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Year 3 Surgery > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

What Classification Is Used for Open Fractures?

A

Gustilo Anderson classification

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2
Q

Classification of Open Fractures

A

Type 1: <1cm would and clean
Type 2: 1-10cm clean wound
Type 3a: >10cm and high energy but with adequete soft tissue coverage
Type 3b: >10cm and high energy but with inadequete soft tissue coverage
Type 3c: All injuries with vascular injury

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3
Q

How do you manage an open fracture?

A

Resuscitation and stabilisation of the patient
Urgent realignment and splinting of the fracture
Broad spectrum antibiotic cover and tetnus vaccination
Wound and fracture site debridement
Removal of devitalised tissue
Reasses and document neurovascular status
Vascular team surgical exploration of any vascular compromise

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4
Q

What problems can an open fracture cause?

A

Skin - significant tissue loss
Soft tiasue devitalisation/muscle, tendon, or ligament loss
Neurovascular injury - nerves and vessels may be compressred
Infection - direct contamination reduced blood supply insertion of metalwork for fracture stablisation

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5
Q

Principals of fracture management?

A

Reduce
Hold
Rehabillitate

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6
Q

Why is fracture reduction important?

A

Tamponade of bleeding
Reduction in the traction on surrounding soft tissues (excessively swollen tissues have higher rates of wound complications)
Reduction in tracture on the ransversing nerves to reduce the risk of neuropraxia
Reduction of pressure on transversing blood vessels restoring any affected blood supply

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7
Q

What does the defeinitive manouvere in fracture reduction entail?

A

Correction of the deforming forces that resulted in the injury
(Sometimes exaggerating fracture first to uncouple the proximal and distal fracture fragments)

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8
Q

What should be considered when immobilising a fracture

A

Whether traction is needed
Which method will be used (splint, plaster cast)
How long ‘hold’ has been in place - in first two weeks there should be space allowed for swelling
If their is axial stability (plaster should cross joint above and below)
Can the patient weight bare?
Will the patient need thromboprohylaxis?
Safteynetting on compartment syndrome

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9
Q

What is compartment syndrome?

A

Critical pressure increase within a compartmental space, can affect any fascial compartment

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10
Q

What are the causes of compartment syndrome?

A 
High-energy trauma, crush injuries, or fractures that cause vascular injury 
Burns
Iatrogenic vascular injury 
Tight casts or splints 
DVT
Post perfusion swelling
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11
Q

What is the pathophysiology of compartment syndrome?

A

Fascial compartments are closed and cannot be descended, so any fluide will cause intra-compartmental pressure increase, compressing the veins. This increases the hydrostatic oressure within them causing fluid to move out of the veins into the compartment causing further presure increase.
The transversing nerves are compressed.
Arterial inflow is compromised leading to ischemia

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12
Q

Signs and symptoms of compartment syndrome

A 
Cold pale limb
Parathesisa 
Paralysis 
Severe pain disproportionate to the injury worsened by passive stretching the muscle bellies of the muscles traversing the affected fascial compartment 
Tension of the compartment
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13
Q

What is the normal pressure within a fascial compartment?

A

0 to 8 mmHg

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14
Q

What organ needs to be monitored in particular in compartment syndrome?

A

Kidneys, potential effects of rhabdomyolysis or reperfusion injury

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15
Q

What is the initial management of compartment syndrome?

A

Keep limb at neutral level with the patient
High flow oxygen
Augment blood pressure
Removal all splints casts and dressings
Treat symptomatically with opiod analgesia
Treat symptomatically with opiod analagesia

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16
Q

What is the defenitive treatment of compartment syndrome?

A

Fasciotomoy

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17
Q

What blood test can be useful in diagnosing compartments syndrome?

A

Creatine kinase

Elevated/trending upwards

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18
Q

What are the common caustive organisms in septic artheritis?

A

Staph aureus (adults)
Streptococcus spp.
Gonorrhoea (sexualy active patients)
Salmonella (sickle cell)

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19
Q

What is the pathophysiology of septic artheritis?

A

Bacteraemia seeds to joint/Direct innoculation/Spreading from adjacent osteomyelitis

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20
Q

What are the risk factors for septic artheritis?

A 
Age > 80
Any pre-existing joint disease
DM or immunosuppresion 
Chronic renal failure
Hip or knee joint prosthesis 
IVDU
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21
Q

How does septic artheritis present?

A

Single swollen joint
Severe pain
Pyrexia (60%)
Red swollen joint
Joint is rigid patient cannot tolerate passive or active movement
Note that in prosthetic joint infections symptoms and signs can be more subtle

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22
Q

Differential diagnosis for Septic Artheritis?

A 
Flare of osteoartheritis 
Haemarthrosis
Crystal arthropathies 
RA
Reactive artheritis 
Lyme disease
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23
Q

Investigations for septic artheritis?

A

Routine bloods including FBC and CRP
Blood ESR and urate levels
A joint aspritation (in theatre if prosthetic joint) and analysis for gram stain, leucocyte count, polarisinf microscopy , fluid culture BEFORE ANTOBITOICS STARTED UNLESS PATIENT OVERLY SEPTIC
Plain radiograph (normal/soft tissue swelling/fat pad shift/ joint space widening)

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24
Q

What are the complications of septic artheritis?

A

Osteoartheritis
Osteomyelitis
Spesis

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25
Q

What is the management of septic artheritis

A

If septic sepsis 6
Empirical antibiotics after any planned cultures of aspirates (4-6 weeks, 2 of which are IV)
Irrigation and debrident
Revision surgery of prosthetic joint

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26
Q

What are the causes of frozen shoulder?

A

Primary adhesive capsulitis (idopathic capsulitis)
Secondary adhesive capsulitis - rotator cuff tendinopathy, subacromial impingement syndrome, bisceps tendinopathy, previous surgery or trauma, or known joint arthopathy

Association with inflamatory diseases - ?autoimmune element

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27
Q

What are the stages of frozen shoulder?

A

Painful
Freezing
Thawing
Pain associated with limitation in shoulder movement present throughout

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28
Q

Clinical features of a frozen shoulder

A

Generalised deep contsant oain radiating to the bicep
Often distrubs sleep
Loss of join function, stiffness
Loss of arm swinf
Atrophy of the deltoid muscle
Generalised tenderness on palpation
Limited ROM - external rotation and flexion of the shoulder

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29
Q

Which sex is frozen shoulder more comman in?

A

Females

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30
Q

What is the peak onset of frozen shoulder?

A

40 to 70 years old

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31
Q

What investigations would you undertake in a patient with frozen shoulder?

A

Can be a clinical diagnosis
Plain film radiographs can rule out acriomioclavicular pathology or atypical fracture presentation
MRI imaging can reveal a thickening of the glenohumeral joint capsule
HbA1c may be useful as may patients with adhesive capsulitis have diabetes

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32
Q

What is tha management of adhesive capsulitis?

A

Self limiting
Recovery months-years
Education reassurance
Physiotherapy
If fails to improve with above and simple analgesia corticosteroid injections can be considered
Potentially surgical interventions: joint manipulation under general anaesthetic to remove capsular adhesions to the humerus, arthogaphic distension, surgical release of the glenohumeral joint capsule

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33
Q

Complications of frozen shoulder?

A

Small proportion of patients will never regain full motion
Perisistence beyond two years
Recurrence in contralateral shoulder

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34
Q

What is adhesive capulitis/frozen shoulder?

A

Glenohumeral joint capsule becomes contracted and adherent to the humeral head
Results in shoulder pain and reduced ROM

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35
Q

What is subacrominal impingement syndrome?

A

Inflamation and irritation of the rotator cuff tendons as they pass through the subacromial space
Attrition between the coracoaceomial arch and the supraspinatus tendon or subacromial bursa

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36
Q

What pathology is encompassed by SAIS

A

Rotator cuff tendionsis
Subacromial bursitis
Calcific tendinitis

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37
Q

Typically what age are oatients presenting with shoulder impingement?

