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4MB Surgery > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

What is ankylosis?

A

Stiffening of a joint with fibrous/bony union across it

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2
Q

What is arthrodesis?

A

Surgical fusion of a joint

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3
Q

What is arthroplasty?

A

Creation of an artificial joint

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4
Q

What is arthroscopy?

A

“Keyhole” joint inspection/surgery

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5
Q

What is osteotomy?

A

Surgical cutting/wedging and realignment of bone

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6
Q

What is spondylolisthesis?

A

Slippage of one vertebra over another

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7
Q

What is spondylolysis?

A

Defect in pars interarticularis of a vertebra

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8
Q

What is spondylosis?

A

Degenerative disease of the spine

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9
Q

What is valgus deformity?

A

Deformity of limb laterally from its normal axis

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10
Q

What is varus deformity?

A

Deformity of limb medially from its normal axis

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11
Q

Which movements test bones/muscles in the neck? Which joints are responsible for these movements?

A 
Flexion, extension (atlanto-occipital joint)
Rotation (atlanto-axial joint)
Lateral flexion (cervical spine)
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12
Q

Which type of XR is used to investigate the cervical spine?

A

Cross-table lateral XR

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13
Q

What is assessed on a cross-table lateral XR of the cervical spine?

A 
Alignment: of vertebral bodies, spinous processes, spinal canal
Bone contours
Cartilages
Soft tissues
All 7 cervical vertebrae should be seen!
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14
Q

What is cervical spondylosis?

A

Degeneration of the cervical spine (annulus fibrosis degenerates, bony spurs form)

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15
Q

List clinical features of cervical spondylosis

A

Slow-onset neck stiffness
Pain, radiating to shoulders/occiput
Radicular pain

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16
Q

Outline treatment for cervical spondylosis

A

Pain relief
Physiotherapy
Surgical decompression of nerve impingement

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17
Q

List clinical features of a prolapsed cervical disc

A

Stiff neck
Arm pain
Dermatomal distribution of symptoms if nerve root compression

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18
Q

Which cervical joint is the most unstable?

A

Atlanto-axial joint

Very prone to subluxation

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19
Q

What is cervical rib?

A

Congenital development of the costal process of C7 produces a rib-like deformity

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20
Q

List clinical features of cervical rib

A 
Pain
Numbness in hand/forearm
Muscle wasting
Thoracic outlet compression
Weak radial pulse
Forearm cyanosis
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21
Q

Outline treatment for cervical rib

A

Physiotherapy to strengthen shoulder elevators

Surgical removal of rib

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22
Q

What is torticollis?

A

Dystonia due to sternocleidomastoid and trapezius muscle spasm

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23
Q

List clinical features of torticollis

A

Tilted head
Retarded facial growth
Thickened muscle
Nodding spasms

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24
Q

Respectively, what is the most likely shoulder pathology if a patient presents with generalised pain on movement vs. pain on specific movement?

A

Generalised pain: arthritis, capsulitis

Specific pain: impingement, muscle tear

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25
Q

Which rotator cuff is responsible for shoulder abduction?

A

Supraspinatus

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26
Q

Which rotator cuff is responsible for shoulder extension?

A

Teres minor

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27
Q

Which rotator cuff is responsible for shoulder internal rotation?

A

Subscapularis

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28
Q

Which rotator cuff is responsible for shoulder external rotation?

A

Infraspinatus

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29
Q

Which shoulder pathologies are the following tests used for: Jobe’s test, Hawkin’s test, apprehension test, scarf test?

A

Jobe’s test for impingement/supraspinatus tear
Hawkin’s test for impingement
Apprehension test for instability
Scarf test for acromioclavicular joint disease

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30
Q

List aetiology/risk factors for shoulder instability

A

Atraumatic (5%): ligamentous laxity, teenagers

Traumatic: usually anterior subluxation/dislocation

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31
Q

What is biceps tendonitis?

A

Inflamed long head of biceps causes anterior shoulder pain

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32
Q

List clinical features of biceps tendonitis

A 
Resisted biceps contraction causes pain
Popeye deformity (bulky biceps)
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33
Q

Outline treatment of biceps tendonitis

A

Pain relief
Physiotherapy
Surgical division of tendon with attachment to humerus

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34
Q

What is painful arc syndrome?

A

Rotator cuff tendons (mainly supraspinatus) become compressed in tight subacromial space during abduction (45-160’)

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35
Q

List aetiology/risk factors for painful arc syndrome

A 
Tendonitis
Subacromial bursitis
Acromioclavicular osteoarthritis (osteophytes)
Hooked acromion rotator cuff tear
Calcification
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36
Q

List clinical features of painful arc syndrome

A

Pain on abduction up to 160’
Tenderness
Cervical radiculopathy

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37
Q

Outline treatment of painful arc syndrome

A

Physiotherapy
Pain relief
IA steroid
Surgical decompression

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38
Q

List aetiology/risk factors for rotator cuff tears

A

Degeneration
Trauma
Sudden jerky movements

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39
Q

List clinical features of rotator cuff tear

A

Weak initation of abduction
Muscle wasting
Full-range passive movement
Shoulder tip pain

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40
Q

Outline treatment of rotator cuff tear

A

Open/arthroscopic repair if complete tear

Otherwise physiotherapy and pain relief

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41
Q

What is adhesive capsulitis?

A

Frozen shoulder occurring over long period of time, usually in elderly

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42
Q

List aetiology/risk factors for adhesive capsulitis

A 
Elderly
Innoccuous trigger
Post-surgery
Diabetes
Hypercholesterolaemia
Dupuytren's contracture
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43
Q

Which muscles are responsible for elbow flexion and extension?

A

Flexion: biceps, brachialis
Extension: triceps

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44
Q

Which muscles are responsible for forearm supination and pronation?

A

Supination: supinator, biceps
Pronation: pronator teres

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45
Q

What is lateral epicondylitis?

A

“tennis elbow”

Inflammation of lateral common extensor tendon

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46
Q

List aetiology/risk factors for lateral epicondylitis

A

Repetitive strain injury involving extension

Degenerative enthesopathy

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47
Q

List clinical features of lateral epicondylitis

A

Painful tender lateral epicondyle

Pain on resisted middle finger + wrist extension

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48
Q

Outline treatment of lateral epicondylitis

A 
Self-limiting
Rest from activity
Pain relief
Physiotherapy
IA steroid
Elbow brace if unresolving, surgical division/excision of fibres
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49
Q

What is medial epicondylitis?

