Orthopaedics Flashcards
Commonest malignant primary bone tumour
Oseosarcoma
50% around the knee
Complications of colle’s fracture
Compression on median nerve
Rupture of extensor pollicis longus tendon
Imaging for scaphoid fractures
If first x-ray NAD
Fix for two weeks then re-x-ray
If still NAD –> MRI
Lasègue’s straight leg raise test
Increases tension along the sciatic nerve (L5 and S1 nerve roots)
97% sensitive for disc prolapse
Intrinsic muscle wasting of the hand
Ulnar nerve palsy T1
Thenar wasting
Median nerve palsy C8
Hypothenar wasting
Ulnar nerve palsy T1
Medial epicondylitis
Golfer’s elbow
Lateral epicomdylitis
Tennis elbow
Morton’s neuroma
Thickening of the tissue that surrounds the digital nerve leading to the toes as the nerve passes under the ligament connecting the metatarsals in the forefoot
It is most frequent between the third and fourth toes.
A neuroma presents with burning pain in the ball of the foot that radiates to the involved toes.
Palpate in the web space between the symptomatic toes for a mass.
Compression of the metatarsals may elicit a ‘click’ betwee the bones (Molders’ click).
Sites of tendon injury with age
Adolescents: tendon insertions
Adults: musculotendinous junction
Grading ligamentous injuries 0-3
0 = Normal ligament
1 No increase in joint laxity but there is tenderness around the injured ligament
2 Partial disruption of the ligament fibres with increased joint laxity, and a soft end point
3 Complete disruption of the ligament; there is a marked increase in joint laxity with no end point clinically
Management of ligamentous injuries
Grade 1 + 2: splinting, anaglesia and fraded mobilisation
Garde 3: surgical repair
Posterior impingement of the ankle and tendinopathy of the flexor hallucis longus tendon
Ballet dancers
Ottawa ankle rules
Bone tenderness along the distal 6 cm of the posterior margin or at the tip of the lateral malleolus
Bone tenderness along the distal 6 cm of the posterior margin or at the tip of the medial malleolus
Inability to bear weight at the time of the accident or at the time of examination
Cervical lordosis
35-45 ‘
Lumbar lordosis
40 - 80’
Mostly occurs L4 - S1
Thoracic kyphosis
20 - 50’ (mean 35’)
Increases with age
Radicular artery of Adamkiewicz
Largest anterior segmental medullary artery
Arises left posterior intercostal artery at the level of the T9 - T12 intercostal artery, which branches from the aorta, and supplies the lower two thirds of the spinal cord via the anterior spinal artery
Ligation –> ischaemia of the spinal column
During anterior approaches to the spine, segmental division is performed to avoid ligating this influental vessel
Cauda equina
Low back pain
Uni- or bilateral sciatica
Saddle anaesthesia
Motor weakness in the lower extremities
Variable rectal and urinary symptoms
Lasègue’s sign
Denotes radicular pain aggravated by ankle dorsiflexion during straight leg raise
Provocative discography
3.5 mL of radio-opaque contrast agent is injected into the disc
The contrast pattern will allow the discrimination of different degrees of disc degeneration; cottonball or lobular would be considered normal
Whereas irregular, fissured or ruptured would be considered degenerate
Indication for surgical intervention in cervical radiculopathy
Intractible pain
OR
Functional neurological deficit
Surgical management of cervical radiculopathy
Anterior cervical discectomy and fusion (using a cage packed with bone graft and plate)
Cervical total disc replacement
Posterior laminoforaminotomy
Cervical myelopathy
LMN signs AT level of lesion
UMN signs below level of lesion
Commonest cause of cauda equina syndrome
Massive central lumbar disc protrusion at L4/5
Lumb disc herniation
90% at L4/L5 or L5/S1 levels
Posterolateral disc protrusion will affect the traversing root, e.g. an L4/5 disc protrusion will affect the
L5 nerve root.