A

Under 25

Active or in manual professions

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38
Q

Clincal features of SAIS

A

Progressive pain in the anterior super shoulder
Exacerbated by aduction, relieved by rest
Associated with weakness and stiffness secondary to the pain
Positive Neers impingement test
Positive Hawkins test

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39
Q

What is Neers impingement test

A

The arm is placed fully internally rotated by the patients side and passively flexed
Positive if pain is oresent in anterolateral aspect of the shoulder

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40
Q

What is Hawkins test?

A

Shoulder and elbow flexed to 90*, examiner stablises the humerus and oassively internally rotates the arm.
Positive if pain in anterolateral aspect of the shoulder.

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41
Q

Intrinsic mechanisms of SAIS

A

Muscular weakness
Overuse of the shoulder
Degenerative tendinooathy

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42
Q

Extrinsic mechanisms of SAIS

A

Anatomical facotrs
Scapular musculature
Glenohumeral instability

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43
Q

Differential diagnosies for shoulder impingement?

A

Muscular tear (rotator cuff tear, long head bisceps tear)
Neurological oain
Frozen shoulder syndrome
Acromioclavicular pathology

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44
Q

How woudl you investigate shoulder impingement?

A

Clinical diagnosis
Confirm via MRI (formation of subacromial osteophytes and sclerosis subacrimial bursitis, humeraly cystic changes, narrowing of the subacromial space)

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45
Q

Management of shoulder impingemeny

A

NSAIDs
Physio
Corticosteroid injections can be trialled
Surgical repair of muscular tears
Surgical removal of the subacromial bursa
Surgical removal of a section of the acromion

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46
Q

Complications of SAIS

A 
Rotator cuff degeneration and tear
Adhesive capulitis
Cuff tear arthropathy 
Complex regional pain syndrome 
Usually resoleves with conservative management
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47
Q

Where is the subacromial space and what runs in it?

A

Below the coracoacromial arch and above the humeral head
Rotator chff tendons long head of the biceps tendon and the coraco-acromial soace run through it, all surrounded by the subacromial bursa

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48
Q

What muscles does the rotator cuff include and what do they do?

A

Supraspinatus - abduction
Infraspinatus - external rotation
Teres minor - external rotation
Subscapularis - internal rotation

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49
Q

What does the rotator cuff do?

A

Supports and rotates the glenohumeral joint

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50
Q

Classication of rotator cuff tears

A

Acute (<3 months)
Chronic (>3 months)
Partial thickness
Full thickness (small/medium/large)

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51
Q

Pathophysiology of rotator cuff tears?

A

Acute: occur within tendons with pre-exisiting degeneration, alone with minimal force (or larger forces in younger individuals)
Chronic: individuals with degenerative microtears to the tendons, most commmonly from overuse, seen more in older patients

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52
Q

Risk factors for a rotator cuff tear

A 
Age 
Trauma
Overuse 
Reoeititve overhead shoulder motions 
BMI>25
Smoking
Diabetes mellitus
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53
Q

Investigating a rotator cuff tear?

A

Urgent plain film radiograph to exclude a fracture
Most likely unremarkable but may be reduced acromiohumeral distance pr sclerosis cyst formation on the greater tuberosity of the humerus
USS to establish size and presence of tear
MRI to dectect size charecteristics and location of the tear

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54
Q

Clinical features of rotator cuff tear

A

Pain over lateral aspect of the shoulder
Inability to abduct the arm above 90 degrees
Tenderness of greater tuberosity and subacrimal bursa regions
Supraspinatus and infraspinatus atrophy can maybe be seen in a massive teR
Positive Jobe’s test
Positive Gerber’s lid off test
Positive posterior cuff test

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55
Q

Differentials for a rotator cuff tear

A

Fracture
Persistent gelnohumeral subluxation
Brachial plexus injury
Radiculopathy

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56
Q

Management of a rotator cuff tear

A

Within 2 weeks of injury - conservative: analgesia, physio, trial of corticosteroid injection
Surgical management after two weeks or if remaining symptomatic despite conservative management - or large and massife tears
Repair - arthroscopically or open

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57
Q

Main complications of rotator cuff tear

A

Adhesive capsulitis

Enlargement of tear

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58
Q

Which patients most commonly present with clavicle fractures?

A
  1. Adolescents and young adults

2. Over the age of 60 - association with osteoperosis

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59
Q

What classification is used for clavicle fractures?

A

The Allman classification system

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60
Q

What are the fracture types of the Allman classification system?

A

Type 1 - middle third of clavicle - most common as this is the weakest segment. Usually stable but significant deformity present.
Type 2 - lateral third of the clavicle. When displaced often unstable
Type 3 - least common, medial third - associated with multi-system polytrauma.
As the mediastinum sits directly behind the medial aspect of the clavicle they can be associated with neurovascular compromise, pneumothorax or haemothorax

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61
Q

How do clavicle fractures occur and where do the fragments typically displace?

A

Direct or indirect trauma
Medial - superior
Lateral - inferior

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62
Q

Clinical features of a clavicle fracture

A

Sudden onset localise severe pain, worsened on active movement of the arm, following trauma
?Open injury - subcut location of clavicle
Threatened skin - tented tethered white non blanching (subcut location of clavicle)
Brachial plexus injury

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63
Q

What differentials should you consider in a broken clavicle?

A

Sternoclavicular dislocation

ACJ seperation

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64
Q

How would you investigate a clavicular fracture?

A

Plain film AP and modified-axial radiograph to assess displacement
(CT imaging to assess medial clavicle injury)

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65
Q

Management of a clavicle fracture

A

Usually conservative even if significant deformity
Sling until pain free movement of the shoulder
Early movement of the shoulder joint
Surgical intervention if open fracture or very communited/very shortened/bilateral fractures
ORIF at 2-3 months if failure to reunite

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66
Q

What are the complications of a clavicle fracture?

A

Neurovascular injury
Puncture injury
Non-union

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67
Q

How long does a clavicular fracture take to heal?

A

4-6 weeks

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68
Q

What are the risk factors of a humeral shaft fracture?

A

Increasing age
Osteoperosis
Previous fractures

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69
Q

Which patients most commonly present with a humeral shaft fracture?

A

Younger pts - high energy trauma

Older patients - low impact

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70
Q

What are the clinical features of a humeral shaft fracture?

A

Pain
Deformity
Reduced sensation over the first dorsal webspace if radial nerve involvement
Weakness in wrist extension if radial nerve involvement

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71
Q

What causes a humeral shaft fracture?

A

FOOSH

Lateral fall onto an adducted limb

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72
Q

What is a Holstein-Lewis Fracture?

A

Distal third of the humerus, entrapment of radial nerve
Wrist drop
Loss of sensation in radial distribution
Surgical management indicated

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73
Q

How would you investigate a humeral shaft fracture?

A

AP plain film radiograph of the humerus

CT for pre op planning in sever comminuted cases

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74
Q

What is the management of a humeral shaft fracture?

A

Realingment of the limb - usually conservative in a funcitional humeral brace
Surgical fixation in few patients involving an open reduction and internal fixation with a plate,
Intramedullary nailing may be indicated in the presence of pathological fractures, polytrauma or severly osteoporotic bones

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75
Q

What is the most common site of shoulder fracture?

A

Proximal humerus

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76
Q

How do proximal humeral fractures usually happen?

A

FOOSH
Often in the contect of osteoporosis
Low energy in elderly or high energy in younger patients

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77
Q

How does a proximal humeral fracture present?

A 
Pain around the upper arm 
Pain around the shoulder 
Restriction of arm movement
Inability to abduct their arm 
Potentially loss of senstation in the lateral shoulder (regemental badge area) and loss of power of the deltoid muscle if damage to axillary nerve
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78
Q

Which vessels can be compromised by a proximal humerus fracture

A

Circumflex vessels

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79
Q

What investigations should be ordered for a proximal humerus fracture?

A

Urget bloods including a coagulation and Group and Save
Serum calcium and myeloma screen if pathological cause suspected
Plain film radiograph - lateral scapular, AP, axillary views
Potentially at CT scan for pre op planning

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80
Q

How do you classify proximal humeral fractures?