A

“golfer elbow”
Inflammation of medial common flexor tendon
Less common than lateral epicondylitis

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50
Q

Which nerve must you be wary of when giving IA steroid for medial epicondylitis?

A

Ulnar nerve

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51
Q

What is olecranon bursitis?

A

“student elbow”

Inflammation of bursae due to repetitive/prolonged pressure on elbow

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52
Q

List aetiology/risk factors for olecranon bursitis

A

Studying medicine
Gout
Septic joint

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53
Q

What investigation should you do for olecranon bursitis?

A

Aspirate swelling and send for Gram stain + microscopy

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54
Q

Outline treatment for olecranon bursitis

A

Injected hydrocortisone
Drain septic bursa + antibiotics
Self-limiting

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55
Q

What is cubital tunnel syndrome?

A

Compression/irritation of ulnar nerve as it passes behind medial epicondyle

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56
Q

List aetiology/risk factors for cubital tunnel syndrome

A

Osteoarthritis, rheumatoid arthritis (narrowing of ulnar groove)
Tight band of Osborne fascia
Tight IM septum between flexor carpi ulnartis
Fluid overload

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57
Q

List clinical features of cubital tunnel syndrome

A

Paraesthesia over medial 1.5 digits
Clumsy, weak hand
Tinel’s sign (percuss over ulnar nerve illicits symptom)
Froment’s sign (weak adductor pollicis)

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58
Q

Outline treatment of cubital tunnel syndrome

A

Surgical decompression +/- transposition of nerve to front of elbow

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59
Q

If someone has a total elbow replacement, what is the maximum weight they can lift?

A

2.5 kg

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60
Q

What is Dupuytren’s contracture?

A

Progressive painless fibrotic thickening of palmar fascia due to type 3 collagen deposition (instead of type 1)
Normal fascial bands form nodules and cords, causing contractures of fingers

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61
Q

List aetiology/risk factors for Dupuytren’s contracture

A 
Genetic (autosomal dominant)
Smoking
Antiepileptics (phenytoin)
Liver disease
Males
Cirrhosis
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62
Q

List clinical features of Dupuytren’s contracture

A 
Puckered skin
Usually ring + little finger affected
MCP + PIP flexion
Peyronie's disease of penis
Ledderhose's disease (plantar fibromatosis)
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63
Q

Outline treatment of Dupuytren’s contracture

A

Fasciectomy if PIP joint stiffening
Fasciotomy
Amputation
Steroid injection for short-term symptom relief

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64
Q

What is trigger finger?

A

Disproportion of tendon to its sheath causes fixed flexion deformity
Nodular tendon enlargement distal to fascial pulley over metacarpal head (usually A1 pulley) causes intermittent locking of finger

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65
Q

Outline treatment for trigger finger

A

Steroid injection into region of nodule

Surgical fixation

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66
Q

What is a ganglion cyst?

A

Common mucinous cyst found adjacent to tendon or synovial joint

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67
Q

List clinical features of ganglion cyst

A

Localised pain
Firm/smooth/rubbery swelling
Transilluminates

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68
Q

Outline treatment of ganglion cyst

A

Needle aspiration

Surgery if painful but not for cosmesis

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69
Q

What is De Quervain’s tenosynovitis?

A

Thickened tendons of abductor pollicis longus and extensoru pollicis brevis

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70
Q

List clinical features of De Quervain’s tenosynovitis

A

Pain over radial styloid process
Worse on stretching (lifting teapot)
Finkelstein’s sign (sharply pull relaxed thumb to cause ulnar deviation)

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71
Q

Outline treatment of De Quervain’s tenosynovitis

A

NSAID
Hydrocortisone injection
Tendon decompression surgery

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72
Q

What is carpal tunnel syndrome?

A

Compression/irritation of median nerve within the carpal tunnel

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73
Q

List aetiology/risk factors for carpal tunnel syndrome

A 
Arthritis
Fluid overload (pregnancy, renal failure)
Diabetes
Tendonitis
Swelling
Fractures (Colles)
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74
Q

List clinical features of carpal tunnel syndrome

A 
Paraesthesiae over lateral 3.5 digits
Worse at night, need to "shake it off"
Weak, clumsy hand
Thenar wasting
Tinel's sign
Phalen's sign (hold wrist hyperflexed to reproduce symptoms)
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75
Q

Outline treatment of carpal tunnel syndrome

A

Wrist splints
Pain relief
Steroid injection
Surgical decompression by dividing transverse carpal ligament

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76
Q

List aetiology/risk factors for exaggerated kyphosis/lordosis

A 
Osteoporosis
Spina bifida
Cancer
Wedge fractures
Tuberculosis
Ankylosing spondylitis
Paget's disease
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77
Q

List clinical features of exaggerated kyphosis/lordosis

A

Increased anterior curvature of spine (hump-back)

Paraplegia

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78
Q

List aetiology/risk factors of scoliosis

A 
Idiopathic
Congenital
Genetics
Neuromuscular
Marfan's
Neurofibromatosis
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79
Q

List clinical features of scoliosis

A

Greater than 10’ lateral curvature of spine
Pain
Impaired lung function
Rib deformity

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80
Q

List aetiology/risk factors for mechanical back pain

A 
Obesity
Poor diet/nutrition
Poor posture
Poor lifting technique
Lack of exercise
Psych disorder
Degenerative discs
Osteoarthritis 
Spondylosis
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81
Q

List clinical features of mechanical back pain

A

Pain worse on movement
Muscle spasms
Recurrent “flares”

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82
Q

Outline treatment of mechanical back pain

A

Conservative pain relief

Physiotherapy

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83
Q

What is disc prolapse?

A

Herniation of nucleus pulposis through disc and impingement of nerve

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84
Q

List clinical features of disc prolapse

A

Radiculopathic pain
Burning, tingling pain
+ve straight leg raise

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85
Q

List clinical features of L3/L4 prolapse

A

L4 entrapment causes pain to medial ankle, reduced knee jerk, reduced quadriceps power

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86
Q

List clinical features of L4/L5 prolapse

A

L5 entrapment causes pain to dorsum foot, reduced power of knee extension, reduced power of leg extension

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87
Q

List clinical features of L5/S1 prolapse

A

S1 entrapment causes pain to sole of foot, reduced power of plantarflexion, reduced ankle jerk

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88
Q

Outline treatment of disc prolapse

A 
Analgesia
Physiotherapy
Early mobilisation
Discectomy if unresolving
Neuropathic pain meds (gabapentin)
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89
Q

What is lumbar spinal stenosis?

