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Plab Hla Myint Aung > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

Baker’s Cyst

A

Painless Popliteal Mass
Rupture cause pain and Mimic DVT
Secondary to Osteoarthritis or Rheumatoid arthritis

Dx is clinical and USG
Resolve itself
Can also be excised

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2
Q

Paget Disease Vs Osteoporosis Vs Osteomalasia

NCa2 NPo4 ↑ALP Vs All normal Vs ↓Ca2 ↓Po4 ↑ALP

A

Osteoporosis: NORMAL serum calcium, serum phosphate & serum ALP

Paget’s Disease: Normal serum calcium & serum phosphate HIGH serum ALP
Bone pain + isolated elevated ALP

Osteomalacia: LOW serum calcium & phosphate HIGH serum ALP

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3
Q

Paget Disease

A 
Normal Ca & PO4 but High ALP + 
Kyphosis + 
Heart Failure + 
Conductive Deafness + 
Hat size ↑ +

Associated with Osteosarcoma + Usually adults +
Due to ↑ osteoclast activity & defective bone modelling +

X ray : Blade of grass V shaped on long bones +
Cotton wool spots on Skull (Fluffy sclerotic patches) due to poor trabeculae +

Rx : Bisphosphonates (1st line)

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4
Q

Osteoarthritis - AGING BONE ARTICULAR CARTILAGE
(Old age ) Impaired homeostasis between bone resorption and formation
Walk - pain and most pain before sleeping
Rest - relief

A

OLD AGE -

EXACERBATED BY EXERCISE & RELIEVED BY REST (PAIN AT THE END OF DAY)

-SINGLE JOINT -OSTEOPHYTE -CREPITUS -

Heberden's nodes ( DISTAL interphalangeal joint )
BOUCHARD NODES (PROXIMAL interphalangeal joint ) - 
XRAY (LOSS) : 
1- L : LOSS OF JOINT SPACE (DEGENERATIVE) 
2- O : OSTEOPHYTE 
3- S: SUBCONDRAL CYST 4- 
S: SUBCONDRAL SCLEROSIS

TREATMENT :
Non pharmaco =EXRECISE and PHYSIO

Pharmaco = PARACETAMOL / NASIDs (Celecoxib ) + PPI
NSAID ( TOPICAL/ORAL)

SURGERY

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5
Q

Achilles tendon rupture (Simmon’s Triad LOOK FEEL SQUEESE )

A

H/O
burst of sudden activity, repetitive jumping, audible snap, someone kicked their heels

Dx >> 
Simmon's Triad : 
1. Dorsiflexed affected leg 
2. palpable gap on the heel 
3. calf muscle squeeze > No plantar flexion

*Mx : Refer to orthopedic ( x-ray to exclude calcaneal avulsion, US to confirm dx, MRI rarely needed) thrombo-prophylaxis could be given to prevent DVT

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6
Q

Sudden onset of Lower back pain During Bending Forward or similar movement
(Like Getting up form Bed )

A

Sciatica (Not a condition it is irritaiton of the sciatic nerve by herniated intervertebral disc)
Most common dt - Intervertebral disc herniation (L5/S1)
Aggregated by - Sitting / Standing / Leg raising
Relieved by - Lying down / Walking

Best Inx - MRI

Dx - Leg raising test / Pain within 30-70 degree

Best Treatment
Rest for 1 month
Physical therapy
Analgesics

Surgery if Progressive or Disabeling pain > 6 months

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7
Q

Gamekeeper’s thumb = Skier’s thumb (liagment injury )

UCL injury

A

gamekeeper’s thumb = skier’s thumb

  • ulnar collateral ligament injury
  • collateral laxity
  • thumb is hyperextended and laterally deviated

RX:
-incomplete injury/ tear = immobilisation 4-6 weeks

  • complete tear = surgery
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8
Q 
Tennis Elbow (Lateral epicondylitis )   Painter - pain upon resisted wrist extension and tenderness on Lat epi condyle
Golfers Elbow (Medial epicondylitis )
A