A

Neer classification system

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81
Q

How are proximal humeral fractures managed?

A

Immobilisation initially with early mobilisation including pendular exercises at weeks 2-4
Correctly applied polysling allowing arm to hang so that gravity can aid the reduction of fragments
Surgical fixation if displaced open or neuro vascular compromise
ORIF, intermedullaey nailing, hemiarthoplasty, reverse shoulder arthroplasty

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82
Q

What are the conplications of a humeral shaft fracture

A

Avascular necrosis of the humeral head
Axillary nerve injury
Reduced ROM

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83
Q

What are the potential complications of a dislocated shoulder?

A 
Chronic pain
Limited mobility 
Stiffness 
Recurrence 
Adhesive capulitis 
Nerve damage 
Rotator cuff injury 
Degerative joint disease 
Chronic joint instability
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84
Q

What is the most common type of shoulder dislocation and how does it occur

A

Anteroinferior

Clasically caused by a force being applied to an extended, abducted, externally rotated humerus

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85
Q

How might a posterior shoulder dislocation be caused

A

Seizure
Electorcution
(A direct vlow to the anterior shoulder or force through a flexed adducted arm)

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86
Q

How does a dislocated shoulder present

A

Pain
Reduced mobility
Instability
Asymmetry with the contralateral shoulder
Loss of shoulder contours (flattened deltoid)
Anterior bulge from head of the humerus
Axillary or suprascapular nerve damage
Associated bony injury
Associated labral ligamentous or rotator cuff injury

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87
Q

How should you invesitgate a shoulder dislocation

A

Plain radiograph
AP
Y-scapular (usefull for diff between anterior and posterior) and or axial views

MRI If suspected labral or rotator cuff injuries

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88
Q

What does the lightbulb sign on an xray of the shoulder mean

A

Anterior dislocation

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89
Q

How to manage shlulder dislocation

A

Assess neurovascular status before and after reduction
Manipulation under anaesthesia if failed closed reduction
Once reduced place arm in broad arm sling for aprox two weeks

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90
Q

What is the olcecranon

A

Region of the proximal ulna from its tip to the coronoid process. It articulates with the trochlea of the distal humerus.

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91
Q

How do olecranon fractures typically occur?

A

FOOSH
Sudden pull of the triceps and brachiallis.
Triceos further distract the fracture

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92
Q

How do olecranon fractures present?

A

Elbow swelling
Elbow pain
Lack of mobility and inability to extend elbow against gravity
Posterior aspect of the elbow is tender

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93
Q

Which imaging should be performed when an olecranon fracture is suspected?

A

Plain AP and lateral radiographs

Affected joint and those above and below

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94
Q

Management of an olecranon fracture

A

Establish the degreee of of the fracture on imaging
Minimal displacement or pt very elderly - imobilise in a 60-90 degree flexion, early introduction of ROM
Displacement >2mm
- proxmial to coranoid process: tension band wiring
- at level of or distal to coranoid process: olecranon plating

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95
Q

What areas, relative to the joint capsule, can a neck of femur fracture occur in?

A
  • Intra-capsular – from the subcapital region of the femoral head to basocervical region of the femoral neck, immediately proximal to the trochanters
  • Extra-capsular – outside the capsule, subdivided into:
    1. Inter-trochanteric, which are between the greater trochanter and the lesser trochanter
    2. Sub-tronchanteric, which are from the lesser trochanter to 5cm distal to this point
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96
Q

Describe the blood supply to the neck of femur

A

Retrograde
Passes from distal to proxmial along the femoral neck to the femoral head
Predominantly through the medial circumflex femoralartery
The medial circumflex femoral artery lies directly on the intra-capsular femoral neck

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97
Q

What are the risks of a displaced intra-capsular neck of femur?

A

If displaced, blood supply to the femoral head may be disrupted
Avascular necrosis of the femoral head
Will require athroplasty

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98
Q

How are intracapsular neck of femur fractures classified?

A

Garden Classification

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99
Q

Describe the Garden CLassification

A

I: non displaced, incomplete
II: non displaced, complete
III: partial displacement
IV: full displacement

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100
Q

How will a fractured neck of femur classically present?

A

Limb is shortened, externally rotated
Hx of trauma, pain in groin/thigh/ref to knee (elderly)
Inability to weight bear

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101
Q

What are the definitive surgical options for a fractured NOF

A 
Hip hemiarthroplasty (displaced sub-capital)
DHS (inter-trochanteric/basocervical)
Cannulated hip screws (non-displaced intra-capsular)
Anterogreade intramedullary femoral nail (sub trochanteric)
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102
Q

What is the one year mortality of a femoral neck fracture?

A

30%

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103
Q

What is osteoarthritis?

A

Degenerative joint disease

Loss of articular cartilage

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104
Q

Risk factors for OA

A 
Age >45 years
Female
Family history 
Low bone density
Vit D deficiency
History of joint trauma
Anatomic abnormalities
Muscle weakness
Joint laxity
Participation in high impact sports
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105
Q

Where do patients with hip OA report pain?

A 
Groin most commonly
Lateral hip
Deep buttock
Aggravated by weight bearing, improved with rest
Dull, aching pain
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106
Q

What gait will a patient with hip OA have?

A

Antalgic

Late stage: fixed flexion deformity causing Trendelenburg gait

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107
Q

Differential Diagnoses for Hip OA?

A

Trochanteric bursitis
Gluteus medius tendinopathy
Sciatica
FNOF

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108
Q

What features will be seen in joints affected by OA on a radiograph?

A

Joint space narrowing
Osteophyte formation
Sclerosis of the subchondral bone
Subchondral bone cysts

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109
Q

What tool can be used for a quantitative evaluation of disease progression in OA?

A

WOMAC

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110
Q

What is the management of OA?

A

Analgesia
Lifestyle modifications: weight loss, regular exercise, smoking cessation
Physiotherapy - improve joint mechanics, strengthens muscles, slows disease progression
Surgical intervention may be warrented if conservative efforts do not work - eg. hip OA hemiarthroplasty

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111
Q

What surgical approaches can be taken to a hip replacement?

A

Posterior (most common, risk of sciatic nerve damage)
Anterolateral
Anterior

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112
Q

How long does a modern hip prostheisis typically last?

A

15-20 years

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113
Q

Which joints are most commonly affected by OA?

A
  1. Knee
  2. Hip
  3. Hand
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114
Q

What clinical sign may you be able to feel when examining a patient with severe knee OA?

A

Crepitus

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115
Q

What differentials should be considered in patients with OA of the knee?

A

Meniscal or ligament injury
Referred pain from another joint (e.g. hip) or the back
Crystal arthropathies
Patellofemoral arthritis

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116
Q

What views of the knee should be obtained on X-ray?

A

AP to assess for OA (LOSS)

Skyline view to see patellar well

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117
Q

What classification system is used to classify OA of the knee?

A

Kellgren and Lawrence

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118
Q

Describe the Kellgren and Larwence system

A

Grade 0- no radiographic features of OA
Grade 1 - unclear joint space narrowing and possible osteophytic lipping
Grade 2 - definite osteophytes and possible joint space narrowing on AP weigh-bearing views
Grade 3 - Multiple osteophytes, definite joint space narrowing, evidence of sclerois and possible bony deformity
Grade 4 - large osteophytes, marked joint spaced narrowing, severe sclerois, definite bony deformity

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119
Q

Total knee replacement is the standard treatment for OA of the knee. How long do these tend to function for?

A

10 years

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120
Q

What is Patellofemoral Osteoarthritis?

A

Degeneration of articular cartilage along the trochlear groove and on the underside of the patella
Specifically worse with activty putting pressure on the patella such as

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121
Q

What is the role of the anterior cruciate ligament?

A

Stabiliser of the knee joint
Limits anterior translation of the tibia relative to the femur
Contributes to internal rotational stability

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122
Q

Typically, what kind of history will a patient with an ACL tear present with?

A

Twisting knee whilst wait bearing - often occuring in athletes
Unable to weight bear
Rapid joint swelling (very vascular so clinically apparent in 15-30 mins)
Significant pain
Joint instability if delayed presentation

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123
Q

What specific tests can identify potential ACL damage on examination?