A

Narrowing lumbar spinal canal, causing nerve root irritation/compression

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90
Q

List aetiology/risk factors for lumbar spine stenosis

A

Facet joint OA
Osteophytes
Disc prolapse
Ligamentum flavum bulge

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91
Q

List clinical features of lumbar spine stenosis

A 
Neuropathic claudication (pain in legs on walking, usually uphill, burning pain)
-ve straight leg raise
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92
Q

Outline treatment of lumbar spine stenosis

A 
Weight loss
Pain relief
Physiotherapy
Spinal canal decompression
Surgery
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93
Q

What is cauda equina syndrome?

A

Compression of all lumbar and sacral nerve roots arising from conus medullaris (L1)

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94
Q

List aetiology/risk factors for cauda equina syndrome

A 
Extrinsic tumour, cord tumour
Spondylosis
Spinal stenosis
Disc prolapse
Subarachnoid haemorrhage
Fracture of vertebra
Trauma
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95
Q

List clinical features of cauda equina syndrome

A

Bilateral leg pain
Paraesthesiae, typically “saddle anaesthesia”
Urinary and bowel incontinence

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96
Q

What investigations would you do for cauda equina syndrome?

A

PR exam

Urgent MRI

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97
Q

Outline treatment of cauda equina syndrome

A

Discectomy

Surgical decompression

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98
Q

List red flags for back pain

A 
New onset back pain
Less than 20 yo
Over 55 yo
Bilateral
Associated weakness
Constant, unremitting
Worse at night
Weight loss
Systemic upset (fever, night sweats, malaise)
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99
Q

What is the difference between “total hip replacement” and “total hip arthroplasty”?

A

Arthroplasty is a broader term encompassing resurfacing technique that does not replace the entire femoral head, so technically not a full hip replacement

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100
Q

What is the gold-standard material used for hip replacement?

A

Cemented metal-polyethylene

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101
Q

List aetiology/risk factors for avascular necrosis

A 
Idiopathic
Alcohol abuse
Steroid abuse
Hypercholesterolaemia
Thrombophilia
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102
Q

What would an MRI and XR of avascular necrosis of the femoral head show?

A

Patchy sclerosis
Lytic zone
Granulation tissue
“hanging rope” sign on XR

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103
Q

Outline treatment of avascular necrosis of the femoral head

A

Decompression via drill hole if detected pre-collapse

Otherwise total hip replacement

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104
Q

What is trochanteric bursitis?

A

Tendonitis and degeneration of insertion of abductor muscles (mainly gluteus medius)

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105
Q

List clinical features of trochanteric bursitis

A

Pain and tenderness near greater trochanter

Pain on resisted abduction

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106
Q

Outline treatment of trochanteric bursitis

A

Analgesia
Physiotherapy
Steroid injection

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107
Q

What is chondromalacia patellae?

A

Patellar aching/weakness associated with dislocation

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108
Q

Who typically gets chondromalacia patellae?

A

Young women/girls

Service men

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109
Q

List clinical features of chondromalacia patellae

A

Pain after prolonged sitting/climbing stairs
Retropatellar tenderness
Clarke’s test: pain on patellofemoral compression with tense quadriceps

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110
Q

Outline treatment of chondromalacia patellae

A

Vastus medialis strengthening
NSAID’s
Arthroscopic lateral retinacular release if ongoing

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111
Q

Why might recurrent patellar subluxation occur?

A

Tight retinaculum causes patella to sublux laterally, causing medial pain

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112
Q

Who typically gets recurrent patellar subluxation?

A

Girls
Valgus knees
Joint/ligamentous laxity
High patella

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113
Q

Which part of the knee is typically affected by osteoarthritis?

A

Posteromedial knee, causing varus deformity

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114
Q

Who typically gets meniscal cysts?

A

Young men

Usually lateral

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115
Q

What is osteochondritis dissecans?

A

Osteochondral fragment separates from underlying bone

Usually occurs on lateral side of medial femoral epicondyles in young adults

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116
Q

List clinical features of osteochondritis dissecans

A

Pain after exercise
Intermittent knee swelling
Locking

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117
Q

Where does bursitis in the knee typically occur?

A

Pre-patellar (housemaid’s knee)

Infra-patellar (clergyman’s knee)

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118
Q

Outline treatment of knee bursitis

A

Aspiration
Hydrocortisone injection
Topical NSAID
Antibiotic if suppurative exudate

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119
Q

What is hallux valgus?

A

Deviation of big toe laterally at metatarsophalyngeal joint

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120
Q

List aetiology/risk factors for hallux valgus

A 
Biomechanical forces
Pointed/poorly fitting shoes
Heels
Rheumatoid
NM disease
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121
Q

List clinical features of hallux valgus

A

Painful

Inflamed bursa over 1st medial metatarsal head (bunion)

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122
Q

Outline treatment of hallux valgus

A

Bunion pads
Plastic wedges between toes
Metatarsal osteotomy
Arthrodesis

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123
Q

What is hallux rigidus?

A

Osteoarthritis of the first MTP joint

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124
Q

Outline treatment of hallux rigidus

A

Wear stiff-soled shoe to limit motion
Remove osteophytes
Arthrodesis is gold-standard

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125
Q

Women can’t wear high-heel shoes after arthrodesis for hallux rigidus. True/False?

A

True

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126
Q

What are claw toes?

A

Hyperextension at the MTP joint

Hyperflexion at the PIP joint and DIP joint

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127
Q

What are hammer toes?

A

Hyperextension at the MTP joint
Hyperflexion at the PIP joint
Hyperextension at the DIP joint

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128
Q

What are mallet toes?

A

Hyperflexion at the DIP joint

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129
Q

Outline treatment of toe deformities

A 
Toe sleeves
Plasters
Surgical tenotomy
Arthrodesis
Tendon transfer
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130
Q

What is pes planus?

A

Flat feet - medial long arch of foot is low

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131
Q

List aetiology/risk factors of pes planus

A

Physiological
Familial
Ligamentous laxity
Tibialis posterior tendon stretch

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132
Q

Outline treatment of pes planus

A

Hindfoot fusion if painful

Generally not for surgery

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133
Q

What is pes cavus?