Far-lateral disc protrusion (extraforaminal) will affect the exiting nerve root, e.g. a far-lateral L5/S1 disc protrusion will affect the L5 nerve root
Spinal stenosis
Classic symptoms: back, buttock, thigh and calf pain
LIGAMENTUM FLAVUM
Provoked by walking and extended posture
Relieved by flexed posture
Symptoms progress in up to one-third of untreated patients
Spondylolysis
Unilateral or bilateral defect in the pars interarticularis without vertebral slippage
Incidence in athletic population 15–47%
May be completely asymptomatic/incidental finding on
radiograph
Difficult to image, but MRI proving more useful
Conservative treatment: activity modification, antilordotic brace
Surgical treatment: direct repair preserving motion or spinal fusion if associated disc degeneration
Spondylolisthesis
Forward slippage of the vertebral body caused by a break in in the continuity of pars interarticularis
Wiltse classification of spondylolisthesis identifies the CAUSE = 6 types
Meyerding classification grades severity = 4 grades
Low grade slip I - II –> fusion-in-situ
High grade slips III - IV–> decompression and fusion
Commonest metatastic malignancy to spine
Breast 21%
Lung 14%
Benign primary spine tumours
Osteoid osteoma
Osteoblastoma
Chondroma
Chondroblastoma
Chondromyoixod fibroma
Giant cell tumous
Haemangioma
Lymphangioma
Lipoma
Benign tumours tend to occur in the posterior elements
Intermediate spinal pimaries
Aggressive osteoblastoma
Haemangiopericytoma
Haemangioendothelioma
Chordoma
Malignant spinal pimaries
Osteosarcoma
Chondrosarcoma
Ewing’s sarcoma
Neuroectodermal tumours
Malignant lymphoma
Myeloma
Angiosarcoma
Fibrosarcoma
Liposarcoma
Malignant tumours tend to involve the entire vertebral column
Neurofibroma
Benign tumours arising from the nerve sheath
Three types:
-Cutaneous
-Spinal
-Plexiform
90% of cases they present as solitary lesions,
Multiple = patients with neurofibromatosis type 1 (NF1), -autosomal dominant
Neurofibromatosis Type 1
Referred to as peripheral neurofibromatosis or von Recklinghausen disease
1 in 3000
Diagnosis of NF1 (2 or more of the following):
-At least 6 cafe au lait spots >5mm pre-puberty
-At least 6 cafe au lait spots >15mm post-puberty
-Two or more neurofibromas (any type)
-Presence of plexiform neurofibroma
-Multiple freckles in the axillary or inguinal regions,
-Distinctive bone abnormality involving the eye socket or arm/leg bones
-Optic glioma in the brain
-Two or more Lisch nodules in the eye,
-Parent, sibling or child with NF1
Neurofibromatosis Type II
Central
1 in 40,000
Schwannomas on both 8th cranial (vestibular) nerves
Parent, sibling or child with NF2 plus:
-One vestibular schwannoma in a person less than 30 years of age
-Any two of the following: meningioma, glioma,
schwannoma, juvenile cataracts
Epidural abscess
Surgical emergency
Majority of cases occur within the thoracic spine.
Without treatment –> neurological deficit including paralysis may develop.
Indications for surgery in atlanto-axis subluxation in rheumatoid arthritis
AAS with a PADI of 14 mm or less
AAS with at least 5 mm of basilar invagination
Subaxial subluxation with a sagittal canal diameter of 14 mm or less
(PADI= posterior atlantodental interval)
Cobb angle of 10° or more
= Scoliosis
Early onset idiopathic scoliosis
Cause disruption to lug development
After 8 years, late onset scoliosis, the alveoli are developed
Early onset may cause cor pulmonale and RHF
Management of idiopathic scoliosis
Idiopathic curves of less than 25° are monitored with clinical and radiographic examination
In growing children (premenarchal) with curves between 20° and 29°, a brace may be indicated. Bracing is used to prevent curve progression
Curves beyond 45° are not amenable to brace treatment.
Surgery in the form of corrective instrumentation and
spinal fusion is indicated for curve progression beyond 40°, truncal imbalance and unacceptable cosmesis.
During surgery, continuous spinal cord monitoring is used in the form of somatosensory evoked potentials (SSEP), motor-evoked potentials (MEP) and free-run and stimulated electromyographic (EMG) activity to minimise the risk of neurological damage. The risk of neurological injury is 0.4% (1 in 250).
Stener lesion
Occurs due to gamekeepers thumb
Aponeurosis of ABductor pollicis longus interposed between the ruptured ulnar collateral ligament (UCL) of the thumb and its site of insertion at the base of the proximal phalanx
No longer in contact with its insertion site, the UCL cannot spontaneously heal
Mx: surgicalk attachment
Scheuermann’s kyphosis
Wedging og T7 - T10 vertebrae
Apical pain and lower back pain
–> attempts by lumbar musculature to compensate for the thoracic hyperkyphosis
Mx
Physiotherapy
Bracing in skeletally immature
Surgical:
-Pain (apical or low back pain produced by
compensatory hyperlordosis)
-Progressive deformity greater than 70°,
-Unacceptable cosmesis and neurological and/or cardiopulmonary compromise
Anterior release followed by posterior correction and
fusion.