A

Lachman Test

Anterior Draw Test

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124
Q

How do you conduct the Lachman’s test?

A
  1. Place knee in 30 deg of flexion, with one hand stablising the femur
  2. Pull the tibia forward to asses the amount of anterior movement of the tibia compared to the femur
  3. Compare to the contralateral knee
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125
Q

How do you perform the anterior draw test?

A
  1. Flex knee to 9o degrees
  2. Place thumbs on the joint line and index fingers on the hamstring tendons posteriorly
  3. Apply force anteriorly to demonstrate any tibial excurison
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126
Q

What is a positive Lachmans test?

A

Soft/mushy feel

Translation of tibia in affected leg is more than 3mm greater than that of the other leg

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127
Q

What is a positive anterior draw test?

A

Tibia has more movement/ligament is loose compared to contralateral side

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128
Q

What is the most specific test for ACL tear?

A

Lachman’s test

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129
Q

What differentials may you consider when suspecting a patient has an ACL tear?

A 
Proximal tibial fracture
Distal femur fracture
Meniscal tear
Collateral ligament tear
Quadriceps tendon tear
Patellar ligament tear
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130
Q

What imaging would you perform on a patient with a suspected ACL tear?

A
  1. Plain film radiograph of the knee - AP and lateral views
    Segond fracture is pathognomic of ACL injury (bony avulsion of the lateral proximal tibia)
    Will rule out any other bony injuries, joint effusion or lipohaemarthosis present
  2. MRI - gold standard for diagnosis, will also pick up any associated meniscal tears
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131
Q

Management of an ACL tear?

A

Rest, Ice, Compression, Elevation
Conservative - rehabilitation to strengthen quadriceps to stabilise the knee, COuld put a cricket pad knee splint for comfort if non-weight bearing.
Surgical - performed after prehabilitation period, surgical reconstruction involving use of a tendon or artificial graft OR in some cases an acute repair if MRI imagin favourable

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132
Q

Main complication of an ACL tear?

A

Post-traumatic osteoarthritis

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133
Q

What are the menisci of the knee?

A

C-shaped fibrocartillage found in the knee joint

134
Q

What is the function of the menisci of the knee?

A

Shock-absorber of the knee

Increase articulating surface area

135
Q

What does the medial meniscus of the knee attach to?

A

Medial collateral ligament

136
Q

Is the lateral meniscus attached to the lateral collateral ligament?

A

No

And it is more circular than the medial

137
Q

What are the two most common causes for meniscal tears?

A

Trauma-related injury

Degenerative disease

138
Q

What is the typical mechanism of a meniscal tear due to trauma>

A

Twisted knee, flexed while weight bearing

139
Q

What are the four types of meniscal tears of the knee?

A

Vertical
Longitudinal (Bucket-Handle)
Transverse (Parrot-Beak)
Degenerative

140
Q

What is the most common type of meniscal tear in the knee?

A

Longitudinal (Bucket-Handle)

141
Q

What history to patients with a meniscal tear present with?

A

Tearing sensation
Intense sudden-onset pain
Invariably slow swelling subsequently over a period of 6-12 hours

142
Q

If a meniscal tear which results in a free body within the knee, in which position will the knee be locked?

A

Flexion

Unable to extend

143
Q

How would a meniscal tear of the knee appear on examination?

A 
Tenderness 
Joint effusion
Limited knee flexion
McMurray's Test Positive 
Apley's Grind Test
144
Q

How do you perform McMurray’s Test and what makes it positive?

A

Hold knee and foot, flex knee whilst externally rotating, Then extend.
Positive in the presence of pain and/or click/snap/clunk/thud

145
Q

Differential Diagnosis for a meniscal tear?

A

Fracture
Cruciate ligament tear
Collateral ligament tear
Osteochondritis dissecans

146
Q

How do you investigate a meniscal tear?

A

Plain film radiograph of knee to exclude a fracture?

An MRI is gold standard investigation to confirm a meniscal tear and to indentify the type of tear.

147
Q

Management of a meniscal tear?

A

Rest, elevation, compression and ice for the acutely swollen knee
Larger tears (>1cm) arthroscopic surgery is indicated
- Outer third (very vascular) suture repair
- Inner third trimmed to reduce locking symptoms
- Middle could be either of the above

148
Q

Complications of knee arthoscopy

A

DVT

Damage to local structures such as the saphenous nerve and vein, peroneal nerve, popliteal vessels

149
Q

What does the extensor mechanism of the knee consist of?

A 
Quadriceps muscle group
Quadriceps tendon
Patella
Patellar retinaculum 
Patellar ligament 
Adjacent soft tissues
150
Q

What can cause injuries to the extensor mechanism?

A 
Chronic degenerative disease (weakening of the collagen)
Overuse injuries (weakening of the collagen)
Acute trauma (contraction against a flexed knee)
151
Q

Where does quadraceps tendon rupture occur?

A

Unilaterally

Site of insertion with the superior pole of the patella

152
Q

Risk factors for extensor mechanism injury?

A 
Increasing age (rare in under 40s)
CKD
DM
RA
Medications (corticosteroids, fluoroquinolones)
153
Q

How do patients with a quadriceps tendon rupture typically present?

A

Report hearing a pop
Tearing sensation followed immediately by pain in the anterior knee or thigh
Difficulty weight bearing
History of sudden and excessive loading of the quadriceps muscles (landing from a jump)

154
Q

How would a quadriceps tear appear on examination?

A

Localised swelling
Tender palpable defect above the superior pole of the patella
(Complete tear: inability to straight leg raise, and loss of the ability to extend the knee. These will be inhibited in a partial tear)

155
Q

Differentials for acute knee pain after intense loading on the quadriceps tendon muscle

A

Patella tendon rupture
Patella fracture
Femoral shaft fracture
Quadriceps tendon rupture

156
Q

How would you investigate a quadriceps tendon rupture?

A

Clinical diagnosis, especially in complete tears (absent SLR, loss of knee extension)
A plain film radiograph will show a caudally displaced patella, useful to r/o fracture
USS for definitive diagnosis and measuring the degree of rupture
MRI if still uncertain

157
Q

How do you manage a quadriceps tendon rupture?

A

Where extensor mechanism is still intact, immobilisation of knee in a brace and rehab
Otherwise, surgical intervention (longitudinal drill holes, suture anchors, end to end sutures) and then brace immobilisation and rehab at 6 weeks

158
Q

How may a patella fracture occur?

A

Direct trauma

Eccentric contraction of the quadriceps muscle

159
Q

How would the examination of a fractured patella present?

A

The pain will be made worse with movement and the patient will be unable to straight leg raise (due to damage to the extensor mechanism). They may not be able to weight bear.
Patellar defect palpable
Bruising and swelling

160
Q

How does the AO FOundation Classification classify patella fractures?

A

(1) extra-articular or avulsion fractures
(2) partial articular
(3) complete articuar

161
Q

Imaging for a patella fracture?

A

Plain film radiograph (skyline, anterior-posterior, lateral)

CT if comminuted fracture

162
Q

How do you manage a patella fracture?

A

Conservative management: non-displaced, minimally displaced, vertical fractures where extensor mechanism remains functional. Brace or cylinder cast.
Surgical otherwise, ORIF with tension band wiring is the most widely accepted method.

163
Q

How does patellar dislocation occur?

A

Lateral shift of the patella, leaving the trochlea groove of the femoral condyle.
Usually due to disruption of the medial patellofemoral ligament.
Usually a result of non-contact injury to the knee

164
Q

What patellofemoral disorders can predispose a patient to a patella dislocation?

A

Ligament laxity
Reduced osseous constraint form the the lateral femoral condyle
Imbalance between stronger lateral tissues which are able to overcome weaker medial structures

165
Q

What kind of stress may cause a patellar dislocation?

A

Valgus stress (strong lateral force)

166
Q

Clinical Presentation of a Patellar DIslocation?