A

Abnormally high arch of foot that does not flatten on weight bearing

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134
Q

List aetiology/risk factors for pes cavus

A 
Idiopathic
Neuro disorder (spina bifida, cerebral palsy, muscular dystrophy)
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135
Q

List clinical features of pes cavus

A 
Pain
Claw toes
Foot fatigue
Ankle instability
Reduced mobility
If foot used to be normal, refer to neurologist
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136
Q

Outline treatment of pes cavus

A 
Orthoses
Custom footwear
Soft tissue release/tendon transfer
Calcaneal osteotomy
Arthrodesis if severe
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137
Q

What is Morton’s neuroma?

A

Pressure/trauma to plantar interdigital nerves nerves overlying intermetatarsal ligaments
Irritated nerves become inflamed and swollen (neuroma)

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138
Q

List clinical features of Morton’s neuroma

A 
Burning/tingling pain radiating laterally
Women with high heels
Usually 3rd webspace
Reduced sensation
Mulder's click test
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139
Q

Outline treatment of Morton’s neuroma

A

Metatarsal pads
Offloading insole
Steroid injection
Excise neuroma

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140
Q

List aetiology/risk factors of Achilles tendonitis

A

Repetitive strain
Quinolones
Inflammatory arthritis
Gout

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141
Q

Outline treatment of Achilles tendonitis

A 
Rest
Physiotherapy
Splinting
Tendon decompression/repair
If rupture, cast in plantarflexion
142
Q

List aetiology/risk factors of plantar fasciitis

A

Diabetes
Hard floors
Poor support

143
Q

List clinical features of plantar fasciitis

A

Pain in instep of foot

Local tenderness

144
Q

Outline treatment of plantar fasciitis

A

Rest
Stretching exercises
Gel-filled heel pad
Steroid injection

145
Q

List “high-energy” incidents that can result in a fracture

A

RTA
Fall from height
Gunshot

146
Q

List “low-energy” incidents that can result in a fracture

A

Trip
Fall
Sports injury
Pathological (osteoporosis)

147
Q

List clinical features of fractures

A 
Pain, tenderness
Loss of function
Deformity, abnormal position/movement
Swelling
Trapped air/foreign  body
148
Q

What is a tranverse fracture?

A

Bending force causes split in the bone

149
Q

What is an oblique fracture?

A

Shearing force causes diagonal break in bone

150
Q

What is a spiral fracture?

A

Rotational force causes diagonal break in bone

151
Q

What is a comminuted fracture?

A

3 or more fragments break off from bone

152
Q

What is a segmental fracture?

A

Fracture in 2 separate places of a bone

153
Q

How is a fracture described?

A

Site: bone fractured, part of bone affected
Angulation: direction in which distal fragment points towards
Displacement: direction of translation of distal fragment

154
Q

What is first intention healing of bone?

A

Less than 1mm gap (hairline fracture) filled by osteoblasts

155
Q

What is second intention healing of bone?

A

Macrophages and osteoclasts remove debris and resorb bone ends
Granulation tissue forms
Chondroblasts form soft callus (2-3 weeks)
Osteoblasts lay down new bone matrix
Calcium mineralisation forms hard callus (6-12 weeks)
Remodelling occurs

156
Q

Outline initial management of a fracture

A

Correct shock
Give blood if 1.5 L lost, monitor BP regularly
Analgesia (IV morphine)
Splinting/immobilisation
Reduce a grossly open fracture, sterile covering over protruding bone
Prevent infection (IV flucloxacillin + benzylpenicillin)

157
Q

Outline definitive management of a minimally displaced, stable fracture

A

Non-operative
Splinting/immobilisation (cast, orthosis, plaster)
Rehabilitation and physiotherapy

158
Q

Outline definitive management of a displaced, angulated fracture

A

Reduction under anaesthetic
Close + cast
or surgery

159
Q

Outline definitive management of an unstable intra/extra -articular diaphyseal fracture

A

Open reduction, internal fixation

If soft tissues too swollen or risk of blood loss, external fixation instead

160
Q

Outline definitive management of an open fracture

A

Assess, anti-sepsis, align, anti-tetanus, antibiotic, analgesia
Early and thorough debridement
Prompt internal/external fixation

161
Q

List early local complications of fractures

A 
Compartment syndrome
Vascular injury/ischaemia
Nerve compression
Skin necrosis
Bleeding
162
Q

List early systemic complications of fractures

A 
Hypovolaemia
Shock
ARDS
AKI
Sepsis
Far embolism
163
Q

List late local complications of fractures

A 
Stiffness
Loss of function
Malunion/non-union
Chronic regional pain syndrome
DVT
164
Q

List late systemic complications of fractures

A

PE
Pneumonia
Renal stones

165
Q

What is compartment syndrome?

A

Limb and life -threatening complication where swollen muscles bound tight in fascial compartments
Bleeding and inflammatory exudate compresses venous system, causing congestion, and arterial supply cannot supply area, causing necrosis

166
Q

List clinical features of compartment syndrome

A 
Severe intense pain outwith anticipated severity
Swelling
Tenderness
Reduced/absent pulses
Pain on passive muscle stretching
167
Q

Outline treatment of compartment syndrome

A

Prompt fasciotomy
Remove tight bandages/dressings
Monitor fluid loss and renal function (dialysis may be needed)

168
Q

What is complex regional pain syndrome?

A 
Heightened chronic pain response following injury
Type 1 (no nerve injury)
Type 2 (nerve injury)
169
Q

List clinical features of complex regional pain syndrome

A 
Lancinating pain with/without trigger point
Weeks or months following injury/surgery
Allodynia
Cold/cyanotic or hot/sweaty limb
Vasomotor instability
170
Q

Outline treatment of complex regional pain syndrome

A

Refer to pain clinic, physiotherapy, OT
Encourage optimism and mobilisation
Neuropathic painkillers (gabapentin, antidepressants, lidocaine)

171
Q

What is neurapraxia?

A

Temporary loss of nerve conduction usually resolving within 28 days
Due to compression/ischaemia of a nerve

172
Q

What is axonotmesis?

A

Damage to nerve but with intact epineural tube
Due to higher force/trauma
Axons regenerate 1mm per day

173
Q

What is neurotmesis?

A

Complete transection of a nerve
Due to closed/penetrating injury
No nerve recovery unless surgery

174
Q

List aetiology/risk factors for nerve injury

A

Fractures: Colles (median), humeral shaft (radial)
Dislocation: ant shoulder (axillary), post hip (sciatic), lat knee (common peroneal)

175
Q

What is the difference between non-union and delayed union of a fracture?