Lateral epicondyl - Wrist extension / while grasping with hand

Tennis elbow –>laTeral epicondylitis –> wrist exTensors

(muscle is in the forearm but function is wrist extension not forearm extension which is done by Triceps muscles)
Extensor Carpii Radialis brevis Muscle.
Insertion =lateral epicondyle of humerus
****Found in the forearm***
Function = Abduction and Extension of the wrist.*******

the opposite to this is :

GloFer’s elbow –> medial epicondylitis –> wrist Flexors add this

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9
Q

Distal Radial Fracture (Old lay fall into pavement with wrist Swollen )
C

A

Minimal Displacement - Closed Reduction / Immobilization / Plaster below elbow backslab )

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10
Q

Below elbow back slab uses

A

Supracondylar fracture
Distal Radial and Ulnar fracture
Colle’s fracture

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11
Q

Hip dislocation after Surgery and types

A

Hip dislocation-
Do X ray (MRI -Controversial)
After Hip SURGERY FOR **6 MONTHS*** avoid bending,
Don’t use LOW toilet / SHOE LACING

Anterior hip dislocation- FABER -
flex ion / abduction / external rotation

Posterior hip dislocation - FADIR -
flex ion / addiction / internal rotation

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12
Q

Time line for Hip Problems in CHILDHOOD

A

< 3 years

DDH = Girl /Painless / Breech deli / Unequal skin folds /
Septic arthritis = Fever / Unwell / Systemic / Acute pain
Toddlers fracture =

3-9
Transient synovitis if ACUTE = Mild Fever / After viral URTI / Well systemically / Pain on weight bearing but not at rest
Pertheus if CHRONIC = Boy / Slowly developing pain / Stiffness and ↓ROM

> 9
Slipped upper Femoral Epiphysis = Painful / Obease /

Other 
Juvenile idiopathic arthritis  = arthritis in <16 and last >3month 
Blanching RASH(salmon pink) /
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13
Q

Bone Tumours
Benign
Malignant

A

MALIGNANT

Osetosarcoma = Sunburst app in Growth plate/ Metaphysis / adolescent

Ewings Scrcoma = eWings Onion peeling of periosteum / adolescent 10-20 / Translocation 11/22 and Neuroectodermal cells + (blue cells with large nucleus)

Chondrosarcoma = ( Old age/ moth eating pelvis )

BENIGN

Osteochondroma (Growth plate tumor)
Extoses overgrowth from growth plate

Giant Cell Tumour ( Osteocytes tumor / eat up bones )
Soap bubble in Epiphysis (Hollow epiphysis )

(Osteoblast tumor )
Osteroid Osteoma(N<2.5)  / Diaphysis of tibia / No erosion 
Osteo Blastoma(N>2.5)  / produce prostaglandin= pain / Erosion of Mandible

Fast grow of new bone cells problem = Forming NIDUS (Trabeculae + blood vs + osteoid)

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14
Q

Child hood fracture (Falling with outstretched Hands )

Most common 1st fracture GREEN STICK FRACTUE

A

Most common =
If # distal to the bone - Torus / Buckle fracture
-Junction of Metaphysis and Diaphysis
The harder diaphysis pushed in softer metaphysis resulting in SLIGHT BULDGE (Transverse line and budging in X ray )

If # middle of the Diaphysis - Green stick fracture OR 4085
not a complete fracture
GreenStick : Child - No Deformity - No Swelling - Only Tenderness.

the common fractures in children depending on age:
➠toddler (1-3Y): Spiral Fc
:midtibial may not be seen on x-ray

➠child (4-10Y): 
-buckle (torus): most common at this age gp, 
radial metaphyseal 
-greenstick: 
mid-diaphyseal in forearm or leg
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15
Q

Acute Hot / Painful joint / SPETIC ARTHRITIS

A

Septic arthritis is a Orthopedic emergency
Pt with DM / RA patient taking Methotrexate

Always go for Aspiration of Joint fluid and culture
X- ray limited or no value

IV for 1 week
Fluoxacillin …
if pencillin allergic use Clindamycin

Give IV antibiotics for 1 week.
After cultures become negative and swelling resolved
switch to oral antibiotics for following 4 weeks

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16
Q

Osteoporosis is PAINLESS (DEXA scan <= -2.5)

