acute or gradual shoulder pain
  • Uncomfortable at night
  • Disrupted sleep
180
Q

How is rotator cuff tear investigated?

A

US or MRI-> doesn’t show on X-ray

181
Q

How is rotator cuff tear managed?

A
  • Conservative if degenerative or high risk for surgery
  • Non-medical-> rest, adaptive activity, analgesia, physio
  • Surgical-> arthroscopic rotator cuff repair (re-attach tendon)
182
Q

What happens in shoulder dislocation?

A

Humeral head comes entirely out of glenoid cavity of scapula

183
Q

What happens in shoulder subluxation?

A
  • Partial dislocation

- Naturally pops back in after

184
Q

What type of shoulder dislocation is most common?

A

Anterior (90%)

185
Q

How does anterior shoulder dislocation occur?

A
  • Arm forced backwards whilst abducted + extended-> eg catch a heavy rock
  • Ball forward on socket
186
Q

When does posterior shoulder dislocation occur?

A

Electric shocks + seizures

187
Q

What associated damage can occur in shoulder dislocation?

A
  • Glenoid labrum tear
  • Bankart lesions-> anterior labrum
  • Hill-Sachs lesions-> compression fracture of humeral head
  • Axillary nerve damage-> C5-6 roots-> regimental badge sensory loss
  • Fractures-> humeral head, greater tuberosity, acromion, clavicle
  • Rotator cuff tear
188
Q

How does shoulder dislocation present?

A
  • Acute injury
  • Dislocates then muscle spasms + tightens
  • Hold arm at side of body
  • Flat deltoid
  • Bulge at front of shoulder-> humeral head
  • May have fractures, vascular or nerve damage
189
Q

What is the apprehension test?

A

For anterior shoulder instability

  • Abduct shoulder to 90 degrees + flex elbow at 90 degrees
  • Slowly externally rotate
  • Anxious + apprehensive as worried will dislocate
190
Q

How is shoulder dislocation investigated?

A
  • Clinical
  • X rays before + after treatment
  • Arthroscopy
  • MRI + contrast into joint-> check for lesions + plan surgery
191
Q

How is shoulder dislocation managed acutely?

A
  • Relocate ASAP-> muscle spasm can make more difficult + more likely to get neurovascular injury
  • Analgesia
  • Muscle relaxants
  • Broad arm sling for support
  • Closed reduction-> need X ray after
  • Surgery
  • Immobilisation
192
Q

How is shoulder dislocation managed long-term?

A
  • Physio
  • Shoulder stability surgery-> open or arthroscopic
  • 3+ months recovery after surgery
193
Q

What causes olecranon bursitis?

A
  • Friction from repeated movement
  • Trauma
  • Inflammation
  • Septic
  • Students/plumbers/drivers elbow-> leaning for long time
194
Q

How does olecranon bursitis present?

A
  • Usually young/middle aged man
  • Swollen, warm, tender, fluid elbow
  • Infection signs-> fever, hot to touch etc
195
Q

What happens on aspiration of olecranon bursitis?

A
  • Do when infection suspected
  • Pus
  • Straw coloured-> less likely infection
  • Blood stained
  • Milky-> gout or pseudogout
  • Ideally beforr antibiotics-> microscopy + culture
196
Q

How is olecranon bursitis managed?

A
  • RICE
  • Analgesia
  • Protect from pressure/trauma
  • Aspirate fluid-> relieve pressure
  • Steroid injections
  • Antibiotics-> flucloxacillin or clarithromycin
197
Q

What is repetitive strain injury?

A
  • Umbrella term for soft tissue irritation, microtrauma, strain
  • Muscle, tendon or nerve
  • Eg lateral epicondylitis (tennis elbow)
198
Q

What causes repetitive strain injury?

A
  • Small repetitive activity eg computer mouse use
  • Vibration
  • Awkward positions + posture
199
Q

How does repetitive strain injury present?

A
  • Pain + ache exacerbated by use
  • Weakness, cramping, numbness
  • Tender, swollen
  • Exam-> ask to repeat movement
200
Q

How is repetitive strain injury diagnosed?

A
  • Clinical

- Rule out other diagnoses-> X rays, bloods etc

201
Q

How is repetitive strain injury managed?