A

Non-union: no evidence of progression towards healing

Delayed union: fracture not healed within expected time

176
Q

List aetiology/risk factors of non-union and delayed union

A 
Instability
Excessive motion
Rigid fixation
Lack of blood supply
Chronic disease
Infection
177
Q

List clinical features of non-union and delayed union

A

Ongoing pain and oedema
Bridging callus on XR
Scaphoid, distal clavicle, subtrochanteric of femur, 5th metatarsal notorious for non-union
Tibia and femur notorious for delayed union

178
Q

Outline treatment of non-union and delayed union

A

Remove dead/infected bone
Fracture stabilisation
Optimise blood supply

179
Q

Outline treatment of cervical spine fractures

A

ABCDE + C-spine approach
C-spine immobilisation using collar and bags
Clinically clear a C-spine if conscious, cooperative, and ALL of:
no history of LOC
GCS 15
no significant injury
no neurological signs
no midline tenderness on palpation
no pain on gentle active neck movement
Firm cervical collar
External fixation “halo vest” if unstable

180
Q

Outline treatment of a thoracolumbar spine fracture

A

Brace to limit flexion if stable
Plaster jacket
Surgical stabilisation with pedicle screws and rods
Spinal fusion

181
Q

What is complete spinal cord injury?

A

No sensory or motor function below the level of the injury

182
Q

What is spinal shock?

A

Physiological loss of sensory and motor function below the level of injury which usually resolves in 24 hours

183
Q

What clinical test can detect spinal shock?

A

Absent bulbocavernous reflex

184
Q

What is neurogenic shock?

A

Hypotension, bradycardia +/- priapism due to temporary shutdown of T1-L2 outflow (unopposed parasympathetic stimulation)

185
Q

Outline treatment of spinal cord injury

A

Immobilise, traction
IV fluids
Surgical decompression
IV steroid

186
Q

What is the clinical pattern of involvement in central cord syndrome?

A

Paralysis of arms more than legs

187
Q

What is the clinical pattern of involvement in anterior cord syndrome?

A

Loss of motor and spinothalamic function

188
Q

What is the clinical pattern of involvement in Brown-Sequard syndrome?

A

Ipsilateral motor and dorsal column loss

Contralateral spinothalamic loss

189
Q

Which neck of the humerus - anatomical or surgical - is most likely to fracture?

A

Surgical neck with medial displacement of humeral shaft due to pul of pectoralis major

190
Q

Outline management of a humeral neck fracture

A

Sling and conservative if minimally displaced
Manipulation/ORIF if displaced upper humeral epiphysis in kids
If comminuted, may need head replacement

191
Q

List clinical features of anterior shoulder dislocation

A 
Loss of shoulder contour
Flattened deltoid
Anterior bulge
Pain
Axillary nerve damage (badge-patch numbness)
192
Q

What is a Bankart lesion?

A

Detachment of anterior glenoid labrum in anterior shoulder dislocation

193
Q

What is a Hill-Sachs lesion?

A

Posterior humeral head impacts on anterior glenoid

194
Q

Outline management of anterior shoulder dislocation

A

Relieve pain - anaesthesia, parenteral opioid, entonox
Closed reduction under sedation
Sling for 2-4 weeks and physiotherapy
ORIF if displaced/fracture of greater tuberosity

195
Q

How does posterior shoulder dislocation usually arise?

A

Posterior force on adducted, internally rotated arm

196
Q

Outline management of posterior shoulder dislocation

A

Closed reduction and immobilisation with physiotherapy

197
Q

How do acromioclavicular joint injuries arise?

A

Fall onto point of shoulder

198
Q

List clinical features of acromioclavicular joint injury

A

Prominence over acromioclavicular joint
Reproducible subluxation
Abduct shoulder and flex elbow and passively flex + extend arm - failure of outer end of clavicle to follow acromion suggests coracoclavicular ligament rupture

199
Q

Outline management of acromioclavicular joint injury

A

Conservative, sling, physiotherapy

Reconstruct ligaments if chronic pain/young

200
Q

Which nerve is at risk of damage in a humeral shaft fracture?

A

Radial nerve

May cause wrist drop and reduced sensation in 1st webspace

201
Q

Outline management of a humeral shaft fracture

A

Splint with humeral brace and immobilise for 8-12 weeks

Internal fixation with IM nail/plate + screws if polytraumatic

202
Q

How does an olecranon fracture occur?

A

Fall onto point of elbow with reflex contraction of triceps

203
Q

Outline management of olecranon fracture

A

ORIF to restore triceps function

Tension band wiring if simple transverse avulsion

204
Q

Outline management of supracondylar elbow fractures

A

Keep elbow in extension, correct valgus/varus
Reduce under GA
ORIF may be more stable
Dunlop traction, olecranon traction

205
Q

What sign may be seen on XR in a radial head/neck fracture?

A

Fat pad “triangular sail” sign at elbow

206
Q

Outline management of radial head/neck fracture

A

Collar and cuff sling if undisplaced + physiotherapy

ORIF if large fragment/displaced

207
Q

Outline management of elbow dislocation

A

Closed reduction under anaesthetic if uncomplicated

ORIF if associated fractures of radius/epicondyles/coronoid process

208
Q

What happens in “pulled elbow”

A

Radial head slips out of annular ligament due to pull on arms

209
Q

Outline management of pulled elbow

A

Elbow rotation - forced supination

Immobilise for a few days

210
Q

What is a nightstick fracture?

A

Fracture of the ulnar shaft

211
Q

What is a Monteggia fracture?

A

Fracture of ulna with dislocation of radial head at elbow

212
Q

What is a Galeazzi fracture?

A

Fracture of radius with dislocation of ulna at radioulnar joint

213
Q

Outline management of Monteggia/Galeazzi fractures

A

Lateral XR of wrist/elbow

ORIF

214
Q

What is a Colles fracture?

A

Extra-articular dorsal displacement of distal radius

215
Q

List aetiology/risk factors for Colles fracture

A

Fall on outstretched hand
Osteoporosis
Post-menopausal

216
Q

Outline management of a Colles fracture

A

Splint if minimal displacement
Reduction + plaster if displaced
ORIF if particularly unstable
Treat median nerve compression if unresolving

217
Q

What is a Smith’s fracture?