Posterior chevron osteotomies carried out at the time of posterior instrumentation may prevent the need for the initial anterior release
Diastematomyelia
An abnormal bony or cartilaginous spur projecting across the middle of the vertebral canal
–> dividing the dural tube and spinal cord in two
Between 50% and 70% of patients are seen to have a skin naevus, dimple or hairy patch when the spine is examined
Management of osteoporotic spinal fractures
Providing no neural comprimise
Bed rest
Analgesia
If painful
–> Kyphoplasty
–>Vertebroplasty
Sprengel’s shoulder
Abnormal descent of the scapular from its embryonic mid-cervical position
High, small, rotated scapular that remains attached to the cervical spine by a:
-bony bar, or
-fibrous band, or
-omovertebral body
Klippel-Feil syndrome
Congenital abnormality involving fusion of at least two cervical vertebrae
–> short neck and reduced mobility, causes apparent low hair-line
Risk factors for frozen shoulder
Diabetes
Cardiovascular disease
Thyroid disease
Female gender
Age
Treatment of calcific tendonitis
Acute pain with restricted movement around the shoulder due to subacromial calcific deposits
BUT external rotation possible
Tx:
Corticosteroid injections
Barbotage: aspiration and flushing
Surgical decompression if persistent
Changes in rheumatoid arthritis
Osteoporosis
Destruction of articular cartilage
Synovial proliferation
Pannus formation
Rupture of the long head of the biceps
Tends to be proximal tendon rupture in elderly patients due to abrasion under the anterior acromion
–> bulge appears in arm
–>sometimes pain of biceps tendonitis is relived by rupture
In elderly it doesn’t alter function –> conservative management
Types of shoulder instability
Traumatic
Atraumatic
Habitual
Types of shoulder instability
Traumatic
-Surgery
Atraumatic
-Surgery
Habitual
-Not for surgery
Bankart’s lesion
Detachment of the anteroinferior labrum
Hill-Sach’s lesion
Damage to the humeral head
Cortical depression on posterolateral humeral head
Management of traumatic recurrent shoulder instability
Repair of labrum
Tightening of anterior capsule
+/- graft of Hill-Sachs
Posterior shoulder dislocation
Forced internal rotation
-Electrocution
-Seizure
-Restraint
Rheumatoid elbow
Radial head excision
Elbow arthroplasty
Points of ulnar compression
Within the cubital tunnel (behind medial epicondyle)
Junction of arcade of Struthers
Medial intermuscular septum as nerve passes into posterior compartment of distal humerus
Between heads of flexor carpi ulnaris
Froment’s sign
Weakness of adductor pollicis
= ulnar nerve palsy
Edinburgh position of safety
Hand splinting position to prevent collateral ligament shortening and deformity during times of immobiliation
= Wrist extension
=MCP flexion
=IPJ extension
Thumb ulnar collateral ligament injury
= Gamekeepers thumb
Chronic overuse –> stretching of ulnar collateral ligament of thumb
Skier’s thumb = forceful abduction causing acute tear
Surgical Mx: pollicis abbductor tendon slips between two ends and prevents healing
Triangular fibrocartilage complex injuries
Triangular fibrocartilage complex:
-Ulnocarpal ligaments
-Extensor carpi ulnaris tendon
-Meniscus-like structure between distal ulna and carpus
Stabilises distal radio-ulnar joint
Injury –> ulna wrist pain and instability
Mx: arthroscopic / open repair
Debridement if chronic damage
Felon
Abscess of specialised fibrous septae in finger pulp
Can cause DIP osteomyelitis
Mx: I&D
Paronchyia
Nail bed infection
Incision, drainage and Abx
+/- partial removal of nail to allow drainage
Flexor tendon sheath infection
Kanavel’s cardinal signs
-held in flexion
-swelling over tendon and digit
-tender
-pain on passive extension
Mx: tendon sheath irrigation and IV Abx
Untreated: adhesions, necrosis, +/- proximal spread
Hand signs of Rheumatoid
Boutonniere
Swan-neck
Flexor tendon synovitis
Radial deviation of wrist + prominent ulnar head
Flexion, subluxation and ulnar deviation of MCPs
Dupuytren’s
Autosomal dominant
Palmar nodules
Skin puckering
Cords
Flexion contractures
Garrods knuckle pads over dorsal of PIPs
Associated with:
Smoking
Trauma
Epilepsy
AIDS
Hypothyroidism
Alcohol liver cirrhosis
Mx: when patient can’t put hand flat on table
OR
Flexion develops in the PIP joint
–> surgery
Z-plasties
Digital nerves at-risk
Proceed to amputation if finger restricting useful movements
Trigger finger
Tendon size mismatch between flexor tendon sheath pulley A1 and size of flexor tendon
–> locking / snapping of finger
–> pain
Mx:
Corticosteroid injection
Proceed to pulley release
In thumb in children –> resolved spontaneosuly
De Quervain’s
Tenosynovitis of abductor pollicis longus and extensor pollicis brevis within first dorsal extensor compartment
1st EC
Associated:
Female patients during pregnancy (New mother’s wrist)
Inflammatory arthritis
Test: Finkelstein’s