A 
Hemarthorois of the knee (rupture of the medial restraints of the patella)
Medial swelling
Reduction when knee extended
Pain
Instability
Locking of the knee after trauma
167
Q

Imaging for a suspected dislocated patella?

A

X-rays; To exclude associated fractures (osteochondral, avulsion); subluxation will be seen on a lateral view
CT: To measure tuberosity tibia-trochlea groove distance
MRI: To differentiate degree of tear; to rule out osteochondral fractures
Indicated in young patients with primary dislocation

168
Q

How do you manage a patellar dislocation?

A

Conservative: immobilistaion for 6 weeks + analgesia
Surgery (if recurrent/chronic, patellofemoral symptoms, failed conservative management), arthoscopically +/- surgical repair od retinaculum or immediate patellar realignment

169
Q

What is trigger finger?

A

Finger or thumb locks in flexion, preventing a return to extension

170
Q

What usually preceeds trigger finger?

A 
Flexor tenosnovitis (from repeatative movement) leading to inflammmation of the tendon and sheath
Superfical and deep flexor tendons with local tenosynovitis at the metacarpal head subsequently develop localised nodal formation on the tendon, distal to the pulley
This node can pass move proximal to the pullex in flexion but can not pass back under during flexion
171
Q

What pulleys are involved in The Flexor Sheath and Pulley System?

A

Palmar aponeurosis
Annular ligaments
Cruciate ligaments

172
Q

Is trigger finger painful?

A

Patients usually report painless clicking/snapping/catching when trying to extend their finger
Can become painful over time, over the volar aspect of the metacarpophalangeal joint

173
Q

Differentials for trigger finger?

A

Dupuytrens contracture
INfection
Ganglion (involving tendon sheath)
Acromegaly (resulting in flexor synovium swelling)

174
Q

How do you diagnose trigger finger?

A

Clinical diagnosis

Bloods if suspicious of another cause

175
Q

How can trigger finger be managed?

A

Conservative if mild: exercises, splint to maintain extension at night ( keeps roughened end of the tendon in the tunnnel, making it smoother). Steroid injections.
Surgical: Usually a percutaneous trigger finger release with a needle under local can be used. If sever may warrent surgical decompression

176
Q

In carpal tunnel syndrome, which nerve is compressed due to raised pressure within the carpal tunnel?

A

Median nerve

177
Q

What are the risk factors for carpal tunnel syndrome?

A 
Female
Increasing age
Pregnancy
Obesity 
DM
RA
Hypothyroidism 
Occupations using repeatitive hand movements (vibrating tools)
178
Q

What are the clinical features of carpal tunnel syndrome?

A

Pain, numbness, paraesthesia throughout the median nerve sensory distribution
Palm sparing (palmar cutaneous branch of the median nerve branches proximal to the flexor teinaculum and passing ove the carpal tunnel)
Symptoms are worse at night
Weakness of thumb abduction (later finding)
Wasting of the thenar eminence (later finding)

179
Q

Which tests can be used on examination to help diagnose carpal tunnel syndrome?

A

Tinels Test

Phalen’s Test

180
Q

What is Tinel’s Test?

A

Percussion over the median nerve can reproduce sensory symptoms of carpal tunnel

181
Q

What is Phalen’s test?

A

Sensory symptoms of carpal tunnel reproduced by holding wrist in flexion for a full minute.

182
Q

Differential Diagnosis for Carpal Tunnel syndrome?

A

Cervical radiculopathy, C6 - will be an element of neck pain or symptoms involving the entire arm
Pronator teres syndrome: Palm not spared, symptoms will extend to proximal forearm
Flexor Carpi Radialis tenosynovitis: Can be distinguished by tenderness at the base of the thumb

183
Q

How might carpal tunnel syndrome be managed?

A
  1. Conservative: hand therapy, wrist splint at night to prevent flexion
  2. Surgical: carpal tunnel release surgery, involving cutting through the flexor retinaculum to reduce pressure on the median nerve
184
Q

What can long term untreated CTS lead to?

A

Permanent neurological impairment

185
Q

What is a Colles’ Fracture

A

Most common wrist fracture
Extra-articular fracture of the distal radius
Dorsal angulation and dorsal displacement within 2cm of the articular surface
FOOSH - wrist forced into supination
Avulsion fracture of the ulnar styloid

Colles’ fracture - Dorsally Displaced Distal radius → Dinner fork Deformity

186
Q

What is a Smith’s fracture?

A

Volar angulation of the distal fragment of an extra-artiuclar fractue of the distal radius +/- volar displacement
Forced pronation type injury (falling backwards)

187
Q

Which wrist fracture is an intra-articular fracture of the distal radius?

A

Barton’s fracture

Associated dislocation of radio-carpal joint

188
Q

What are the main risk factors for osteoporosis?

A 
Increasing age
Female gender
Early menopause
Smoking or alcohol excess
Prolonged steroid use
189
Q

How should you assess a fracture for neruovascular compromise?

A
  1. Check nerve function
  2. Check limb perfusion (cap refil + pulses)
  3. Remember to examine joints above and below for occult injuries
190
Q

How would you check the motor function of the median nerve?

A

Abduction of the thumb

191
Q

How would you check the motor function of the ulnar nerve?

A

Adduction of the thumb

192
Q

How would you check the motor function of the radial nerve?

A

Extension of the IPJ of the thumb

193
Q

How would you check the sensory function of the median nerve?

A

Radial surface of distal 2nd digit

194
Q

How would you check the sensory function of the ulnar nerve?

A

Ulnar surface of 5th digit

195
Q

How would you check the sensory function of the radial nerve?

A

Dorsal surface of 1st webspace

196
Q

How would you check the motor function of the anterior interosseous nerve?

A

Make and OK sign (opposition of thumb and index finger)

197
Q

Which three measurements on a plain radiograph would help diagnose a distal radial fracture?

A

Radial height <11cm
Radial inclincation <22 degrees
Radial volar tilt > 11 degrees

198
Q

When reducing a distal radius fracture, ensuring sufficient traction and manipulation, which blocks may be used?

A

Haematoma block

Bier’s block

199
Q

What should happen after an open reduction of a distal radial fracture?

A

Below-elbow backslab cast

Radiograph after 1 week to check for displacement

200
Q

When might a distal radial fracture require surgery and what options are there?

A

Significant displacement
UNstable
Intra-articular step of radiocarpal joint >2mm

ORIF with plating or K wire fixation

201
Q

Main complications of any fracture?

A 
Neurovascular compromise (ie. median nerve compression in a wrist fracture)
Malunion
OA
202
Q

Which structure is contracted in Dupuytren’s contracture?

A

Longitudinal palmar fascia

203
Q

Which digits are usually affected by Dupuytren’s contracture?

A

Ulnar digits (ring finger and little finger)

204
Q

Where to fiborous cords and flexion contractures develop as painless nodules in Dupuytren’s contracture?

A

MCP and interphalangeal joints

205
Q

What demographic typically present with Dupuytren’s contracture?

A

Men

40-60 years

206
Q

What is the basic pathophysiology of Dupuytren’s contracture?

A

Fibroplastic hyperplasisa
Altered collagen matrix of palmar fascia
Compositional changes lead to the thickening and contraction of the palmar fascia

207
Q

Risk factors for Dupuytren’s contracture?

A

SMoking
Alcoholic liver cirrhosis
DM
Occupational exposures (heavy manual work, vibrating tools)

208
Q

Clinical features of Dupuytren’s contracture?

A

Reduced ROM
Nodular deformity
May be complete loss of movement
Bilateral in half of patients

209
Q

How with Dupuytren’s contracture appear on examination?

A

Thickened band
Palpable firm nodule adherent to the skin
Skin blanching on active extension of the affected digits
MCP PIP joints in affected digit contracted in advanced disease
Positive Huestons test

210
Q

What is Hueston’s test?

A

Ask patient to lay their palm flat on a tabletop
Positive if they cannot
Specific for Dupuytren’s contracture

211
Q

What differentials should be considered in suspected Dupuytren’s contracture?