Osteomalasia is Painful

A 
STEROID CAUSES: 
1- OSTEOPOROSIS 
2- PEPTIC ULCER 
3- INCREASE BLOOD SUGER 
4- CATARACT

OSTEOPOROSIS: SILENT TILL CAUSE FRACTure

OSTEOP. ALSO AFFECT DENTAL AND GUM HEALTH

17
Q

Dermatomes and Sciatic nerve compression

A

Most common compresion site

L4-L5 = L4 will be compressed / 4 = knee **********************
L5-S1 = L5 will be compressed / 5 = Dorsum of foot (except little toe / Planter foot  = S1)**************

Spinal fracture and Cauda equina syndrome= S1-5 / Loss of sensation around Anus
Bowel incontinences / Urinary retention / saddle paresthesia ******(Medical emergency )

Other dermatomes

Half back face - C2
Upper neck -C3
Lower and base of neck -C4
Biceps lateral half - C5
Forearm lateral half - C6
Thumb - C7
Index / Middle - C8 
Ring / Little and Medial half of Forearm and biceps - T1
chest - T2-T12
xiphoid - T7 
Umbilicus - T10
Pubic / groin - L1 
Ant thigh - L2,3
Knee - L4
Anter / Dorsum of shin and feet - L5 
Little finger / Plantar of feet / posterior foot / thigh up till gluteus - S1,2 
Around the Anus - S3,4,5
18
Q

Myotone or Jerks area

A

1,2 buckle my shoe— ankle (S1, S2)
3,4 kick the door——– knee (L3, L4)
5,6 pick up sticks ——– biceps (C5,C6)
7,8 lay them straight——— triceps (C7,C8)

19
Q

OR 1320 recheck

A
20
Q

Ca breast remission / bone metastasis without Neurological symptoms

A

INITIAL -inv: serum calcium Ca2+

DIAGNOSIS - Bone mets gold standard : MRI or BONE SCINTIGRAPHY

But, if multiple bones are involved (for eg. spine+shoulder), do BONE SCINTIGRAPHY as MRI whole body would be costly.

But, if neurological signs +, go for MRI first.
Usually, MRI done within 7 days if only bone pain present

but done within 24 hrs if Bone pain + neurological involvement is present.

21
Q

60 year old patient fall on side of the road # 2 days ago
BMI 22 non smoker all good
Would like to decrease his risk for fracture in the future

A

history of fracture&raquo_space; Dexa scan ,
DEXA scan should be requested for any patient > 50 years who has a FRAGILITY FRACTUE (low impact #)
If DEXA <= -2.5 (start Bisphosphonate )

no fracture history but history of family # &raquo_space; calculate FRAX score
If >10% next step DEXA scan

22
Q

Ultrasound in ORTHO

A

US in ortho: -

baker’s cyst - + Foutcher’s sign (tense when knee extension and softens on knee flexion )
DDH -
tenosynovitis

23
Q

Scaphoid fracture :

A

(fall outstretched hand)
tender snuff box,
pain thumb base,
**ulnar deviation or supination against resistence***

Mx: X-Ray is usually -ve (1st 2 wks)
(X ray positive is only 7%)(Scaphoid # is infamous for non union and -ve X ray )

so immobilization for 2 wks then repeat x-ray

if becomes +ve&raquo_space; then cast for another 4 wks .
Total period of immobilization is 6 wks

24
Q

To watch before answering Ortho
Knee anatomy
Elbow anatomy

A

https: //www.youtube.com/watch?v=_q-Jxj5sT0g
https: //www.youtube.com/watch?v=XeiApVseric

25
Q

Types of elbow fracture / Falling on elbow / Radial fracture / Child and Adult

A

Adults are the head of the family,
children are the necks …

Supracondylar fracture-
inability to move elbow & 3 bony points are maintained.