A

Extra-articular volar displacement of distal radius

218
Q

What is a Barton’s fracture?

A

Intra-articular fracture of dorsal radius (dorsal or volar)

219
Q

Outline management of a scaphoid fracture

A

XR lateral AP and 2 x oblique views
Splint and further XR in 2 weeks if unsure
Plaster for 6-12 weeks
Compression screw if displaced/non-union

220
Q

Volar injury to the hand risks damage to which tendons?

A

Flexor tendons

221
Q

Dorsal injury to the hand risks damage to which tendons?

A

Extensor tendons

222
Q

What is mallet finger?

A

Avulsion of extensor tendon from terminal phalanx, causing flexion of the DIPJ

223
Q

What are the 3 main types of pelvic fracture and their patterns of injury?

A

Lateral compression: half of pelvis displaced medially
Vertical shear: half of pelvis displaced superiorly
Anteroposterior compression: disrupted pubic symphysis

224
Q

Outline management of pelvic fracture

A

PR exam is mandatory
Relieve pain and replace blood
ORIF/external fixation

225
Q

List features of a pelvic radiograph that would be reassuring following a fracture

A

Less than 1cm pubic symphysis separation
Symmetrical
Integrity of superior pubic rami, acetabula and femoral necks

226
Q

List clinical features of hip fractures

A

External rotation, adduction
Limb shortening
Antalgic/abnormal gait

227
Q

Nearly all patients undergo surgery for hip fracture. True/False?

A

True

228
Q

Where do intracapsular hip fractures occur?

A

Occur just below femoral head

Risk of disruption to arterial supply and AVN

229
Q

Outline management of intracapsular hip fracture

A

Hemiarthroplasty/total hip replacement

Treat shock and relieve pain

230
Q

Outline management of extracapsular hip fracture

A

Dynamic hip screw

231
Q

Outline management of proximal femoral fractures

A

Intramedullary nailing

232
Q

Outline management of femoral shaft fractures

A

Femoral nerve block
Thomas splint
Closed reduction and stabilisation with IM nail

233
Q

The patella usually dislocates laterally. True/False?

A

True

234
Q

Outline management of patellar dislocations

A

Temporary splintage and physiotherapy

Vastus muscle strengthening

235
Q

What is a tibial plateau fracture?

A

Proximal tibia intra-articular fracture with either a split in bone or depression of articular surface

236
Q

What is a pilon fracture?

A

Intra-articular fracture of distal tibia where talus driven into tibia

237
Q

When is an ankle fracture stable and unstable?

A

Stable: distal fibular fracture with no medial fracture of rupture of deltoid ligament
Unstable: distal fibular fracture with rupture of deltoid ligament

238
Q

What is a Lisfranc fracture?

A

Fracture of base of 2nd metatarsal with dislocation of 2nd metatarsal and dislocation of other metatarsals

239
Q

Which meniscal tear - medial or lateral - is more common?

A

Medial (it’s more fixed and less mobile)

240
Q

List clinical features of a meniscal tear

A

Localised pain to medial/lateral joint line
Steinmenn’s test +ve
Effusion after 24h
Catching/”locking” sensation if bucket-handle tear
True lock = mechanical block to full extension

241
Q

Outline management of meniscal tear

A

Arthroscopic menisectomy

Leave if asymptomatic

242
Q

What is the soft tissue injury triad of the knee?

A

ACL rupture
Medial meniscus tear
Medial collateral ligament tear

243
Q

How does ACL rupture usually occur?

A

High rotational force (twisting injury)

Posterior blow to tibia

244
Q

List clinical features of ACL rupture

A 
Rotatory instability
Initial "pop" sound
Give way on turning
Deep pain
Knee effusion
Anterior translation of tibia (anterior draw test)
245
Q

Outline management of ACL rupture

A

3 weeks’ rest and physiotherapy
Pain relief
1/3 compensate, 1/3 avoid movement, 1/3 persistent symptoms
ACL reconstruction with tendon grafts

246
Q

How does medial collateral ligament (MCL) rupture occr?

A

Valgus stress injury

247
Q

How does lateral collateral ligament (LCL) rupture occr?

A

Varus stress injury

248
Q

MCL rupture is more common than LCL rupture. True/False?

A

True

249
Q

Which nerve is at risk in LCL rupture?

A

Common fibular nerve

250
Q

What is a sequestrum in osteomyelitis?

A

Dead fragment of bone that breaks off

251
Q

What is an involucrum in osteomyelitis?

A

New bone formation around an area of necrosis

252
Q

Who typically gets acute osteomyelitis?

A

Children (sluggish blood supply)
Post-surgery
Trauma

253
Q

What is a Brodie’s abscess?

A

Subacute osteomyelitis where bone walls off abscess with a rim of slcerotic bone

254
Q

List organisms that typically cause osteomyelitis

A 
Staph aureus
Pseudomonas
E. coli
Streptococci
Salmonella (esp sickle cell patients)
255
Q

Outline management of osteomyelitis

A

Drain abscess, surgical debridement
Vancomycin + cefotaxime IV (empirical) for 6-12 weeks
Flucloxacillin IV typically used
Stabilise bone with internal/external fixation

256
Q

List patients who are particularly susceptible to osteomyelitis of spine

A

Poorly controlled diabetes
IV drug users
Immunocompromised

257
Q

List clinical features of osteomyelitis of the spine

A 
Usually lumbar spine
Insidious pain, constant, unremitting
Paraspinal muscle spasm
Tenderness
Systemic upset
Neuro deficit
Epidural abscess
Kyphosis
258
Q

Which organisms typically cause surgical implant infections?

A

Staph aureus
E. coli
Staph epidermidis
Enterococci

259
Q

What happens in osteochondritis?

A

Softening of bony centres following necrosis

260
Q

List aetiology/risk factors for osteochondritis

A

Children, adolescents
Repetitive stress
Trauma
Familial predisposition

261
Q

Outline management of osteochondritis

A

Osteotomy if joint damage

Casting of large joints

262
Q

What is osteochondritis dissecans?

A

Segment of subchondral bone and cartilage becomes avascular and separates from underlying bone, resulting in a loose body

263
Q

List clinical features of osteochondritis dissecans

A 
Early aching
Adolescents
Knee, elbow, hip, ankle
Sudden painful locking
Effusions
264
Q

What is avascular necrosis?

A

Ischaemic necrosis of bone due to disrupted blood supply

265
Q

Which areas are susceptible to avascular necrosis?