A

Stenosing tenosynovittis
Ulnar nerve palsy
Trigger finger (nodule present associated with finger motion)

212
Q

Conservative management of Dupuytren’s contracture?

A

Suitable at early presentation without functional disability or rapid progression
Hang therapy, stretching exercises
Injecyable collagenase clostridum histolyticum (CCM), guided sometimes by USS

213
Q

Surgical management of Dupuytren’s contracture?

A 
Progressive disease, functional disability, MCP joint contracture >30 degrees, PIP contracture
Excision of diseased fascia:
-Regional fasciectomy
-Segmental fasciectomy 
-Dermofasciectomy
214
Q

Post surgical prognosis for Dupuytren’s contracture?

A

Excellent functional outcomes

But recurrence up to 66 percent

215
Q

What is the most common cause of cauda equina?

A

Lumbar disc herniation

216
Q

How will osteomyelitis present on an x-ray?

A

Regional osteopenia
Focal cortical loss
Periosteal changes

217
Q

What are the criteria that must be fufilled in order for patients to recieve a total hip replacement over a hemiarthoplasty?

A
  1. Able to mobilise independently with no more than a walking stick
  2. Are not cognitatively impaired
    3, Are medically fit for anaesthesia and the procedure
218
Q

What T score on DEXA scan confirms the diagnosis of osteoperosis?

A

Less than -2.5

219
Q

Use of which antibiotics are a known risk factor for developing Achilles tendon rupture?

A

Fluoroquinolones such as ciprofloxacin

220
Q

How does pagets disease present on blood tests?

A

Normal electrolytes

Markedly raised ALP

221
Q

What may be seen on X Ray in Pagets disease?

A

Mixed osteolytic, osteoblastic and sclerotic appearance

222
Q

Which ATT can cause gout?

A

Pyrazinamide and ethambutol

Due to reduced renal urate excretion

223
Q

What is a boxers fracture?

A

Fracture of the hand caused by a direct blow to the hand or high energy
Fifth metacarpal fracture (usually)

224
Q

Patterns of radial never injury

A

Very high lesions - impingement: wrist drop and triceps weakness
High lesions - humeral shaft fracture: reduced sensation in the anatomical snuffbox but no triceps weakness
Low lesions - fracture of foreham (e.g. radial head): finger drop and no sensory loss

225
Q

How are scaphoid fractures managed?

A

Not always detected by initial radiographs, especially if undisplaced
If clinical suspicion, patient hsould have wrist immobilised in a thumb splint and repeat plain radiograph in 10-14 days for further evaluation

226
Q

Why is propanolol useful in portal HTN as prophylaxis against variceal bleeds and therefore the long term intervention of choice?

A

Non-selective beta blockers reduce portal blood pressure

227
Q

How would you test for axillary nerve damage?

A

Test sensation over the lower half of the right deltoid muscle

228
Q

How does axillary nerve damage most commonly occur?

A

Shoulder injuries such as dislocation or fracture of the surgical neck of the humerus
The terminal branch of this nerve supplies the upper lateral cutaneous nerve of the arm which innervated the skin over the inferioir portion of the deltoid (regimental badge area)

229
Q

Frozen shoulder features

A

Absense of symptoms outside of the shoulder region is consistent with frozen shoulder
Pain at night
Pain on both passive and active movement

230
Q

Features of impingement syndrome?

A

Pain on shoulder abduction
Which is worse at night
Painful arc between 70-120 degrees of abduction

231
Q

How does patellar tendinitis present?

A

Anterior knee pain at inferior pole of the patella
Chronic course
Often occurs in people who run of perform repetative jumping movements (also known as jumpers knee) - pressure on extensor mechanisms and consequently the patella tendon
Pain initially only present on exercise but progresses to all the time, exacerbated by exercise
Negative hence the cruciate ligaments are intact

232
Q

What will worsen pain in lateral epicondylitis?

A

pain worse on wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended

233
Q

An allergy to which drug would contraindicate use of sulfasalazine?

A

Aspirin

234
Q

What other common rheumatology drug does azathiprine have a severe interaction with?

A

Azathioprine and allopurinol have a severe interaction causing bone marrow suppression

235
Q

What is osteosarcoma?

A

Osteosarcoma - malignant tumour that occurs most frequently in the metaphyseal region of long bones prior to epiphyseal closure

236
Q

What type of soft tissue injury is most commonly associated with fracture of the medial part of the tibial plateau?

A

ACL

237
Q

What type of fractures are inter and sub-trochanteric fractures of the femoral neck classed as?

A

Extracapsuler

238
Q

What is the supraspinatous muscle responsible for?

A

first 15 degrees of abduction

239
Q

What nerve innervates the supraspinatous muscle?

A

Suprascapular nerve

240
Q

How is the common peroneal nerve commonly damaged?

A

Fibula fracture

Use of tight plaster cast

241
Q

Where does the sensory function of the common peroneal nerve cover?

A

ANterolateral aspect of leg and dorsum of the foot

242
Q

Boarders of the femoral triangle?

A

SAIL
S – Sartorius – lateral border
A – Adductor longus – medial border
IL – Inguinal Ligament – superior border

243
Q

Contents of the femoral triangle from lateral to medial across the top of the thigh?

A 
N – Femoral Nerve
A – Femoral Artery
V – Femoral Vein
Y – Y-fronts
C – Femoral Canal (containing lymphatic vessels and nodes)
244
Q

Risk factors for malunion and nonunion?

A

Smoking
Cardiac disease
Diabetes
Infection

245
Q

What kind of nerve damage causes a winged scapula?

A

Long thoracic nerve

246
Q

What injury is acute rotator cuff tear associated with?

A

Shoulder dislocation

247
Q

Which muscle is responsible for shoulder abducation beyond 15 degrees?

A

Deltoid muscle

248
Q

Which muscles might be torn during a shoulder dislocation?

A

Supraspinatous
Infraspinatous
Teres minor

249
Q

What does the infraspintus muscle do?

A

Laterally rotates the arm at the shoulder (glenohumeral) joint

250
Q

Which nerve innervates the infraspinatous?

A

The suprascapular nerve is a nerve, same as supraspinatus

251
Q

Which nerve innervates the deltoid muscle?

A

Axillary nerve

252
Q

What does the deltoid muscle do?

A

Stabalises the glenohumeral joint
Anteior head: f;exes and internally rotates arm
Middle head: abducts arm
Posterior head: Extends and laterally rotates arm

253
Q

Which imaging is best to visualize the rotator cuff?

A

MRI (mostly formed of ligaments and muscles)

254
Q

Action of teres minor?

A

Laterally rotate arm

Helps to hold humeral head in glenoid cavity of scapula

255
Q

What is the nerve supplying teres minor?

A

Axilary nerve (C5, C6) - same as deltoid

256
Q

What muscles make up the rotator cuff?

A

Supraspinatous
Infraspinatus
Teres minor
Subscapularis

257
Q

What does the lateral cutaneous nerve supply?

A

The lateral cutaneous nerve supplies sensation to the anterior and lateral aspect of the thigh.

258
Q

Entrapment of the lateral cutaenous nerve is commonly due to intra and extra pelvic causes, what presenting complaint will it cause?

A

burning pain of anterior thigh which worsens on walking.

There is a positive tinel sign over the inguinal ligament.

259
Q

Symptoms of illeoingual nerve compression?

A

Pain over the inguinal ligament which radiates to the lower abdomen.
There is tenderness when the inguinal canal is compressed.

260
Q

How might a femoral nerve injury present?

A

On examination pt has weak hip flexion, weak knee extension, and impaired quadriceps tendon reflex, as well as sensory deficit in the anteromedial aspect of the thigh.

261
Q

Where does the femoral nerve supply sensation to?

A

the anteromedial aspect of the thigh

262
Q

What nerve is at risk during a total hip replacement?

A

Sciatic nerve is at risk during a total hip replacement

263
Q

Being unable to dosiflex or plantar flex the foot suggest damage to which nerve?

