Orthopaedics Flashcards
Baker’s Cyst
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
Paget Disease Vs Osteoporosis Vs Osteomalasia
NCa2 NPo4 ↑ALP Vs All normal Vs ↓Ca2 ↓Po4 ↑ALP
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
Paget Disease
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)
Osteoarthritis - AGING BONE ARTICULAR CARTILAGE
(Old age ) Impaired homeostasis between bone resorption and formation
Walk - pain and most pain before sleeping
Rest - relief
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
Achilles tendon rupture (Simmon’s Triad LOOK FEEL SQUEESE )
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
Sudden onset of Lower back pain During Bending Forward or similar movement
(Like Getting up form Bed )
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
Gamekeeper’s thumb = Skier’s thumb (liagment injury )
UCL injury
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
Tennis Elbow (Lateral epicondylitis ) Painter - pain upon resisted wrist extension and tenderness on Lat epi condyle Golfers Elbow (Medial epicondylitis )
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
Distal Radial Fracture (Old lay fall into pavement with wrist Swollen )
C
Minimal Displacement - Closed Reduction / Immobilization / Plaster below elbow backslab )
Below elbow back slab uses
Supracondylar fracture
Distal Radial and Ulnar fracture
Colle’s fracture
Hip dislocation after Surgery and types
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
Time line for Hip Problems in CHILDHOOD
< 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) /
Bone Tumours
Benign
Malignant
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)
Child hood fracture (Falling with outstretched Hands )
Most common 1st fracture GREEN STICK FRACTUE
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
Acute Hot / Painful joint / SPETIC ARTHRITIS
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
Osteoporosis is PAINLESS (DEXA scan <= -2.5)
Osteomalasia is Painful
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
Dermatomes and Sciatic nerve compression
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
Myotone or Jerks area
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)
OR 1320 recheck
Ca breast remission / bone metastasis without Neurological symptoms
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.
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
history of fracture»_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 # »_space; calculate FRAX score
If >10% next step DEXA scan
Ultrasound in ORTHO
US in ortho: -
baker’s cyst - + Foutcher’s sign (tense when knee extension and softens on knee flexion )
DDH -
tenosynovitis
Scaphoid fracture :
(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»_space; then cast for another 4 wks .
Total period of immobilization is 6 wks
To watch before answering Ortho
Knee anatomy
Elbow anatomy
https: //www.youtube.com/watch?v=_q-Jxj5sT0g
https: //www.youtube.com/watch?v=XeiApVseric
Types of elbow fracture / Falling on elbow / Radial fracture / Child and Adult
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
Colles fracutre
Gar li ar zee and Mon tay gyar #
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
Bone # with Heart failure and hearing loss
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»_space; Biphosphonates
NB»
- Risk of OSTEOSARCOMA
- Calcium level is normal ( may increased due to immobilization )
- 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
Kocher Criteria for Septic Arthritis
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)
Fracture and dislocation of the Femur
Ant dislocation Ext rotation abd
Post dislocation Int rotation add and Foot drop
●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
Humerus #
Humerus fx=>
upper->Auxillary nerve injury
shaft=> radial nerve injury
lower part(supracondylar)=> Brachial artery injury*****
Padget’s vs Multiple Myeloma
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:
- Punch out lytic lesion
- Skull-Papet pot appearance
Falling on Feet from 8 feet OR 4520
Feet fractures
Most common Calcaneus
*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
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
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 #
SUFE - Slipped Upper Femoral Epiphysis
Obese boy Eating Melting Ice cream
who has a Short left limb that Externally rotates When Flexed
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 -
Thumb Related Injuries :
●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
Rta 28 year old / Tremendous pain / Obvious deformity / No dorsalis pedis pulse
what to do? X ray ? or ..
ANY FRACTURE WITH EITHER ( OBVIOUS DEFORMITY OR NEUROVASCULAR COMPROMISE)»_space;
IMMEDIATE REDUCTION EVEN VEFORE X-RAY
IF: BLOOD FLOW NOT RETURNED»_space; VASCULAR / ORTHOPAEDIC SUREN - STERILE DRESSING USED FOR OPEN FRACTURES
Colles fracture
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
Sprain injury
Worker injured his hand into a machine
Sprained the feet while walking with high heels
cant flex or extend
Sprain Injury (overstetch of ligaments) - swelling, pain & limited movement range (after TRAUMA)
Rx: PRICE Protect, Rest, Ice, Compression, Elevation **************(HIGH ARM SLING)**************
Pain when Lifting Arm Above the Shoulder
Moving house
Basketball / Volley ball / Batminton / Tennis / swimming
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