A
  • RICE
  • Adaptive activity
  • Occupational health at work
  • Analgesia
  • Physio
  • Steroid injections
202
Q

What is tennis elbow?

A
  • repetitive strain injury
  • inflammation where tendon inserts into lateral epicondyle
  • due to wrist extension
203
Q

What are the symptoms of tennis elbow?

A

Pain, tenderness, radiation down forearm, weak grip strength

204
Q

What is Mill’s test?

A

For lateral epicondylitis (tennis elbow)

  • Extend elbow, supinate forearm + extend wrist/fingers
  • Hold elbow with pressure on lateral epicondyle
  • Positive if painful
205
Q

What is Cozen’s test?

A

For lateral epicondylitis (tennis elbow)

  • Elbow extended + forearm pronated
  • Deviate wrist to radius with hand in fist
  • Hold with pressure on lateral epicondyle + resistance to back of hand
  • Positive if painful
206
Q

What is golfer’s elbow?

A
  • repetitive strain injury
  • medial epicondylitis
  • inflammation where tendon inserts into medial epicondyle
  • due to wrist flexion
207
Q

What are the symptoms of golfer’s elbow?

A

Pain, tenderness, radiation down forearm, weak grip strength

208
Q

How do you test for golfer’s elbow?

A
  • Extend elbow + supinate forearm
  • Extend wrist + fingers
  • Hold condyle with pressure
  • Positive-> painful
209
Q

How is epicondylitis (tennis/golfer’s elbow) managed?

A
  • Clinical diagnosis
  • Can take years to resolve
  • Rest
  • Adaptive activity
  • Analgesia
  • Physio
  • Steroid injections
  • Platelet-rich plasma injections
  • ECST
  • Surgery
210
Q

What is De Quervain’s Tenosynovitis?

A
  • Swelling + inflammation in tendon sheaths of wrist
  • Often abductor pollicis longus (APL) + extensor pollicis brevis (EPB)
  • Repetitive strain injury
  • Bilateral-> ‘mummy thumb’ ie repeated picking up of babies
211
Q

What is the pathophysiology of De Quervain’s Tenosynovitis?

A
  • Tendon sheath (synovial membrane + fluid) protects tendons
  • Extensor retinaculum-> fibrous band across dorsal wrist + APL + EPB pass underneath
  • Repeat movement-> inflammation + swelling of sheath
212
Q

How does De Quervain’s Tenosynovitis present?

A
  • Pain, ache, weakness, burning, numbness, tenderness
  • At radial aspect of weist near thumb base
  • Tests-> Finkelstein’s + Eichhoff’s
213
Q

How is De Quervain’s Tenosynovitis managed?

A
  • Rest
  • Adaptive movement
  • Splints
  • Analgesia
  • Physio
  • Steroids
  • Surgery
214
Q

What is the pathophysiology of trigger finger?

A
  • Thickened tendon or tightening of sheath-> stenosing tenosynovitis
  • Prevents smooth movement when finger flexed/extended
  • Nodule-> gets stuck when extended and causes locking/stuck in position then released with sudden painful pop
  • Usually 1st annular pulley (A1) at MCP
215
Q

What are the risk factors for trigger finger?

A
  • Age 40-50
  • Women
  • Diabetes
216
Q

How does trigger finger present?

A
  • Pain + tender around MCPJ or palm side of hand
  • Finger doesn’t move smoothly, stuck when flexed, pop/click sound when released
  • Worse in morning
  • Improve during day
217
Q

How is trigger finger managed?

A
  • rest
  • analgesia
  • splints
  • steroid injections
  • surgery to release
218
Q

What is Dupuytren’s contracture?

A

Fascia of the hand tightens + thickens causing contractures-> fixed flexion

219
Q

What is the pathophysiology of Dupuytren’s contracture?

A
  • Palmar fascia of hand forms strong connective tissue triangle
  • Thicker + nodules develop-> cords extend to fingers + pull into flexion
  • Inflammatory response to microtrauma
220
Q

What are the risk factors for developing Dupuytren’s contracture?

A

Older age, FH (autosomal dominant), male, manual labour, diabetes, epilepsy, smoking, alcohol

221
Q

How does Dupuytren’s contracture present?

