Orthopaedics Flashcards
What is the difference between osteoporosis and osteomalacia in terms of…
Pathology
Blood results
Bone density
Osteoporosis // osteomalacia
Fragile bones due to reduced density // Soft bones due to abnormal mineralisation
Normal bone profile and vitamin D // Abnormal bone profile and low vitamin D
Reduced bone density // Normal bone density
How do you decide who gets a DEXA scan in osteoporosis?
Offer FRAX/Q-fracture to those…
All over 75
Those >50 who…
- Personal falls or fragility fracture history
- Malabsorption (inc HPT) or steroids
- Skinny, drinkers (>4U)
What is diagnostic of osteoporosis?
DEXA T-score of -2.5 or below
What is the medical management of osteoporosis
Ensure adequate Ca2+ and vitamin D then…
1st: Alendronate OR Risendronate/etidronate if alendronate not suitable
If not tolerated: strontium ranelate/raloxifene pending T score
+ Denosumab if further needed
+ HRT if post-menopausal with vasomotor symptoms
What is the action of…
bisphosphonates
Strontium ranelate
raloxifene
Desonumab
Block osteoclastic breakdown
Increase osteoblastic activity + inhibit osteoclastic breakdown
Modulates oestrogen receptors to reduce vertebral fracture risk
RANKL inhibitor that prevents osteoclastic maturation
What lifestyle acivities reduce osteoporosis risk?
Stop smoking and diabetes
Weight bearing excercise
Hip protectors in nursing homes
What are the side effects of bisphosphonates
Osteonecrosis of the jaw and ear canal
Reflux –> Prescribe a PPI
Atypical femoral fractures
Leg twisted outwards and shortened indicates what?
How do you investigate this?
Hip fracture
AP and lateral hip XR +/- MRI to confirm
Whaat is seen in this X-ray?
Normal hip XR
What is the significance of intracapsular vs extracapsular fractures?
Intracapsular more likely to lose blood supply resulting in AVN
What does this XR show?
Intraacapsular (subcapital)
Shenton’s line disrupted
Femoral neck shortening
Increased view of lesser trochanter
What does this XR show?
Intertrochanteric fracture
Fracture runs between greater and lesser trochanter
Femoral neck intact
What does this XR show
Subtrochanteric fracture
Fracture distal to trochanters
Femoral neck remains intact
What garden staging of hip fracture is AVN likely to occur in?
3-4: Indicates displacement
What surgery do you perform a hip fracture is
Intracapsular
Extracapsular
Intra: THR if fit, hemi if not
Intertrochanteric: Dynamic screw
Subtrochanteric (<5cm distal to lesser): IM nail
How does hip dislocation characteristically differ from fracture in presentation?
Dislocation: Internal rotation if posterior, external with no shortening if anterior
Fracture is external rotation WITH shortening
How do you manage hip dislocation?
ABCDE with 4hr reduction with GA
What nerve injuries occur in hip dislocation?
Sciatic: Foot drop, loss of external rotation + abduction of hip
Femoral: Poor hip flexion, sensation loss over medial leg
How do you differ between acute and chronic osteomyelitis?
Acute: Fever, pain swelling and redness of surgical joint site
Chronic: History of pain, persistently draining wound, diabetics
How do you investigate and treat osteomyelitis?
Image with MRI, biopsy is definitive
Treat with fluclox (clindamycin)
Acute: 4-6 weeks
Chronic: 3-6 months
–> IVOST once stable or 2 weeks post surgery
Severly painful, paraesthetic leg following trauma suggests what?
How do you treat this?
Compartment syndrome
Raise, fasciotomy and fluids
What are the red flags for back pain?
Age < 20 years or > 50 years
History of previous malignancy
Night pain
History of trauma
Systemically unwell e.g. weight loss, fever
What are the key things to examine in the back?
LNDN
Localised spinal tenderness (esp thoracic)
Neurological deficits bilaterally
Distended bladder
No or reduced anal tone
How can you tell between a prolapsed disc at L3 and L4?
Both have + ve femoral stretch test and reduced knee reflex
L3: sensation over thigh
L4: Sensation over knee
How do L4 and L5 compressions compare?