A 
Femoral head
Humeral head
Capitellum
Proximal pole of scaphoid
Talus
266
Q

List aetiology/risk factors for avascular necrosis

A 
Fractures
Alcoholism
Steroid abuse
Hyperlipidaemia
Thrombophilia
Sickle cell disease
267
Q

Outline management of avascular necrosis

A

Decompression via drill if not collapsed

Joint replacement if collapsed

268
Q

What is the commonest benign primary bone tumour?

A

Osteochondroma

269
Q

Describe osteochondroma

A

Bony outgrowth on external surface

Usually on knee, proximal femur, proximal humerus

270
Q

Which benign tumour is an intramedullary cartilagenous tumour caused by failure of normal endochondral ossification at the metaphysis?

A

Enchondroma

271
Q

Describe enchondroma

A

Lucency in bone that may mineralise to give patchy sclerotic appearance

272
Q

Which benign tumour is a nidus of immature bone surrounded by a sclerotic halo?

A

Osteoid osteoma

273
Q

List clinical features of osteoid osteoma

A

Intense constant pain worst at night relieved by NSAID’s

274
Q

Which benign tumour looks like a Shepherd’s crook deformity at the femur?

A

Fibrous dysplasia

275
Q

Which benign tumour has a soap-bubble appearance on XR?

A

Giant cell tumour

276
Q

What is the most common primary malignant bone tumour?

A

Osteosarcoma

277
Q

List clinical features of most primary malignant bone tumours

A

Unexplained, non-mechanical pain
Constant severe pain
Systemic upset
Swelling

278
Q

Which malignant bone tumour looks like popcorn calcification on XR?

A

Chondrosarcoma

279
Q

Which malignant bone tumour usually affects adolescents and has the poorest prognosis?

A

Ewing sarcoma

280
Q

List typical sources of metastatic tumours to bone

A 
Breast
Prostate
Lung
Renal
Thyroid
281
Q

What is osteoporosis?

A

Reduced bone mineral density with increased bone mineral porosity
i.e. good quality bone, just not enough of it

282
Q

What are the cut-offs for bone mineral density for osteopenia and osteoporosis?

A

Osteopenia: 1.5-2.5 standard deviations below mean peak
Osteoporosis: greater than 2.5 standard deviations below mean peak

283
Q

List aetiology/risk factors for osteoporosis

A 
Type 1 (post-menopausal)
Smoking
Alcohol abuse
Lack of exercise
Poor diet
Reduced sun exposure
Chronic disease
Immunosuppression
284
Q

Ca and phosphate are low/normal/high in osteoporosis

A

Ca and phosphate are normal in osteoporosis

285
Q

Outline management of osteoporosis

A 
Exercise, good diet
Vit D supplements
Calcium supplements
Bisphosphonates
Monoclonal antibody
Strontium ranelate if unresponsive/intolerant
286
Q

What is osteomalacia?

A

Softening of bone due to deficient mineralisation

i.e. poor quality bone but plenty of bone

287
Q

List aetiology/risk factors for osteomalacia

A 
Malabsorption of Ca and vit D
Reduced sunlight exposure
Hypophosphataemia
Chronic kidney disease
Anticonvulsant use
288
Q

Ca and phosphate are low/normal/high in osteomalacia

A

Ca and phosphate are low in osteomalacia

289
Q

What is Paget’s disease?

A

Increased osteoclastic activity with inefficient osteoblastic activity results in impaired remodelling of bone

290
Q

List clinical features of Paget’s disease

A

Thickened, brittle, fragile, mis-shapen bone

Usually affects pelvis, femur, skull, tibia, ear ossicles

291
Q

Ca and phosphate are low/normal/high in Paget’s disease

A

Ca and phosphate are normal in Paget’s disease

292
Q

What is osteogenesis imperfecta?

A

Defect of maturation and organisation of type 1 collagen

293
Q

List clinical features of osteogenesis imperfecta

A 
Brittle-bone disease
Fragile bones
Multiple fractures
Short stature
Deformities
Blue sclerae
Loss of hearing
294
Q

Outline management of osteogenesis imperfecta

A

Splint/traction/surgical stabilisation of fractures

Sofield procedure for progressive deformity

295
Q

What is achondroplasia?

A

Skeletal dysplasia/short stature involving reduced growth of cartilagenous bone due to mutations in fibroblast growth factor receptor 3 (FGR3)

296
Q

List clinical features of achondroplasia

A 
Disproportionately short limbs
Short stature
Prominent forehead
Wide nose
Joint laxity
Large head
Increased lumbar lordosis
Bow legs
Learning difficulty
Organ dysfunction
297
Q

Outline management of achondroplasia

A

Correct deformities
Growth hormone
Limb lengthening

298
Q

What is Marfan’s syndrome?

A

Ligamentous laxity due to defect in collagen synthesis, causing hypermobility

299
Q

Which gene is mutated in Marfan’s syndrome?

A

Fibrillin

300
Q

List clinical features of Marfan’s syndrome

A 
Tall stature
Lig laxity
Long limbs
High-arched palate
Scoliosis
Pectus excavatum
Eye problems (retinal detachment)
Aortic aneurysm
Valve incompetence
301
Q

What is Ehlers-Danlos syndrome?

A

Abnormal collagen-elastin formation/ratio causes profound joint hypermobility

302
Q

What is cerebral palsy?

A

Insult to immature brain causes reduced/impaired function

Onset usually before 2-3 years of age

303
Q

List aetiology/risk factors for cerebral palsy

A 
Insult to brain around/during/after birth
Genetics
Brain malformations
Intrauterine infections
Prematurity
Intracranial haemorrhage
Hypoxia at birth
Meningitis
304
Q

List clinical features of cerebral palsy

A 
Weakness
Paralysis
Delayed milestones
Seizures
Language/speech difficulty
Depends on area of brain affected
305
Q

What is the difference between monoplegic, diplegic, hemiplegic and quadriplegic cerebral palsy?

A

Monoplegic: one limb
Hemiplegic: ipsilateral upper + lower limb
Diplegic: lower limbs
Quadriplegic: all four limbs

306
Q

Which area is affected in spastic cerebral palsy?

A

Injury to precentral gyrus/UMN/corticospinal tract

307
Q

Which area is affected in ataxic cerebral palsy?

A

Cerebellum

308
Q

Which area is affected in athetoid cerebral palsy?