A
  • Hard nodules on palm
  • Skin thick + pitting
  • Held in flexion
  • Usually ring finger (index is rare)
  • No pain but affects function
  • Table-top test-> can’t rest hand flat
222
Q

How is Dupuytren’s contracture managed?

A
  • Conservative
  • Needle fasciotomy-> divide + loosen cord
  • Limited fasciectomy-> remove abnormal fascia + cord
  • Dermofasciectomy-> remove fascia, cord + skin and add skin graft
223
Q

What nerve is affected in carpal tunnel syndrome?

A

Median nerve-> compressed from contents swelling or narrow tunnel

224
Q

What is the anatomy of the carpal tunnel?

A
  • Between flexor retinaculum (fibrous band around front of wrist) and carpal bones
  • Median nerve + flexor tendons run through
225
Q

What does the median nerve supply?

A
  • Palmar digital cutaneous branch-> sensory to palmar aspects + fingertips (thumb, index, middle, lateral 1/2 of ring)
  • Palmar cutaenous branch-> sensory to palm
  • Motor-> thenar muscles (APB, opponens, pollicis, flexor pollicis brevis)
226
Q

What are the risk factors/causes for carpal tunnel syndrome?

A

Idiopathic, repetitive strain, obesity, peri-menopause, RA, DM, acromegaly (bilateral), hypothyroidism

227
Q

What can cause bilateral carpal tunnel syndrome?

A

Acromegaly

228
Q

How does carpal tunnel syndrome present?

A
  • Gradual onset + intermittent numbness, paraesthesia, burning, pain
  • Often worse at night
  • Sensory-> palmar digital cutaneous branch-> sensory to palmar aspects + fingertips (thumb, index, middle, lateral 1/2 of ring)
  • Motor-> thenar muscle weakness/wasting, grip strength problems, fine movement difficulty
  • Phalen’s + Tinel’s tests
229
Q

What questions are included in the carpal tunnel syndrome questionnaire?

A

Predicts likelihood of diagnosis-> need nerve conduction studies?

  • Do symptoms wake at night?
  • Trick movements (eg shaking hand) to improve it?
  • Little finger affected-> negative scoring
230
Q

What is the primary investigation for carpal tunnel syndrome ?

A

Nerve conduction studies-> small current made by electrode to median nerve + record how well signalled

231
Q

How is carpal tunnel syndrome managed?

A
  • Rest
  • Alternate activity
  • Splints-> 4+ weeks at night
  • Steroid injections
  • Surgery-> day case under local to cut flexor retinaculum + release pressure
232
Q

What are ganglion cysts?

A
  • Sacs of synovial fluid from tendon sheath or joint
  • Usually wrist or finger
  • Synovial membrane herniates + form pouch-> fluid into cyst
233
Q

How do ganglion cysts present?

A
  • Rapid or gradual
  • Usually not painful
  • Lump-> 0.5-5cm, firm, non-tender, well circumscribed, transilluminates
234
Q

How is ganglion cyst diagnosed?

A
  • Clinical
  • X rays-> normal
  • US
235
Q

How is ganglion cyst managed?

A
  • 40-50% spontaneously resolve
  • Needle aspiration-> high recurrence
  • Surgical excision
236
Q

What is meralgia paraesthetica?

A
  • Compression of lateral femoral cutaneous nerve-> mononeuropathy
  • Due to pressure, deformity or trauma
237
Q

How does meralgia paraesthetica present?

A
  • Dysesthesia (abnormal sensation) and anaesthesia in nerve distribution
  • Upper-outer thigh
  • Burning, numb, pins + needle, cold, local hair loss
  • Worsened by-> walking, standing for a long time, hip extension
  • Improve-> when sit down
238
Q

How is meralgia paraesthetica diagnosed?

A
  • Clinical

- May exclude other causes

239
Q

How is meralgia paraesthetica managed?

A
  • Mild to severe
  • Conservative-> rest, looser clothes, weight loss, physio
  • Medical-> NSAIDs, paracetamol, neuropathics, local injections
  • Surgical-> decompression, transection, resection

Surgery (8 decks)

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