A

Sciatic nerve

264
Q

What is Lamber Eatonsyndrome

A

Lambert Eaton syndrome involves weakness in the muscles of the proximal arms and legs, and one of the ways it can be differentiated from myasthenia gravis is that the legs are normally worse affected

autoimmune response to sclc

265
Q

Lumbar spinal stenosis may mimic IC, how can it be differentiated?

A

Lumbar spinal stenosis is a condition in which the central canal is narrowed by tumour, disk prolapse or other similar degenerative changes.

Patients may present with a combination of back pain, neuropathic pain and symptoms mimicking claudication. One of the main features that may help to differentiate it from true claudication in the history is the positional element to the pain. Sitting is better than standing and patients may find it easier to walk uphill rather than downhill. The neurogenic claudication type history makes lumbar spinal stenosis a likely underlying diagnosis, the absence of such symptoms makes it far less likely.

266
Q

What common analgesia might delay bone healing?

A

Use of NSAIDS will slow bone healing

267
Q

What is tennis elbow and where is the pain?

A

Tennis Elbow = LaTeral Epicondyle = wrist exTension

268
Q

What suggests a femoral shaft fracture as opposed to a hip fracture?

A

In femoral shaft fractures, the area over the fracture site (the thigh) is often visibly deformed. Additionally, you would expect the pain to be located primarily at this site rather than in the hip.

269
Q

How will x ray appear in frozen shoulder

A

Normal

270
Q

What causes wrist drop on pronating the wrist

A

Radial never damage often secondary to mid shaft fracture of humerus

an inability to extend his right wrist and fingers and when he pronates his right arm his wrist drops

271
Q

What is spinal stenosis and where does it most commonly affect?

A

Narrowing of spinal canal which results in compression of the spinal cord or nerve roots
Usually affects the lumbar or cervical spine

272
Q

What are the three types of spinal stenosis?

A

Central stenosis - narrowing of central spinal cord
Lateral stenosis - narrowing of the nerve root canals
Foramina stenosis - narrowing of the intravertabral foramina

273
Q

Causes of spinal stenosis?

A

Congenital
Degenrative - facet joint changes, disc disease, bone spurs
Herniated discs
Thickening of the ligamenta flava or posterior longitudinal ligament
Spinal fracture
Spondylothesis
Tumours

274
Q

What is spondylolisthesis

A

Anterior displacement of a vertebra out of line with the one below
Can cause spinal stenosis

275
Q

How might spinal stenosis present?

A

Gradual onset
Severity varies as per degree of narrowing
Lower back pain, Buttock leg pain, leg weakness - central lumbar - worse with standing straight better with bending
Sciatica - lateral stenosis and foramina stenosis
Radiculopathy

Severe compression - cauda equina syndrome

276
Q

What is radiculopathy?

A

Compression of the nerve roots as they exit the spinal collum leading to motor and sensory symptoms

277
Q

Investigating spinal stenosis?

A

MRI primary imaging investigation

Exclude PAD - ABPI Ct angio may be appropriate in central lumbar stenosis as mimics IC - pseudoclaudication

278
Q

Management options in spinal stenosis?

A

Exercise and weight loss if appropriate
Analgesia
Physiotherapy
Decompression surgery where conservative treatment fails (with variable results)

279
Q

What is laminectomy?

A

Removal of part of or all of the lamina (bony part forming the posterior part of vertebral foramen, attaching to spinous process) from the affect vertebra

Can be used in management of spinal stenosis

280
Q

What is lumbago?

A

Lower back pain

Usually non-specific/mechanical

281
Q

How long does it take for acute lower back pain to improve?

A

1-2 weeks

282
Q

How long does it take for sciatica to recover?

A

4-6 weeks

283
Q

What is sciatica and the sciatic nerve?

A

Symptoms associated with irritation of the sciatic nerve, formed by L4-S3

It exits the posterior part of the pelvis through the great sciatic foramen, in the buttock area on either side and travels down the back of the leg.

At the knee it divides into the tibial nerve and common peroneal nerve

Supplies sensation to the lateral lower leg and the foot

Supplies motor function to the posterior thigh, lower leg and foot

284
Q

Symptoms of sciatica?

A 
Unilateral pain from the buttock radiating down the back of the thigh to below the knee or feet
'Electric' 'shooting' pain
Paraesthesia
Numbeness
Motor weakness
Reflexs may be affected
285
Q

When is sciatica a red flag symptom?

A

Bilateral - cauda equina

286
Q

Main causes of sciatica?

A

Lumbosacral nevre root compression:
Herniated disc
Spondylolithesis
Spinal stenosis

287
Q

Challenges with lower back pain?

A

Identifying serious pathology
Speeding up recovery
Reducing risk of chronic lower back pain
Managing symptoms

288
Q

Causes of mechanical back pain?

A 
Muscle or ligament sprain
Facet joint dysfunction
Sacroilliac joint dysfunction
Herniated disc
Spondylosithesis
Scoliosis
Arthritis affecting discs and facet joints
289
Q

Causes of neck pain?

A

Muscle or ligament strain
Torticollis (waking up with unilaterally stiff and painful neck due to muscle spasam)
Whiplash (RTA)
Cervical spondylitis (degenrative changes to the vertebrae)

290
Q

Red flag causes of back pain?

A

Spinal fracture
Cauda equina
Spinal stenosis (itermittent neurogenic claudication)
Ankylosing spondylitis (under 40, gradual onset, morning stiffness, nighttime pain)
Spinal infection (fever of hx of IVDU)

291
Q

What are some non MSK causes of back pain?

A 
Pneumonia
Ruptured AAA
Kidney stones
Pyelonephritis
Pancreatitits
Prostaitis 
PID
Endometirosis
292
Q

Key aspects of back pain hx?

A

Major trauma (spinal fracture)
Stiffness in the morning or with rest (ankylosing spondylitis)
Age under 40 (ankylosing spondylitis)
Gradual onset of progressive pain (ankylosing spondylitis or cancer)
Night pain (ankylosing spondylitis or cancer)
Age over 50 (cancer)
Weight loss (cancer)
Bilateral neurological motor or sensory symptoms (cauda equina)
Saddle anaesthesia (cauda equina)
Urinary retention or incontinence (cauda equina)
Faecal incontinence (cauda equina)
History of cancer with potential metastasis (cauda equina or spinal metastases)
Fever (spinal infection)
IV drug use (spinal infection)

293
Q

Key examination findings on spinal examination?

A

Localised tenderness (fracture, cancer)
Bilateral neurological motor or sensory signs (cauda equina)
Bladder distension (urinary retention - cauda equina)
Reduced anal tone on PR examination (cauda equina)

294
Q

What cancers commonly metastisise to the spine?

A

PoRTaBLe

Po – Prostate
R – Renal 
Ta – Thyroid
B – Breast
Le – Lung
295
Q

Investigation of chronic back pain?

A

Clinical diagnosis: mechanical/non-specific back pain
X-ray CT for fracture
Emergency MRI if ?cauada equina
AS: CRP and ESR, X ray spinal and sacrum (bamboo spine- fusion - late disease), MRI (bone marrow odema in early disease)

296
Q

What tool can be used to stratify the risk of a patient with acute back pain?

A

STarT Back tool
Low risk: total score 3 or less subscore 3 or less
Med risk: Total score over 3 subscore 3 or less
High risk: Total score over 3 subscore over 3

297
Q

Management of acute lower back pain secondary to a serious underlying condition?

A

Same-day ref to on-call orthopedic team for urgent MRI in ?cauda equina
Inflammatory markers and urgent rhuematology review if ?AS
Full in-line spinal immobilisation, admission to a trauma unti and x-rays/CT scans for spinal injury after major trauma

298
Q

How would you manage patients presenting with acute lower back pain (with serious underlying causes ruled out) with low risk of chronic back pain?

A 
Self management
Education
Reassurance
Anlagesia
Staying active and continuing to mobolise as tolerated
299
Q

How would you manage patients presenting with acute lower back pain (with serious underlying causes ruled out) with moderate-high risk of chronic back pain?

A 
Self management
Education
Reassurance
Anlagesia
Staying active and continuing to mobolise as tolerated
Physiotherapy
Group exercise CBT
300
Q

When might patients presenting with acute lower back pain require ref to orthopedics or neurosurgery?