Radial head/neck fracture- flexion & extension are possible but pronation & supination (rotatory) movement cause sever pain.
3bony points are not maintained
PAIN AT THE RADIAL TUNNEL

Inter condylar fracture - Direct blow to the elbow
Condylar fracture - Direct blow to the flexed elbow
Olecranon fracture - Direct blow to the elbow (in children ) / Pulling of the triceps / brachioradialis

26
Q

Colles fracutre

Gar li ar zee and Mon tay gyar #

A

Dinner fork = (Fork look like upside down M ) = Medial nerve injury

COLLE’S # –> Median N damage (numbness in 3.5P)

Monteiggia # –> MUgGER , so MU, so Ulna involved , opposite of bone in this forumla is Nerve, opposite of Ulna -> is Radius, so Ulnar Bone + Radial Nerver

Similarly, Gallazia = GeR, so R means Radius Bone, opposite is Nerve so, Radial bone & Ulnar nerve

27
Q

Bone # with Heart failure and hearing loss

A

Pagets Disease:
increased bone resorption & abnormal osteoclast activity followed by rapid bone formation by osteoblast. S
o the new bones will be weaker, less compact, more vascular

( CCF ) & more liable to deformity and ptho. fractures

C/P :
1-BONE (pain, deforimity, path. fracture

2- DEAFNESS

3- HERAT FAILURE (high co)

X-RAY > . Blade of grass lesion (V shaped pattern between healthy & diseased bone ) . Cotton wool pattern in skull

Mx&raquo_space; Biphosphonates

NB»

  1. Risk of OSTEOSARCOMA
  2. Calcium level is normal ( may increased due to immobilization )
  3. HIGH ALP

Differentials

  • normal Ca, normal P, normal ALP > OSTEOPOROSIS
  • normal Ca, normal P. High ALP > Pgets dis. -Low Ca, Low P, High ALP > OSTEOMALACIA
28
Q

Kocher Criteria for Septic Arthritis

A

Distinguishes septic arthritis from transient synovitis in a child with an inflamed hip.

Non weight-bearing (Can be both)

Temp > 38.5°C / 101.3°F (septic)

ESR > 40mm/hr (septic)

WBC > 12,000 cells/mm3 (septic)

29
Q

Fracture and dislocation of the Femur
Ant dislocation Ext rotation abd
Post dislocation Int rotation add and Foot drop

A

●Fracture femur neck : Shortened and ExtRotation
●Ant. Hip dislocation : Shortened and ExtRotation and Abducted
●Posterior Hip dislocation: Shortened , Internal Rotation and Adducted

Regarding related injury :
●Fracture Neck and Posterior Hip dislocation: Sciatic Nerve (Foot drop )
●Anterior Hip dislocation: Femoral Nerve , Atery , Vein

30
Q

Humerus #

A

Humerus fx=>

upper->Auxillary nerve injury

shaft=> radial nerve injury

lower part(supracondylar)=> Brachial artery injury*****

31
Q

Padget’s vs Multiple Myeloma

A

Padget’s = Sclerotic Lesion (Thickening of bone / White patches on bone)
Multiple Myeloma = Lytic Lesion (Softening of bone / more translucent )

Isolated raised ALP
Physiological - Pregnancy / Growing child
Pathological - Padget / Liver disease

PADGET (Hat getting smaller) Old age / Axial Skeleton
1.Blade of grass apperance
2.Skull-Cotton wool appearance»
Multifocal SCLEROTIC PATCH 3.Mixture of sclerotic+lytic lesion and coarse TRABECULAR pattern

MULTIPLE MYELOMA:

  1. Punch out lytic lesion
  2. Skull-Papet pot appearance
32
Q

Falling on Feet from 8 feet OR 4520
Feet fractures
Most common Calcaneus

A

*Vertical fall > The CALCANEOUS is the most commonly fractured

*Stress Fracture > the METATARSALS are commonly involve
followed by Navicular & Calcaneous

NB: if calcaneal fracture is seen on foot xray,
you have to examine the pt for SPINAL Fracture as well

Calcaneal fracture aka lovers fracture
Because it is the type of fracture that could presumably be caused by a lover jumping out of the bedroom window
to escape from a surprised and enraged spouse

33
Q

Trigger finger - temporary dt inflammation dt overuse
(Inflamed liagment of the finger squeezing the tendon making it difficult to move / POP CLICKING SOUND giving away feeling )
Vs

Dupuytren contracture (Permanent flexed finger dt contracture of Liagment )

Vs Dequervain Vs Scaphoid fracture

A

Dupuytren’s contracture
loss of full extension of the affected finger or fingers at the MCP joint.
The loss of extension is fixed and chronic,
while in a Trigger Finger it is dynamic and episodic.