L4: Sensory over knee, knee reflex, femoral stretch
L5: Dorsal foot, foot and 1st toe dorsiflexion, sciatic stretch
How do L5 and S1 compression compare?
L5: Sensory dorsal foot, weakness in foot and big toe, ANKLE REFLEX INTACT
S1: Posterolateral leg and lateral foot, weak plantar flexion, Ankle reflex lost
How do you manage a prolapsed disc?
Analgesia, physio, exercise
4-6 weeks persistence: MRI
How does mechanical back pain present and what is the pain ladder for it/
Pain brought on by actvity
- NSAIDs
- Codeine
+ Benzos for spasm for 5 days
What drugs are avoided in mechanical back pain?
Opioids, antidepressants or atypicals
How do you differentiate between cauda equina and metastatic spinal cord compression?
MSCC worse on valsalva movements
For cauda equina what is the…
most common mechanism
Imaging
Treatment
L3-4 OR L5-S1 herniation
Admite then emergency MRI
Surgical compression
Tender swollen knee following twisting movement, extension causes locked knee indicates what?
Meniscal tear
How do investigate and treat a meniscal tear?
Can do an Apley grind test
MRI if cant weight bear or flex to 90 degrees
RICE, arthroscopic repair if severe
How do anterior and posterior cruciate ligaments differ in terms of mechanism?
Anterior: Popping noise following twisting injury, can have rapid swelling
Posterior: Anterior force to tibia (eg dashboard injury)
How do you differentiate between tendinopathy and rupture of the achilles tendon?
How does management differ?
Simmond’s calf squeeze, US
RIPE and orthotics for tendon, NO STEROIDS
Plantarflexion boot, surgical reattachment
What are the rules for XR in ankle injuries
- Tenderness along the lateral malleolar zone
- Tenderness along the medial malleolar zone
- Can’t walk 4 weight bearing steps
What is this X ray of?
Normal shoulder XR
Glenoid and humeral head aligned
What does this XR show?
Anterior dislocation
Humeral head overlaps glenoid more
has moved below coracoid
What does this XR show?
Posterior dislocation
Humeral head does not touch glenoid
Internal rotation means you can see more rounded part of head causing the lightbulb sign
How do you manage shoulder dislocation?
Recent: Reduction
Less recent: Analgesia and sedation
Sling immobilisation 1-3 weeks
What nerve injury is most associated with shoulder dislocation?
Axillary nerve (C5,6)
Deltoid weakness and ‘badge patch’ sensation loss
Compare medial and lateral epicondylitis and radial tunnel syndrome in terms of:
Mechanism/worsening pain
Medial (Golfer’s) // Lateral (Tennis) // Radial tunnel
Wrist flexion and pronation // wrist extension or supination with extended elbow // pain distal to lateral elbow, worse on PRONATION
Compare cubital and carpal tunnel syndrome in terms of affected area?
Cubital: 4th and 5th finger, following elbow trauma
Carpal: pain in lateral hand, THENAR wasting; autoimmune, pregnant or lunate fracture
How do you treat carpal tunnel?
6 weeks rest and splints
Day case surgery and steroids if resistant
How do you disntinguish Colle’s and Smith’s fracture
Colle’s // Smith
Distal Displaced Dorsally // Volar displacement
Dinner fork deformity // garden spade deformity
What does this XR show?
Colle’s fracture
Tranverse fracture radius
+/- ulnar styloid fracture
What does this XR show?
Smith fracture
How to tell difference between monteggia and galeazzi fracture?
Monteggia: Ulnar fracture, prox radioulnar joint dislocation
Galeazzi: Radial fracture, distal radioulnar joint fracture
How does facet joint pain differ from prolapse?
No straight leg test in facet joint, worse on back extension
Hypoxaemia, neuro changes and petechial rash post op suggests?
Fat embolism syndrome
How can you differ between PAD and spinal stenosis?
PAD will have CVD history
SS will improve on sitting and bending back
For avascular necrosis, what are the
Risk factors
Investigations
Management
RFs: Steroids, chemo, alcohol excess, trauma
Investigations: XR shows normal or crescent sign; MRI most sensitive.
Joint replacement may be necessary