A

Neurological signs or symptoms particullarly if progressive or severe

301
Q

Pain relief for chronic low back pain?

A
  1. NSAIDs (ibuprofen or naproxen)
  2. Codeine as an alternative
  3. Benzodiazepines (e.g. diazepam) for muscle spasam (up to 5 days max)

If pain originates in facet joints radiofrequency denervation may be an option (raidofrequency targets medial branch nerves that supply sensation to the facet joints associated with back pain under local)

DO NOT USE: TCAs, opioids gabapentin or pregabalin

302
Q

Management of sciatica

A
  1. NSAIDs (ibuprofen or naproxen)
  2. Codeine as an alternative
  3. Amitriptyline
  4. Duloxetine
Specialist managementL
Epidural corticosteroid injections
Local anaesthetic injections
Radiofrequency denervation
Spinal decompression

DO NOT USE: Benzodiazapines, oral corticosteroids, gabapentin or pregabalin

303
Q

What is osteomylitis and how does it occur?

A

Osteomyelitis refers to inflammation in a bone and bone marrow, usually caused by bacterial infection.

Haematogenous osteomyelitis refers to when a pathogen is carried through the blood and seeded in the bone. This is the most common mode of infection.
Alternatively, osteomyelitis can occur due to direct contamination of the bone, for example, at a fracture site or during an orthopaedic operation.

May be acute or chronic

304
Q

Most common causative organism for osteomyelitis?

A

Staphylococcus aureus

305
Q

Risk factors for osteomyelitis?

A

Open fractures
Orthopaedic operations, particularly with prosthetic joints
Diabetes, particularly with diabetic foot ulcers
Peripheral arterial disease
IV drug use
Immunosuppression

306
Q

How does osteomyelitis present?

A

Fever
Pain and tenderness
Erythema
Swelling

The presentation of osteomyelitis can be quite non-specific, with generalised symptoms of infection such as fever, lethargy, nausea and muscle aches.

307
Q

X rays cannot exclude osteomyelitis and are often normal, what changes might they show, usually in later disease?

A 
Periosteal reaction (changes to the surface of the bone)
Localised osteopenia (thinning of the bone)
Destruction of areas of the bone
308
Q

What are the best imaging investigation for establishing a diagnosis of osteomyelitis?

A

MRI scans

309
Q

How might you investigate osteomyelitis?

A

MRI scans are the best imaging investigation for establishing a diagnosis.

Blood tests will show raised inflammatory markers (e.g., WBC, CRP and ESR).

Blood cultures may be positive for the causative organism.

Bone cultures can be performed to establish the causative organism and the antibiotic sensitivities.

X-rays

310
Q

How is osteomyelitis treated?

A 
Surgical debridement of the infected bone and tissues
Antibiotic therapy (6 weeks acute, 3 months chronic)

Osteomyelitis associated with prosthetic joints (e.g., a hip replacement) may require complete revision surgery to replace the prosthesis.

311
Q

Antibiotic management of osteomyelitis?

A

Prolonged courses of antibiotics are required to treat osteomyelitis. The BNF page on osteomyelitis recommends for acute osteomyelitis:

6 weeks of flucloxacillin, possibly with rifampicin or fusidic acid added for the first 2 weeks

Alternatives to flucloxacillin are:

Clindamycin in penicillin allergy
Vancomycin or teicoplanin when treating MRSA

Chronic osteomyelitis usually requires 3 months or more of antibiotics.

312
Q

What is sarcoma and what are the different types?

A

Sarcomas are cancers originating in the muscles, bones or other types of connective tissue. There are many subtypes of sarcoma, which vary in their histology, location and degree of malignancy.

Types of bone sarcoma include:

Osteosarcoma – the most common form of bone cancer
Chondrosarcoma – cancer originating from the cartilage
Ewing sarcoma – a form of bone and soft tissue cancer most often affecting children and young adults

313
Q

Types of soft tissue sarcoma?

A

Rhabdomyosarcoma – originating from skeletal muscle
Leiomyosarcoma – originating from smooth muscle cancer
Liposarcoma – originating from adipose (fat) tissue
Synovial sarcoma – originating from soft tissues around the joints
Angiosarcoma – originating from the blood and lymph vessels
Kaposi’s sarcoma – cancer caused by human herpesvirus 8, most often seen in patients with end-stage HIV, causing typical red/purple raised skin lesions but also affecting other parts of the body

314
Q

How does sarcoma present?

A

A soft tissue lump, particularly if growing, painful or large
Bone swelling
Persistent bone pain

315
Q

How might you investigate sarcoma?

A

X-ray is the initial investigation for bony lumps or persistent pain.

Ultrasound is the initial investigation for soft tissue lumps.

CT or MRI scans may be used to visualise the lesion in more detail and look for metastatic spread (particularly a CT thorax, as sarcoma most often spreads to the lungs).

Biopsy is required to look at the histology of the cancer.

316
Q

What system is used to stage sarcoma?

A

TNM staging system or a number system

317
Q

How is sarcoma managed?

A

Surgery (surgical resection is the preferred treatment)
Radiotherapy
Chemotherapy
Palliative care

318
Q

Where does sarcoma most commonly metastise to?

A

Lung

319
Q

Degenerative disc disease is often related to ageing. What factors may precipitate it?

A

Progressive dehydration of the nucleus pulposus
Daily activities causing tears in the annulus fibrosis
Injuries or pathology resulting in instability
Including mechanical insults (such as spinal fractures), iatrogenic injuries (such as spinal surgery), or systemic metabolic processes (such as osteoporosis)

320
Q

Stages of changes in degenerative disc disease?

A
  1. Dysfunction – outer annular tears and separation of the endplate, cartilage destruction, and facet synovial reaction
  2. Instability – disc resorption and loss of disc space height, along with facet capsular laxity, can lead to subluxation and spondylolisthesis
  3. Restabilisation – degenerative changes lead to osteophyte formation and canal stenosis
321
Q

What is Lasègue test?

A

Lasègue test, also known as the straight leg raise, is used to assess for disc herniation in patients presenting with lumbago.

With the patient lying down on their back, the examiner lifts the patient’s leg while the knee is straight. The ankle can be dorsiflexed and / or the cervical spine flexed for further assessment.

A positive sign is when pain is elicited during the leg raising +/- ankle dorsiflexion or cervical spine flexion. Sensitivity and specificity have been reported at 91% and 26% respectively.

322
Q

What test can be used to support the diagnosis of OA over De Quervain’s tenosynovitis in a pt with a painful wrist?

A

The key differentiator is the grind test. This is performed by holding the 1st proximal phalanx and metacarpophalangeal joint in examiner’s hands and forcefully pushing against trapeziometacarpal joint, while also rotating it slightly, to cause grinding motion. A positive test is one that induces pain, suggestive of osteoarthritis of the trapeziometacarpal joint.

323
Q

Features of ulnar nerve injury?

A

Pt unable to fully extend or flex 4th and 5th fingers

Numbness in the hand which is particularly pronounced over the 4th and 5th fingers.

324
Q

When the radial nerve is injured in elbow fracture what features might be present?

A

Pt is unable to flex or extend the elbow.
Extension of the wrist and fingers in the arm is weak.
Sensory loss over the dorsum of the hand.

325
Q

Positive test in tennis elbow (epicondylitis)

A

Cozen’s test positive

326
Q

What X ray sign is pathognomonic for a posterior shoulder dislocation?

A

lightbulb sign on AP view.

327
Q

What type of shoulder dislocation is most common?

A

Anterior

328
Q

Female atheletic triad?

A

Amennorhea
Osteoperosis
Anorexia

329
Q

What is a Colles fracture?

A

This describes a fracture of the distal radius along the metaphysis with no articular involvement. They are the most common type of distal radius fractures.

330
Q

Lateral cutaneous nerve of thigh compression

A

Burning thigh pain - ? meralgia paraesthetica - lateral cutaneous nerve of thigh compression

Year 3 Surgery (6 decks)

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