A

Basal ganglia/extrapyramidal tract/pyramidal tract

309
Q

Outline management of cerebral palsy

A 
Physiotherapy
Splintage/orthotics
Baclofen, botox for spasticity
Hip excision/replacement
Correct severe scoliosis/joint contractures
310
Q

What is spina bifida?

A

Two halves of posterior verebral arch fail to fuse

311
Q

List clinical features of spina bifida occulta

A 
Mild form: some develop tethering of spinal cord and roots
Pes cavus
Clawed toes
Neuro deficit
Tell-tale dimple
Tuft of hair
312
Q

List clinical features of spina bifida cystica

A 
Severe form: vertebral canal contents herniate through defect
If meningocele (herniation of meninges), usually no neuro deficit
If myelomeningocele (herniation of meninges and cord), usually neuro deficit below level of lesion
313
Q

Outline management of spina bifida

A

Treat hydrocephalus
Scoliosis correction
Contracture release/correction
Avoid formation of sores

314
Q

List clinical features/examples of limb malformations

A

Syndactyly - two digits fused
Polydactyly - extra digit
Fibular hemimelia - partial/complete loss of fibula

315
Q

Outline management of limb malformations

A 
Surgical separation/amputation
Limb lengthening
External fixation
Prosthetic limb
Surgical reconstruction
Deformity correction
316
Q

List aetiology/risk factors for obstetric brachial plexus palsy

A

Macrosomia
Twin delivery
Shoulder dystocia

317
Q

What are the features of Erb’s palsy?

A

C5 + C6 damage
Loss of innervation to deltoid, supraspinatus, infraspinatus, biceps, brachialis
Results in internal rotation of humerus, “waiter’s tip” posture

318
Q

What are the features of Klumpke’s palsy?

A

C8 + T1 damage
Paralysis of intrinsic hand muscles with/without finger/wrist flexors
Results in flexed fingers, Horner’s syndrome

319
Q

Outline management of obstetric brachial plexus injury

A

Physiotherapy to prevent contractures
Surgical release of contractures
Tendon transfers if no recovery

320
Q

Define pathological genu varus/valgus

A

Greater than/less than 6’ of angulation from mean

321
Q

List conditions where genu varus is typically seen

A

Osteochondroma
Skeletal dysplasia
Trauma

322
Q

List conditions where genu valgus is typically seen

A 
Idiopathic
Ricket's
Enchondromas
Trauma
Neurofibromatosis
323
Q

What is in-toeing?

A

Feet that point towards midline

324
Q

List aetiology/risk factors for in-toeing

A

Femoral neck anteversion
Internal tibial torsion
Forefoot adduction

325
Q

When would surgery be considered for in-toeing?

A

Only consider after 7-8 years of age as most resolve

326
Q

What is pes planus?

A

Flat footedness due to loss of medial plantar arch

327
Q

What is the difference between mobile/flexible pes planus and rigid/fixed pes planus?

A

Mobile: flattened medial arch forms on dorsiflexion of great toe, present on weight-bearing only, usually due to lig laxity
Rigid: persistently flat medial arch, with/without weight bearing, usually due to tarsal coalition

328
Q

What is developmental dysplasia of the hip (DDH)?

A

Dislocation/subluxation of femoral head during perinatal period results in abnormal hip joint

329
Q

List aetiology/risk factors for DDH

A 
Females
Left hip usually affected
Family history
Breech presentation
First-born
Down's syndrome
Increased birth weight
Oligohydramnios
330
Q

List clinical features of DDH

A 
Unstable hips
Shallow acetabulum
Arthritis early on
False acetabulum may develop, causing limb shortening
Asymmetrical groin/thigh skin creases
Delayed walking, waddling gait
331
Q

What are the clinical tests for DDH?

A

Ortolani: reduce dislocated hip with abduction and elevation of femur
Barlow: dislocate hip with adduction and flexion

332
Q

When would you scan for suspected DDH?

A

USS before 6 months

XR after 6 months

333
Q

Outline management of DDH

A

Serial observation if relocated
Pavlik harness (splint in abduction) for 3 months if unstable
Open reduction if persistent dislocation over 18 months

334
Q

What is transient synovitis of the hip?

A

Chief cause of hip pain in kids

Self-limiting inflammation of synovium, usually post-URTI

335
Q

List clinical features of transient synovitis of the hip

A

Limp
Reluctant to weight bear
Restricted motion
Low-grade fever

336
Q

What investigations would you do for transient synovitis of the hip?

A

Need to EXCLUDE septic arthritis, Perthes, juvenile arthritis, SUFE
Aspirate/surgical drainage if uncertain

337
Q

Outline management of transient synovitis of the hip

A

NSAID short-course

Rest

338
Q

What is Perthes disease?

A

Idiopathic osteochondritis of femoral head in aged 4-9

339
Q

List clinical features of Perthes disease

A 
Pain
Limp
Loss of internal rotation, loss of abduction
\+ve Trendelenberg
Restricted motion
340
Q

Outline management of Perthes disease

A 
Avoid physical activity
Rest
Radiographic surveillance
Osteotomy of femur/acetabulum if subluxation/dislocation
Hip replacement if collapse
341
Q

What is slipped upper femoral epiphysis (SUFE)?

A

Femoral head epiphysis slips inferiorly in relation to femoral neck

342
Q

List aetiology/risk factors for SUFE

A

Overweight prepubertal adolescent boys
Hypothyroidism
Renal disease

343
Q

List clinical features of SUFE

A

Limping
Pain in growin/thigh/knee
Loss of internal rotation
Limited motion

344
Q

Outline management of SUFE

A

Urgent surgery to pin femoral head
Hip replacement
Femoral osteotomy

345
Q

What is talipes equinovarus?

A

Clubfoot - congenital deformity due to in utero malalignment of joints between talus, calcaneus and navicular

346
Q

List clinical features of clubfoot

A

Contracture of soft tissue
Plantarflexion
Supination
Varus alignment of forefoot

347
Q

Outline management of clubfoot

A

Early splintage - Ponseti technique

Surgery may be required

348
Q

Describe Salter Harris physeal fracture I and II

A

I: pure physeal separation
II: physeal separation with metaphyseal fragment

349
Q

Describe Salter Harris physeal fracture III and IV

A

III: intra-articular with physis split
IV: Intra-articular with physis and metaphysis split

350
Q

Describe Salter Harris physeal fracture V

A

Compression injury to physis

4MB Surgery (3 decks)

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