Unlike trigger finger, Dupuytren’s is painless and nodular lesions are typically evident in the palmar fascia.
The nodule typically progresses over a period of time to form a fibrous cord that extends from the palm to the digits, which also helps distinguish it from trigger finger

Alcoholic/DM/Liver disease/RA with a fixed flexed 4th/5th finger + nodules at base + strong FHx + due to fibrosis of palmar fascia = Duputren’s contracture

Pain in thumb/ring/little finger during motion + “POP” sound/”CLICKS” when trying to straighten out the flexed finger = Sclerosing tenosynovitis, aka TRIGGER FINGER

Pain near base of thumb + overuse/mild trauma history + pain during grasping + swelling + “STOP & GO” sensation/sticking sensation when moving the thumb + pain in thumb in a new mom (Mammy thumb - pain when lifting baby) = deQuervain tenosynovitis

Pain in root of thumb + tender anatomical snuffbox + h/o direct trauma + median nerve damage = Scaphoid #

34
Q

SUFE - Slipped Upper Femoral Epiphysis
Obese boy Eating Melting Ice cream
who has a Short left limb that Externally rotates When Flexed

A

SUFE An orthopedic emergency must be suspected

n a limping, obese boy aged 11-14 years, & girl 10-13,

complaining of knee pain. - Commonly in Boys and on left side

Clinical Features - SUFE 
S - Shortened affected limb 
U- unable to abduct 
F - Flexed hip will rotate externally 
E - external rotation of the hip

Investigation -
Xray Pelvis - “Melting ice cream cone” appearance
head of the femur in relation to the shaft

Management - Avoid walking and rotating the leg -
Surgical realignment of the bone ASAP -

35
Q

Thumb Related Injuries :

A

●Dequervan: (Mother holding her child)
Mode of injury: tendinitis of dorsal wrist compartment tendons (APL,EPB)
CP: Pain during thumb motion +Pain and swelling at base of thumb

●Gamekeeper thumb (killing birds with thumb)
Mode of injury: forced Abduction of 1st MCP (ulnar collateral ligament avulsion)
CP: lax thumb+hyperextended+laterally deviated+weak pincer grip

●Scaphoid # (No X ray findings but cast and repeat x ray 2 week )
Mode of injury: Fall on outstretched hand+forced dorsiflexion
CP: tender anatomical box or at scaphoid tub
And pain on axial compression of thumb/pronation with ulnar deviation/s or Supination against resistance

36
Q

Rta 28 year old / Tremendous pain / Obvious deformity / No dorsalis pedis pulse
what to do? X ray ? or ..

A

ANY FRACTURE WITH EITHER ( OBVIOUS DEFORMITY OR NEUROVASCULAR COMPROMISE)&raquo_space;

IMMEDIATE REDUCTION EVEN VEFORE X-RAY

IF: BLOOD FLOW NOT RETURNED&raquo_space; VASCULAR / ORTHOPAEDIC SUREN - STERILE DRESSING USED FOR OPEN FRACTURES

37
Q

Colles fracture

A

Surgical reduction or Open reduction if
Intra articular fracture = Fracture going into the wrist joint

Closed reduction
Extra articular fracture (normal fracture ) = # of the bone but intact joint area

38
Q

Sprain injury

Worker injured his hand into a machine
Sprained the feet while walking with high heels
cant flex or extend

A 
Sprain Injury (overstetch of ligaments) -
 swelling, pain & limited movement range (after TRAUMA) 
Rx: PRICE 
Protect, 
Rest, 
Ice, 
Compression, 
Elevation **************(HIGH ARM SLING)**************
39
Q

Pain when Lifting Arm Above the Shoulder

Moving house
Basketball / Volley ball / Batminton / Tennis / swimming

A

Supraspinatius Tendinitis (repetitive overhead action )

SHOULDER IMPINGEMENT SYNDROME
or PAINFUL ARC SYNDROME

Pain when abducting shoulder –> arc of 60 to 120 degrees

NSAIDs+ Rest + Physiotherapy (main) Surgery in extreme cases

Plab Hla Myint Aung (29 decks)

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